Superficial femoral artery atherosclerotic occlusive diseases a comparison between endovascular techniques and surgical bypass
Mohamed Salah Mahmoud Kabis;
Abstract
Chronic lower extremity ischemia due to peripheral arterial disease (PAD) is the most common cause of walking disability seen by vascular specialists. The manifestations of chronic lower extremity ischemia often include pain produced by varying degrees of ischemia, ranging from no or atypical leg symptoms to typical exertional muscular pain (intermittent claudication, IC) to ischemic rest pain (Dosluoglu, 2014).
A clear association between the prevalence of peripheral artery disease (PAD) and increased age has been established. In an analysis of 2381 patients who participated in the United States National Health and Nutrition Examination Survey, the prevalence of PAD was found to be 4.3% overall, with prevalence of 0.9% in patients between the ages of 40 and 49 years, 2.5% in patients between the ages of 50 and 59 years, 4.7% in patients between the ages of 60 and 69 years, and 14.5% in patients more than age 69 years. The prevalence of PAD is expected to increase worldwide as the population ages, cigarette smoking persists, and the epidemics of diabetes mellitus (DM), hypertension, and obesity grow (Norgren, et al. 2007).
PAD may be asymptomatic in the early stages, but is always associated with shortened survival due to the invariable association with atherosclerosis in other arterial territories, especially the coronary, carotid and cerebral circulation. This is highlighted by observational studies showing that reduced ankle–brachial pressure index (ABI, a marker of disease severity in PAD) is associated with an increased risk of cardiovascular mortality (McKenna, et al. 1991).
Patients with lower extremity ischemia are typically divided into two groups, those with intermittent claudication and those with critical limb ischemia (CLI), depending on symptoms at presentation. Claudication and CLI are managed differently because of major differences in their natural histories and expected clinical outcomes after treatment (Muluk, et al. 2001).
Prognosis for CLI is generally considerably worse than for intermittent claudication; as many as 25% of CLI patients progress to major limb amputation within 1 year, and 25% die of cardiovascular complications within 1 year (Taylor, et al. 2003).
There is more consensus among clinicians regarding decision making for CLI because the natural history of untreated CLI more frequently leads to limb loss than does claudication. Patients with CLI often have severe associated cardiovascular comorbidities and are generally older and in poorer health than those with claudication (Muluk, et al. 2001).
In contrast, patients with claudication typically seek treatment for the relief of lifestyle limiting pain with ambulation. These patients exhibit a more benign natural history with respect to limb viability, with amputation rates of 1% to 7% at 5 years and clinical deterioration of the limb in only 25% (Muluk, et al. 2001).
As with CLI, claudication is a marker of significant systemic atherosclerosis, with associated cardiovascular mortality rates at 1, 5, and 10 years as high as 12%, 42%, and 65%, respectively. All patients with PAD require medical management of their cardiovascular disease (Muluk, et al. 2001).
Any patient older than 40 years who has an ankle-brachial index (ABI) of less than 0.90 has significant PAD, even in the absence of symptoms (Hiatt, 2001).
An ABI of less than 0.90 is 95% sensitive in identifying angiographically confirmed PAD, more than 50% of patients with an abnormal ABI fail to show typical symptoms of claudication or CLI because of the coexistence of other major co-morbidities, a condition sometimes referred to as “chronic subclinical lower extremity ischemia” (Hawkey, et al. 2006).
Treatment recommendations for intermittent claudication have balanced the risk of intervention against the natural history of the disease with the goal of preserving life and limb. Many experts agree that the best strategy is to initiate systemic medical therapy aimed at reducing cardiac morbidity. This strategy is based on the low relative risk of limb loss in patients with claudication compared with the significant relative risks of stroke, MI, and death (Hirsch, et al. 2006).
Revascularization is recommended only in cases of severe claudication, and only after medical therapy has failed. Medical treatment for intermittent claudication consists of smoking cessation, exercise training, and pharmacologic therapy (Hirsch, et al. 2006).
The classic treatment approach for CLI has been open surgery. CLI is usually associated with multilevel arterial disease that is not ideally suited to percutaneous intervention. Diffuse, extensive PAD causing CLI in both aortoiliac and femoropopliteal locations are best treated by surgical bypass according to TASC II (Norgren, et al. 2007).
Those who favor open surgery for the treatment of CLI often cite superior reconstruction patency and increased durability (Van der Zaag, et al. 2004).
However, open surgery is usually associated with higher perioperative morbidity and longer hospitalization (Hobbs, et al. 2005).
A re-intervention rate of 20% to 30% to treat failing grafts due to intrinsic vein graft stenosis is usually necessary to maintain the increased durability attributed to open surgery (Davies, et al. 2005).
Endovascular therapy of infrainguinal PAD has since gained acceptance owing to reported improvements in outcome and diminished rates of morbidity and mortality compared with standard surgical bypass (Rogers, et al. 2007).
Novel technologies and refinements of previous technologies are enabling endovascular therapy for increasingly complex vascular pathology. Patients with multiple comorbidities or those lacking adequate autogenous conduits may derive particular benefit from an endovascular approach, because the utility of standard bypass is more limited in these cases (Menard, et al. 2007).
Primary limb amputation continues to be required in 10% to 40% of CLI patients because of overwhelming infection or unreconstructable vascular disease. Unreconstructable vascular disease accounts for nearly 60% of patients requiring secondary amputation (Norgren, et al. 2007).
