Appropriate Use Criteria on PAD Intervention Favors Endovascular Tx

Several societies joined in releasing guidance for interventions in peripheral artery disease (PAD), pending more evidence to back formal recommendations in the future.

Summarizing the Appropriate Use Criteria (AUC), Steven Bailey, MD, chair of the writing group, and collaborators wrote:

“After considering factors such as symptom burden, anatomic distribution, and ischemic burden, the rating panel determined that both endovascular and surgical approaches are Appropriate in clinical scenarios involving concomitant tissue loss or end organ compromise. There was a tendency to select endovascular approaches in these scenarios, particularly in anatomic distributions below the knee and where prior endovascular or surgical revascularization has been performed.

For example, endovascular treatment was rated by a panel as “appropriate” for symptomatic in-stent restenosis and “may be appropriate” for asymptomatic cases. Surgery, on the other hand, was deemed “may be appropriate” and “rarely appropriate,” respectively.

The recommendations were published online in the Journal of the American College of Cardiology and endorsed by the American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, and Society for Vascular Medicine.

Other guidance offered for clinical scenarios include:

• Critical limb ischemia: appropriate to intervene via endovascular or surgical treatment
• Lesions in the superficial femoral artery or popliteal artery: drug-coated balloons, bare metal stents, and drug-eluting stents are generally appropriate
• Below-the-knee lesions: plain balloon angioplasty is appropriate and other devices may be appropriate, with the exception of covered stents, which were deemed rarely appropriate

“Although PAI [peripheral artery intervention] has been the subject of prior single-society papers, this is the first multisocietal effort on the topic,” according to the group.

“This was more challenging than the development of AUCs on other topics mainly because supporting literature is not as developed or robust as for other topics covered,” they noted. “The study of PAD is continuously changing as new devices, techniques, and approaches are developed, and a regular review of these clinical scenarios will be imperative in moving the field forward.”