SCAI publishes expert consensus recommendations for treating arterial disease below the knee

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The third paper in the series, published online on 18 July 2014 in Catheterization & Cardiovascular Interventions, outlines recommendations for treating infrapopliteal, or arterial disease below the knee.

Bruce H Gray, professor of Surgery/Vascular Medicine, University of South Carolina School of Medicine, and lead author of the consensus paper said: “Depending on the patient’s condition, open surgery, an endovascular intervention or amputation are considered an appropriate course of action. These new recommendations aim to help guide physicians to make the best care decisions when an endovascular approach is appropriate.”

The expert panel reviewed scientific data on each critical limb ischaemia treatment option, including balloon angioplasty, stents, atherectomy, as well as experimental therapies such as drug-coated balloons.

The recommendations state that patients with severe disease, those with pain at rest and those with minor or major tissue loss should be considered for revascularisation, with either surgery or endovascular treatment to prevent amputation or improve healing following amputation. Currently there is insufficient evidence to support treatment in those with asymptomatic disease.

“Intervention to treat infrapopliteal arterial disease can be challenging because the patients’ comorbidities, the anatomic variables, and the limitations of our techniques. Clinical scenarios based on anatomic and clinical variables are presented. Recommendations regarding intervention (appropriate care, may be appropriate care, rarely appropriate care) are made based on best evidence),” the authors write while introducing the recommendations.

“Critical limb ischaemia is the predominant clinical indication for treatment of infrapopliteal arterial disease and occurs when arterial perfusion is reduced below a critical level resulting in ischaemic pain and/or skin breakdown. Prompt revascularisation is aimed at symptom relief with improved limb salvage and ulcer healing. Multilevel disease is more common than isolated infrapopliteal disease, and a systematic approach to achieve straight-line flow from the iliac to pedal arch with complete revascularisation is necessary to optimise outcomes.

“Percutaneous transluminal angioplasty is the current standard for endovascular therapy for clinically significant infrapopliteal disease. Bailout bare metal and drug-eluting stents in the tibial arteries should be considered for failures of balloon angioplasty. Studies are currently enrolling patients to address the use of combined strategies (ie atherectomy and drug-coated balloons). Further data are needed regarding the utility of atherectomy devices, drug-coated balloons, drug-eluting stents, and bioabsorbable stents in infrapopliteal interventions. However, until these results are available, given the increased costs of other modalities (e.g., cutting balloons, cryoplasty, laser, orbital, rotational, and directional atherectomy catheters), and the lack of comparative data to support their efficacy, balloon angioplasty should remain the initial endovascular therapy for most infrapopliteal disease,” the document concludes.

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