A clear association between the prevalence of peripheral artery disease (PAD) and increased age has been established. In an analysis of 2381 patients who participated in the United States National Health and Nutrition Examination Survey, the prevalence of PAD was found to be 4.3% overall, with prevalence of 0.9% in patients between the ages of 40 and 49 years, 2.5% in patients between the ages of 50 and 59 years, 4.7% in patients between the ages of 60 and 69 years, and 14.5% in patients more than age 69 years. The prevalence of PAD is expected to increase worldwide as the population ages, cigarette smoking persists, and the epidemics of diabetes mellitus (DM), hypertension, and obesity grow (Norgren, et al. 2007).
PAD may be asymptomatic in the early stages, but is always associated with shortened survival due to the invariable association with atherosclerosis in other arterial territories, especially the coronary, carotid and cerebral circulation. This is highlighted by observational studies showing that reduced ankle–brachial pressure index (ABI, a marker of disease severity in PAD) is associated with an increased risk of cardiovascular mortality (McKenna, et al. 1991).
Patients with lower extremity ischemia are typically divided into two groups, those with intermittent claudication and those with critical limb ischemia (CLI), depending on symptoms at presentation. Claudication and CLI are managed differently because of major differences in their natural histories and expected clinical outcomes after treatment (Muluk, et al. 2001).
Prognosis for CLI is generally considerably worse than for intermittent claudication; as many as 25% of CLI patients progress to major limb amputation within 1 year, and 25% die of cardiovascular complications within 1 year (Taylor, et al. 2003).
There is more consensus among clinicians regarding decision making for CLI because the natural history of untreated CLI more frequently leads to limb loss than does claudication. Patients with CLI often have severe associated cardiovascular comorbidities and are generally older and in poorer health than those with claudication (Muluk, et al. 2001).
In contrast, patients with claudication typically seek treatment for the relief of lifestyle limiting pain with ambulation. These patients exhibit a more benign natural history with respect to limb viability, with amputation rates of 1% to 7% at 5 years and clinical deterioration of the limb in only 25% (Muluk, et al. 2001).
As with CLI, claudication is a marker of significant systemic atherosclerosis, with associated cardiovascular mortality rates at 1, 5, and 10 years as high as 12%, 42%, and 65%, respectively. All patients with PAD require medical management of their cardiovascular disease (Muluk, et al. 2001).
Any patient older than 40 years who has an ankle-brachial index (ABI) of less than 0.90 has significant PAD, even in the absence of symptoms (Hiatt, 2001).
An ABI of less than 0.90 is 95% sensitive in identifying angiographically confirmed PAD, more than 50% of patients with an abnormal ABI fail to show typical symptoms of claudication or CLI because of the coexistence of other major co-morbidities, a condition sometimes referred to as “chronic subclinical lower extremity ischemia” (Hawkey, et al. 2006).
Treatment recommendations for intermittent claudication have balanced the risk of intervention against the natural history of the disease with the goal of preserving life and limb. Many experts agree that the best strategy is to initiate systemic medical therapy aimed at reducing cardiac morbidity. This strategy is based on the low relative risk of limb loss in patients with claudication compared with the significant relative risks of stroke, MI, and death (Hirsch, et al. 2006).
Revascularization is recommended only in cases of severe claudication, and only after medical therapy has failed. Medical treatment for intermittent claudication consists of smoking cessation, exercise training, and pharmacologic therapy (Hirsch, et al. 2006).
The classic treatment approach for CLI has been open surgery. CLI is usually associated with multilevel arterial disease that is not ideally suited to percutaneous intervention. Diffuse, extensive PAD causing CLI in both aortoiliac and femoropopliteal locations are best treated by surgical bypass according to TASC II (Norgren, et al. 2007).
Those who favor open surgery for the treatment of CLI often cite superior reconstruction patency and increased durability (Van der Zaag, et al. 2004).
However, open surgery is usually associated with higher perioperative morbidity and longer hospitalization (Hobbs, et al. 2005).
A re-intervention rate of 20% to 30% to treat failing grafts due to intrinsic vein graft stenosis is usually necessary to maintain the increased durability attributed to open surgery (Davies, et al. 2005).
Endovascular therapy of infrainguinal PAD has since gained acceptance owing to reported improvements in outcome and diminished rates of morbidity and mortality compared with standard surgical bypass (Rogers, et al. 2007).
Novel technologies and refinements of previous technologies are enabling endovascular therapy for increasingly complex vascular pathology. Patients with multiple comorbidities or those lacking adequate autogenous conduits may derive particular benefit from an endovascular approach, because the utility of standard bypass is more limited in these cases (Menard, et al. 2007).
Primary limb amputation continues to be required in 10% to 40% of CLI patients because of overwhelming infection or unreconstructable vascular disease. Unreconstructable vascular disease accounts for nearly 60% of patients requiring secondary amputation (Norgren, et al. 2007).
Other data
| Title | Superficial femoral artery atherosclerotic occlusive diseases a comparison between endovascular techniques and surgical bypass | Other Titles | مقارنة علاج أمراض انسداد الشريان الفخذى السطحى بالقسطرة التداخلية أو التدخل الجراحى | Authors | Mohamed Salah Mahmoud Kabis | Issue Date | 2015 |
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