Is angioplasty preferable over surgery?

If feasible, angioplasty is recommended because it has a lower complication rate, is less expensive, and does not preclude future surgery.

What are the appropriate lesions for angioplasty?

Angioplasty is most effective for localized disease, especially of the iliac and femoral arteries. Extensive disease (lesion 10 cm in length) or disease at multiple sites is often best treated surgically. These decisions are best made in consultation with a vascular surgeon and interventional radiologist.

How do you evaluate operative risk in a patient scheduled for vascular surgery?

The major concern for PVD patients is evaluating risk of a perioperative cardiac complication. This is the most common cause of mortality with vascular surgery because approximately one-half of such patients have significant coronary artery disease. Many of these patients do not have angina and cannot exercise because of their PVD.

The proper preoperative evaluation of the patient for vascular surgery has been extensively studied but remains controversial. One approach is based on the clinical evaluation and begins with the assessment of the patient for the following risk factors: age 70, diabetes, previous myocardial infarction, angina, or history of ventricular ectopy.

If the patient has no risk factors and can walk approximately two blocks, then he or she is at low risk and can proceed to surgery.

If the patient has three or more risk factors, then he or she is at high risk for surgery. Consideration should be given to performing a lower risk procedure, such as axillofemoral bypass or angioplasty, or foregoing surgery. Coronary angiography should also be considered, but the risk of any intervention based on coronary angiography must be considered in addition to the risk of the vascular surgery. Invasive monitoring with Swan-Ganz and arterial catheters, perioperative use of beta blockers and nitrates, and careful monitoring for ST depression perioperatively (up to 48 hours postoperatively) may decrease the risk of cardiac complications.

If the patient has one or two risk factors or is unable to walk two blocks, then he or she is at intermediate risk. Dipyridamole-thallium imaging should be done. If the study is negative, the patient is at low risk and can proceed to surgery. If the study is positive, then the patient is at high risk and is approached as above.

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