Chapter 54: Peripheral Arterial Disease

INTRODUCTION

Since the time of the first edition of this book by Yeung and King in 2006,¹ the practice of peripheral vascular medicine has evolved into a more effective and well-organized discipline. Most would agree that practice guidelines for the management of patients with peripheral arterial disease (PAD) first published in 2006,² with updates in 2011³ and 2013,⁴ and 2016, coupled with the rapid innovation in technology (Table 54-1), clinical research, and continuing educational programs, have provided the backbone for the remarkable progress in this field.

Vascular physicians representing a variety of medical, surgical, and imaging societies continue to work tirelessly to improve the quality of care, such as by writing guidelines for the management of patients with PAD and defining medical competence in the diagnosis and treatment of PAD.⁵ Since 2005, several thousands of physicians, mostly cardiologists and vascular surgeons, have become credentialed in vascular imaging interpretation after passing the Registered Physician in Vascular Interpretation examination.⁶ The American Board of Vascular Medicine also offers certification that recognizes expertise in both general vascular medicine and endovascular specialty.

In addition, hospitals have implemented plans to protect patients and health care personnel from the frequently prolonged radiation exposure in the catheterization laboratory at the time of treatment. The PVI Registry of the American College of Cardiology further demonstrates ongoing efforts to improve care by voluntarily tracking the outcomes of peripheral vascular procedures.⁷ The ultimate common goal is to deliver a safe, effective, sustained, and valuable service to the increasing number of PAD patients.

This chapter provides interventional cardiology specialists with practical information and general guidance for the evaluation and treatment of patients with PAD of the lower extremities. In part, this chapter replicates what the Emory interventional cardiology trainees are expected to learn during their years of training and represents a compilation of knowledge extracted from practice guidelines, relevant publications, and our personal experience.

As in other areas of medicine, treatment recommendations can be controversial and open to revision informed by research. Most controversy lies in the choice of treatment and the effectiveness of a variety of stents, balloons, and medical devices currently used in patients with symptomatic PAD.

For example, perhaps the most exemplary case of practice variation among vascular specialists is the treatment of a totally occluded, 15-cm-long, moderately calcified superficial femoral artery (SFA). The SFA is one the most commonly affected vessels ...