Revascularization Strategy for PAD/CLTI: Endovascular, Open, Hybrid, Conduit, and Device Choice

40.1Definition and presentation

Chronic limb-threatening ischemia (CLTI) defines an advanced stage of peripheral artery disease presenting with ischemic rest pain, tissue loss, or infection requiring intervention. Objective hemodynamic criteria support the diagnosis and drive the WIfI ischemia grade: with ischemic rest pain, an ankle pressure below 50 mmHg or a toe pressure below 30 mmHg; with tissue loss, an ankle pressure below 70 mmHg, a toe pressure below 50 mmHg, or a transcutaneous oxygen tension below 30 mmHg GVG 2019. Revascularization is pursued not merely to improve angiographic appearance, but to achieve durable perfusion sufficient to support wound healing, alleviate ischemic pain, and prevent major amputation. In diabetic patients, revascularization is coordinated alongside source control of infection, ulcer debridement, offloading, and cardiovascular risk management rather than executed as an isolated procedure AHA 2023 · IWGDF/ESVS/SVS 2023.

40.2Stratification and anatomic staging

Clinical stratification integrates patient operative risk, the severity of limb threat, and anatomic complexity. The Wound, Ischemia, and foot Infection (WIfI) classification stages the limb threat, clarifying the relative contributions of ischemia and infection. The Global Limb Anatomic Staging System (GLASS) grades the complexity of the target arterial pathway GVG 2019. WIfI grades Wound, Ischemia, and foot Infection each from 0 to 3 and combines them into clinical stages 1 through 4 that estimate 1-year amputation risk and the expected benefit of revascularization. GLASS assigns a femoropopliteal grade and an infrapopliteal grade along the preferred target artery pathway to yield an overall stage I to III; stage III marks high anticipated immediate technical failure and under 50% limb-based patency at 1 year with an endovascular-first approach, tilting the decision toward bypass in a patient who can tolerate it. Preprocedural mapping is required to establish the presence and quality of an adequate single-segment great saphenous vein, which serves as a primary determinant for surgical bypass selection ACC/AHA 2024 · BEST-CLI · 2022.

40.3Treatment decision and revascularization strategy

All patients receive baseline medical therapy consisting of blood-pressure control, a statin, and smoking cessation, integrated with comprehensive diabetic foot care IWGDF/ESVS/SVS 2023 · SVS 2016. The modality choice is subsequently governed by conduit availability, anatomic target, and surgical risk.

The stepwise decision logic for intervention proceeds as follows:

1. Establish the baseline medical and wound-care regimen, addressing acute infection via debridement and source control first.
2. Determine whether the expected limb benefit justifies procedural intervention, reserving the no-intervention pathway for prohibitive operative risk or unsalvageable limbs.
3. Assess conduit availability via vein mapping; an adequate single-segment great saphenous vein in a patient with acceptable risk favors an open bypass-first approach.
4. Opt for an endovascular-first approach when usable vein is absent, operative risk is high, or the intervention primarily involves infrapopliteal targets.

40.4Conduit and device selection

Autogenous vein provides superior outcomes compared to prosthetic conduits for lower-extremity bypass in CLTI, reinforcing the necessity of preoperative vein mapping Prosthetic Conduits · 2025. In the femoropopliteal segment, drug-coated balloons confer a substantial patency advantage over standard percutaneous transluminal angioplasty.

40.5Post-revascularization management and surveillance

Dual-pathway antithrombotic therapy is established for failure prevention following revascularization. Low-dose rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin reduces the composite of acute limb ischemia, major amputation, myocardial infarction, ischemic stroke, or cardiovascular death at 3 years compared with aspirin alone (17.3% vs 19.9%), at the cost of higher TIMI major bleeding (2.65% vs 1.87%, HR 1.43) VOYAGER PAD · 2020. This regimen is recommended following both surgical and endovascular lower-extremity revascularization when bleeding risk is acceptable ACC/AHA PAD 2024.

Routine duplex surveillance is standard following vein bypass to identify graft-threatening lesions prior to thrombosis. Surveillance pairs interval history, pulse and ABI check, and duplex within the first postoperative month, then at 3, 6, and 12 months through the first year and annually thereafter GVG 2019. A graft-threatening high-grade (>70%) lesion is flagged by a focal peak systolic velocity above 300 cm/s with a velocity ratio over 3.5 across the stenosis, or by a uniformly low graft-flow velocity below 45 cm/s; either finding warrants preemptive revision before the graft thromboses. Early and 1-year graft event rates observed in the PREVENT III cohort serve as the baseline expectation for contemporary surveillance planning PREVENT III · 2006. Following endovascular procedures, reintervention is triggered by clinical failure, such as recurrent ischemic symptoms or a stalled wound-healing trajectory, rather than by asymptomatic restenosis alone.

40.6Areas of controversy

The safety of paclitaxel-coated femoropopliteal devices remains contested following a 2018 meta-analysis that reported a late mortality dose-response signal (5-year risk ratio 1.93) Katsanos 2018. Subsequent evidence, including the pragmatic SWEDEPAD 1 registry trial and a 2026 updated meta-analysis, has found no significant difference in major amputation or all-cause mortality through 5 years Paclitaxel Safety Update 2026 · SWEDEPAD 1 (2025).

The optimal modality for isolated infrapopliteal disease is also actively debated. The survival and limb advantage of open bypass in BEST-CLI Cohort 1 contrasts with the lower major amputation or death rate observed with an endovascular-first approach in BASIL-2 BASIL-2 (2023) · BEST-CLI · 2022. In BEST-CLI Cohort 1 the composite of major adverse limb event or death was 42.6% with bypass-first versus 57.4% with endovascular-first, a 14.8 percentage-point difference (hazard ratio 0.68). BASIL-2 favored endovascular-first for amputation-free survival (adjusted hazard ratio 1.35, P=0.037). Retrospective registry data report lower 5-year mortality with bypass for below-knee targets, leaving the decision highly dependent on local center expertise and patient anatomy VQI Registry 2023.

Finally, the routine use of distal embolic protection in complex endovascular cases is not uniformly standardized. Flow-controlled anti-embolic techniques using proximal antegrade flow arrest are described to reduce distal emboli, though broad comparative-effectiveness evidence against standard interventions remains limited FCAT 2026.