Appropriate use criteria give edge to endovascular therapies for treating PAD
Several professional societies collaborated to release appropriate use criteria for peripheral artery intervention (PAI), a field the authors acknowledged still has an emerging evidence base that is likely to change these recommendations in the future.
“Although PAI has been the subject of prior single-society papers, this is the first multisocietal effort on the topic,” a group chaired by Steven R. Bailey, MD, wrote in the Journal of the American College of Cardiology. Participating organizations included the American College of Cardiology, the American Heart Association, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology and Society for Vascular Medicine.
With the caveat that guideline-directed medical therapy be considered as a first-line option for symptom management in most patients with peripheral artery disease (PAD), the rating panel tended to favor endovascular treatment over surgical treatment in cases when more intensive interventions were necessary.
“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,” Bailey et al. wrote. “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, both surgical and endovascular techniques were considered “appropriate” for the treatment of critical limb ischemia. But for in-stent restenosis, endovascular therapy was deemed appropriate for symptomatic cases, while surgical treatment was downgraded to “may be appropriate.” For asymptomatic instances of in-stent restenosis, endovascular treatment was in the “may be appropriate” category while surgical intervention was rated as “rarely appropriate.”
The writing group crafted 45 common clinical scenarios and then a separate panel ranked up to six intervention options per scenario based on their level of appropriateness for that situation. The nine-point scale was divided into three categories: appropriate (score of 7 to 9), may be appropriate (score of 4 to 6) and rarely appropriate (score of 1 to 3).
For below-the-knee lesions, plain balloon angioplasty was considered appropriate for both short and long lesions with scores of 7. Bare-metal and drug-eluting stents, atherectomy and drug-coated balloons were dubbed may be appropriate, while covered stents were rated with a rarely appropriate designation. Drug-coated balloons, bare-metal stents and drug-eluting stents were all given “appropriate” scores of 7 for treating femoropopliteal lesions.
Still, Bailey and colleagues cautioned clinicians against comparing the scores head-to-head, noting each treatment option should be “considered on its own merits.” Operator experience with specific techniques, patient preference, clinical judgment and unique patient characteristics may also inform which treatment is best in a given scenario, they said.
“Future studies to evaluate implementation of these (appropriate use criteria) in clinical settings will be useful not only in identifying any deficiencies in the current document, but also in defining patterns of care for individual practitioners and understanding variations in the delivery of care,” the authors wrote. “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.”
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.