|
Recommendations
for Surgical Revascularization for CLI |
|
COR |
LOE |
Recommendations |
|
I |
A |
When surgery is performed for
CLI, bypass to the popliteal or infrapopliteal arteries (ie,
tibial, pedal) should be constructed with suitable
autogenous vein.263,266,269,272
|
|
See Online Data Supplement
37. |
Many large RCTs have demonstrated
that bypasses above the knee should be autogenous vein either
reversed or in situ vein.263,266,269,272 There are large single-center trials
showing the efficacy of autogenous vein to distal tibial
vessels.324,325 In addition, composite sequential
femoropopliteal-tibial bypass and bypass to an isolated
popliteal arterial segment that has collateral out flow to the
foot are both acceptable methods of revascularization and should
be considered when no other form of bypass with adequate
autogenous conduit is possible.326,327
|
|
I |
C-LD |
Surgical procedures are
recommended to establish in-line blood flow to the foot in
patients with nonhealing wounds or
gangrene.328–330
|
|
See Online Data Supplement
42. |
In patients presenting with
nonhealing ulcers or gangrene, surgical procedures should be
performed to establish in-line blood flow to the foot.328–330
Table 10 addresses
factors that may prompt a surgical approach to the patient with
CLI. |
|
IIa |
B-NR |
In patients with CLI for whom
endovascular revascularization has failed and a suitable
autogenous vein is not available, prosthetic material can be
effective for bypass to the below-knee popliteal and tibial
arteries.331–333
|
|
See Online Data Supplement
42. |
There are studies demonstrating
that patients for whom endovascular treatment for CLI has failed
can be treated successfully with autogenous vein bypass
graft332,333 or prosthetic material.331 Although
autogenous vein is the preferred conduit for surgical
revascularization, prosthetic conduit is a secondary option for
patients with CLI without suitable saphenous vein who require
surgical revascularization. |
|
IIa |
C-LD |
A staged approach to surgical
procedures is reasonable in patients with ischemic rest
pain.334–336
|
|
N/A |
It is reasonable to perform a
staged approach to revascularization in patients with ischemic
rest pain with multilevel disease. For example, aortoiliac
(inflow) disease may be treated first with endovascular
treatment or by surgical reconstruction, depending on lesion
characteristics, patient comorbidities, and patient
preference.337,338 Combined percutaneous and surgical
revascularization may require separate interventions, typically
with the most proximal procedure performed first. |
|