Percutaneous Therapies for Peripheral Artery Disease

Mehdi H. Shishehbor, DO, MPH, PhD; Michael R. Jaff, DO

Disclosures

Circulation. 2016;134(24):2008-2027. 

In This Article

Abstract and Introduction

Abstract

Percutaneous therapies for peripheral artery disease continue to evolve with new techniques and devices. Although guidelines-recommended therapies have impacted cardiovascular morbidity and mortality, endovascular interventions have been shown to reduce limb pain, improve quality of life, and prolong walking distance for those with claudication and to reduce amputation rates among those with critical limb ischemia. Novel devices such as drug-eluting stents and drug-coated balloons have improved patency for moderate-length lesions, whereas others allow treatment of heavily calcified and tortuous segments. New adjunctive devices to cross lesions and reduce or modify associated plaque have also been developed, although level 1 data regarding their efficacy are sparse. There has also been a better mechanistic understanding of lower extremity endovascular treatment using tools such as intravascular ultrasound. This information has highlighted the need for better stent size selection for the femoropopliteal arterial segments and larger balloon diameters for the tibial arteries. Moreover, a wound perfusion approach with direct in-line flow, the so-called angiosome approach, and reconstruction of the pedal loop have been advocated for improved wound healing. Technical advances such as the tibiopedal access and reentry methods have allowed crossing of lesions that were considered no option for the endovascular approach in the past. Collectively, there has been increased awareness, interest, and commitment by various specialty societies and organizations to advance the treatment of peripheral artery disease and critical limb ischemia. This is also evident by the recent coalition of 7 professional societies and organizations that represented >150 000 allied health professionals and millions of patients with peripheral artery disease at the 2015 Centers for Medicaid and Medicare Services Medicare Evidence Development and Coverage Analysis Committee meeting. The percutaneous therapies for peripheral artery disease continue to evolve with longer follow-up with randomized data and larger prospective registries. In the future, it is hopeful that we will treat the lower extremity arteries according to segments, taking into account plaque morphology, luminal versus subintimal crossing, location, and stenotic versus occlusive disease. Until then, we must identify the most cost-effective, efficacious, and safe treatment for each patient. The goal of this article is to aid the practicing vascular specialist consider the optimal choices for the management of patients with vascular disease.

Introduction

The incidence and prevalence of peripheral artery disease (PAD) continues to rise with >200 million individuals living with this diagnosis worldwide.[1] It has been associated with significant morbidity and mortality, and it is considered a coronary artery disease risk equivalent.[2,3] All current guidelines recommend aggressive lifestyle and risk factor modification for patients with PAD to reduce the risk of major cardiovascular events and premature mortality.[2,3] However, aside from a supervised exercise program and cilostazol, few medical advances have been shown to improve claudication walking distance or to prevent amputation in patients with critical limb ischemia (CLI).[4] Endovascular therapy, however, has been shown to reduce limb pain, improve quality of life, and prolong walking distance for those with claudication and has been associated with reduced amputation rates among those with CLI.[5–9] Many advances in devices and techniques have emerged, but it is more important to note that the body of evidence and quality of data in support of current devices and approaches continue to grow. These advances have led to a surge in long-term (5-year) randomized trials, head-to-head comparative studies, cost-effectiveness analyses, and multicenter registries. The purpose of this article is not to review all treatment strategies for PAD, because we specifically do not address comprehensive medical therapy and surgical revascularization, both of which have significant roles to play. In this article we will provide an in-depth review of the current state of percutaneous endovascular therapies for PAD.

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