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Report guides clinicians on revascularization options for PAD
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Five societies released appropriate use criteria for interventions for peripheral artery disease.
According to the report from the American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology and Society of Vascular Medicine, the purpose “is to provide guidance to clinicians who may refer patients for revascularization treatments and to interventionalists and surgeons themselves. With the field of peripheral artery disease constantly evolving, it is imperative to offer tools and resources that physicians can utilize to provide the best care for their patients.”
Scoring system
A writing group chaired by Cardiology Today’s Intervention Editorial Board Member Steven R. Bailey, MD, FACC, MSCAI, FAHA, chief of cardiology at the University of Texas Health Sciences Center, developed common scenarios for patients with PAD and an independent rating panel ranked each scenario from 1 to 9, with 1 to 3 representing rarely appropriate care, 4 to 6 representing possibly appropriate care and 7 to 9 representing appropriate care.
In renal artery stenosis, continuing or intensifying medical therapy was identified as appropriate in almost all cases, with renal artery stenting classified as appropriate only for patients with chronic kidney disease and accelerating decline in renal function and for patients with cardiac destabilization.
In lower-extremity disease, endovascular therapy was endorsed for patients with intermittent claudication despite guideline-directed medical therapy with stenotic lesions in the aortoiliac, superficial femoral or popliteal arteries; it received a “may be appropriate” grade for stenotic lesions below the knee. For patients with intermittent claudication and chronic total occlusion, endovascular treatment was endorsed in stenotic aortoiliac lesions and deemed a possibility in stenotic SFA, popliteal or below-the-knee lesions. Surgical treatment generally received less of an endorsement than endovascular treatment in this population, whereas for patients with intermittent claudication not on medical therapy, medical therapy was endorsed over either intervention.
In critical limb ischemia, endovascular and surgical interventions were endorsed in all scenarios.
The panel also evaluated options for different types of endovascular treatments in various arteries. For the SFA and popliteal artery, drug-coated balloons, bare-metal stents and drug-coated stents were endorsed in all lesions, and balloon angioplasty was endorsed in lesions less than 100 mm. For below-the-knee arteries, balloon angioplasty was endorsed in all lesions, and drug-coated stents were endorsed in lesions less than 100 mm.
Continuing or intensifying medical therapy was endorsed in all scenarios of in-stent restenosis, whereas endovascular therapy was endorsed if recurrent symptoms occurred.
Clinical judgment needed
“This was more challenging than the development of [appropriate use criteria] on other topics mainly because supporting literature is not as developed or robust as for other topics covered,” Bailey and colleagues wrote. “Although the [appropriate use criteria] ratings in this report provide guidance for specific treatment options in patient populations, the scores are not a replacement for clinical judgment and practice experience in determining the best options for individual patients. Each patient is unique, and the possible use of different treatment options deserves to be considered in full clinical context.” – by Erik Swain
Disclosures: Bailey reports he serves on a data and safety monitoring board for Boston Scientific. Please see the study for all other authors’ relevant financial disclosures.
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