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

Background

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.