Surgical Technique and Peripheral Artery Disease

Invasive treatment for patients with peripheral artery disease (PAD) has changed dramatically. Medicare claims data from 1996 to 2006 reveal an almost doubling of lower-extremity vascular procedures: The use of endovascular repair increased >3-fold, bypass surgery decreased 42%, and the amputation rate decreased by 29%.1 For patients admitted to hospital for PAD between 1996 and 2005, the likelihood of undergoing surgery decreased from 34.5% to 26.3%.2 Although the rate of bypass is decreasing, surgery remains an important component in the armamentarium for treating patients with advanced vascular disease. Surgical revascularization is indicated in patients with acceptable surgical risk who require a more durable repair, in those with lesions technically unsuitable for endovascular repair, and in patients who experienced failure of endovascular repair.Despite significant increases in patient morbidity, surgical bypass has become safer over the past 2 decades. Nationally, mortality after surgical bypass decreased from 7% to 4% from the 1980s to mid-1990s. From 1998 to 2003, mortality for open and combined procedures stabilized at 3% to 4%.3 Data from the National Inpatient Survey comparing outcomes in 1998 and 2007 show significant reductions in complication rates across all categories except infection.4 Several factors may account for improved outcomes: a shift to endovascular therapy or “limited” open surgery to achieve revascularization in high-risk patients; better patient selection; more effective medication regimens consisting of a statin, an antiplatelet agent, and β-blocker; and improved intraoperative care and postoperative management.This review examines the risk of adverse events after vascular surgery, identifies strategies for determining and decreasing cardiac risk, and describes contemporary surgical approaches to treating patients with PAD.Patients with symptomatic PAD frequently have concomitant cerebrovascular or coronary artery disease (CAD) that places them at high risk for adverse cardiovascular outcomes after surgery. Direct reconstruction for aortoiliofemoral disease is …