Lower extremity atherosclerosis is not an isolated disease, but a local manifestation of systemic atherosclerosis in the lower extremities. It is an important evidence to predict the prognosis of patients because they are mostly combined with coronary heart disease, hypertension, diabetes, etc. The main life-threatening diseases are cardiovascular and cerebrovascular diseases. According to statistics, the 5-year mortality rate of patients with intermittent claudication due to atherosclerosis can reach 50%, and that of patients with critical limb ischemia (CLI) is as high as 70%. Such a high mortality rate does not seem to attract sufficient attention from clinicians. Therefore, the real treatment of lower extremity atherosclerosis should not only focus on the improvement of technology, but also on the diagnosis and treatment of systemic concomitant diseases. The choice of surgery should not be based on imaging findings alone, but must be based on a comprehensive consideration of the patient’s clinical symptoms and systemic condition to select reasonable treatment measures. The treatment of patients with intermittent claudication should be drug therapy as the first choice, and when drug therapy is ineffective or the patient’s quality of life is significantly affected, revascularization (surgery or endoluminal therapy) can be considered. That is, the treatment goals for patients with Fontaine m and stage IV are to relieve pain, cure ulcers and infections, save limbs, improve patients’ quality of life and prolong life span. The mastery of treatment indications is mainly based on revascularization, while attention should be paid to the management of systemic comorbidities. Pre-operative assessment is needed: (1) whether the vascular lesion is suitable for revascularization surgery; (2) whether the patient has serious cardiovascular and cerebrovascular diseases and contraindications to surgical treatment. For high-risk patients with severe combined cardiovascular and cerebrovascular diseases, stage I amputation is a reasonable option because their life expectancy is not optimistic. However, it is difficult for most patients to accept it, so it is recommended to perform imaging or CTA to clarify the possibility of revascularization before the possible need for one-stage amputation. Overall, the main indications for lower extremity arterial reconstruction (surgical or endoluminal treatment) should be: (i) severe intermittent claudication; (ii) resting pain; and (iii) ischemic ulceration and gangrene of the extremity. TASC classification and treatment choice The TASC classification is a comprehensive guideline document for the diagnosis and treatment of lower extremity atherosclerotic occlusive disease, which is of great clinical significance. In order to make a reasonable choice between surgical or endoluminal interventions, TASC classifies atherosclerotic occlusions of the main iliac artery and femoral carotid artery into 4 grades according to the morphology of the lesion: “A” grade lesions are limited and have a good expected outcome and should be treated by endoluminal techniques; “B Class “B” lesions are slightly prolonged, but endoluminal therapy is still the mainstay, weighing the risks and expected patency of surgery versus endoluminal therapy; Class “C” lesions have better results with surgical reconstruction, but patients with high-risk factors may try to choose less invasive endoluminal techniques. Class “D” lesions should be treated surgically. For cases where surgical or endoluminal treatment is expected to be the same, endoluminal treatment should be preferred. Evidence-based medical data confirm that endovascular luminal treatment reduces complications and perioperative mortality, is less invasive, has faster recovery, and offers the opportunity for reoperation. However, TASC classification is not the only criterion to guide treatment, and in some cases, the choice needs to be based on the experience of the operator and the treatment conditions. Angioplasty (PTA) vs. Phase I stenting Previously, it was thought that stenting was only indicated for entrapment or elastic retraction after PTA of the lower extremity. However, with the advancement and updating of stent products, stenting has achieved better clinical outcomes than PTA, particularly for severely calcified, occlusive lesions and after subintimal PTA, phase I stenting is significantly better than PTA alone. some studies have found similar outcomes for both iliac artery PTA and stenting, with both achieving a 5-year patency rate of 80% or more. Recent randomized clinical trials have confirmed that stenting of the femoral carotid artery has a higher first-stage patency rate at 1 year than PTA alone. Lower extremity arterial bypass There is evidence that autologous veins have higher patency rates than artificial vessels as bypass material for the inferior inguinal artery, and the saphenous vein can be used as bypass material either inverted or in situ with no difference in patency rates, but there is a problem of limited access to autologous veins. The application of tetrafluoroethylene (PTFE) artificial blood vessel for femoral carotid artery (suprapopliteal) bypass is suitable for patients with poor autologous vein condition or saphenous vein has been removed, and it is generally believed that the 2-year patency rate of PTFE artificial blood vessel for suprapopliteal bypass is 70% to 80%, while the patency rate of infrapopliteal is only 30% to 40%. When a prosthetic vessel needs to be grafted to the infrapopliteal artery, it has been suggested that the arteriovenous fistula can be created by anastomosing the I=/ distal to it to improve patency rates. However, randomized trials have shown that the addition of a distal arteriovenous fistula does not improve patency and is not recommended, whereas the use of a venous patch or cuff in the infrapopliteal artery or distal anastomosis has been considered feasible in some cases, although evidence from controlled trials is lacking. The combination of an artificial vessel distal to the vein to form a composite bypass to the infrapopliteal can increase the 2-year patency rate to more than 50%, so infrapopliteal arterial bypass should be performed with either an autologous vein or a composite bypass. Surgical procedures combined with endovascular treatment Extensive multisegmental atherosclerotic occlusive disease is the main cause of CLI. The traditional treatment for this disease is a series of main iliofemoral N artery bypasses, which has a high long-term patency rate but is more invasive and can lead to increased surgical risk, especially in elderly and high-risk patients. In recent years, the hybrid technique of intraoperative iliac artery stenting combined with femoral N artery bypass has been increasingly used as an important tool for the treatment of multisegmental atherosclerotic occlusive disease. This endoluminal treatment combined with surgical procedures can avoid the huge trauma of serial bypasses requiring open abdomen, reduce the incidence of surgical complications and mortality, and provide treatment opportunities especially for patients with high-risk and severe disease. Treatment of lesions below the N artery The indication for endovascular treatment below the N artery is mainly limb salvage, using special dilating balloons to rapidly re-establish blood flow to the lower extremity by interventional means to gain time for ulcer healing and achieve the purpose of limb salvage. Comparative studies of surgical or endoluminal treatment of infrapopliteal artery lesions are lacking, but there is more clinical evidence recommending endoluminal treatment for infrapopliteal artery lesions. According to the author’s experience and the literature, the technical success rate of infrapopliteal arterioplasty can reach more than 90%. Despite the high restenosis rate of infrapopliteal arterioplasty, restenosis is a gradual process, and with the formation of restenosis, collateral circulation is gradually established and compensated. Also, failure of PTA does not affect subsequent bypass surgery.
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