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4 - Endovascular and surgical options for peripheral revascularisation

Colin Nice
Queen Elizabeth Hospital, UK
Vish Bhattacharya
Queen Elizabeth Hospital
Gerard Stansby
Freeman Hospital
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Key points

  • Risk factor optimisation and best medical therapy are the standard of care for all patients

  • Severe acute ischaemia is best managed with surgery, there is a role for thrombolysis in less severe cases

  • Thrombolysis requires intensive monitoring to identify and manage complications

  • Surgical or endovascular revascularization is appropriate for patients with limiting claudication or critical limb ischaemia

  • Non-invasive imaging should be used for procedural planning

  • Bypass grafts with autologous vein produce the best long-term patency rates

  • Endovascular procedures have lower mortality and morbidity rates than the equivalent surgery

  • Stents and stent grafts improve endovascular results and are important for managing complications

  • Patient fitness, co-morbidity and preference are as important as lesion characteristics in informing revascularization decisions

  • Multi-disciplinary teams are best placed to manage individual patients in this rapidly evolving field


Many patients with peripheral arterial disease (PAD) do not require any revascularization procedure. Identification and management of modifiable risk factors are effective in reducing the excess risk of cardiovascular mortality and preventing acute limb ischaemia due to disease progression. Also supervised exercise programmes can benefit those with intermittent claudication, a Cochrane review of randomised trials in patients with stable intermittent claudication suggested an improvement in walking distance of 150% with a regime of three sessions per week of walking to near maximum pain.

However, surgical and endovascular revascularization procedures produce substantial additional benefits when proficiently performed upon carefully selected and prepared patients.

Postgraduate Vascular Surgery
The Candidate's Guide to the FRCS
, pp. 72 - 85
Publisher: Cambridge University Press
Print publication year: 2011

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Watson, L, Ellis, B, Leng, GC. Exercise for intermittent claudication. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No. CD000990. DOI: 10.1002/14651858.CD000990.
Adam, DJ, Beard, JD, Cleveland, T and BASIL Trial Participants. Bypass Versus Angioplasty in Severe Ischaemia of the Leg (BASIL): multicentre, randomised, controlled trial. Lancet 2005; 366: 1925–34.
Marcus, AJ, Lotzof, , K, Kamath, et al. A new approach: regional nerve blockade for angioplasty of the lower limb. CardiovascIntervent Radiol 2006; 29: 235–40.
Earnshaw, JJ, Whitma, B, Foy, Con behalf of the Thombolysis Study Group. National Audit of Thrombolysis for Acute Limb Ischaemia (NATALI) clinical factors associated with early outcome. J Vasc Surg 2004; 39: 1018–25.
Berridge, DC, Kessel, , Robertson, I. Surgery versus thrombolysis for initial management of acute limb ischaemia. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No. CD002784. DOI: 10.1002/14651858.CD002784.
AbuRahma, AF et al. Prospective controlled study of polytetrafluoroethylene versus saphenous vein in claudicant patients with bilateral above knee femoropopliteal bypasses. Surgery 1999; 126: 594–602.
Green, RM et al. Prosthetic above-knee femoropopliteal bypass grafting: five year results of a randomized trial. J Vasc Surg 2000; 31: 417–25.
Stonebridge, PA, Prescott, RJ, Ruckley, CV. Randomized trial comparing infrainguinal polytetrafluoroethylene bypass grafting with and without vein interposition cuff at the distal anastamosis. The Joint Vascular Research Group. J Vasc Surg 1997; 26: 543–50.
Greenhalgh, RM, Belch, JJ, Brown, LC et al. and , Mimic Trial Participants. The adjuvant benefit of angioplasty in patients with mild to moderate intermittent claudication (MIMIC) managed by supervised exercise, smoking cessation advice and best medical therapy: results from two randomised trials for stenotic femoropopliteal and aortoiliac arterial disease. Eur J Vasc Endovasc Surg 2008; 36: 680–8.
Norgren, T, Hiatt, , L, Dormandy, , WR. Transatlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45: S5.

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