New guidance for clinicians in determining the role of different revascularization options for patients with peripheral artery disease (PAD) was released Dec. 17 and published in the Journal of the American College of Cardiology. The document, 2018 Appropriate Use Criteria for Peripheral Artery Intervention, was developed by the ACC, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology and Society for Vascular Medicine.

The writing group, led by Steven R. Bailey, MD, FACC, used published guidelines, trial data, and expert opinion to identify 45 common, clinical scenarios within the field of PAD.  An independent rating panel then scored the scenarios to rank each as "appropriate," "may be appropriate," or "rarely appropriate." The indication topics include renal artery stenosis, lower extremity disease, critical limb ischemia, asymptomatic artery disease, options for endovascular treatment when deemed appropriate or may be appropriate, and secondary treatment options for lower-extremity disease.

Of note, the rating panel deemed patients with cardiac destabilization such as recurrent heart failure or uncontrolled unstable angina despite maximal medical therapy and severe renal artery stenosis as "may be appropriate" for renal stenting. For patients with PAD and intermittent claudication who have already completed a guideline-directed medical therapy and structured exercise strategy, surgical or endovascular randomization will depend on the risk-benefit ratio unique to each patient. In patients with critical limb ischemia, both endovascular and surgical revascularization "is critical for the reduction of high morbidity and mortality rates."

The document also points out several areas where research is lacking. In the asymptomatic artery disease category, the writing group explains that there is no published research, so the recommendations represent a consensus of expert opinions. In addition, "further comparative investigation is recommended into the risks and benefits of atherectomy in femoral popliteal lesions." Research is also limited in comparing treatment modalities for in-stent stenosis, venous graft failures, and arterial graft failures.

The authors explain that although AUC are evidence-based, they are "not a replacement for clinical judgement and practice experience in determining the best options for individual patients." According to Bailey, "AUC are designed to provide an assessment of care decisions in aggregated patient populations, not to determine reimbursement or coverage decisions for the treatment of individual patients."

The authors conclude that moving forward, "future studies to evaluate implementation of these AUC in clinical settings will be useful." As the field of PAD is continuously evolving, they add that a regular review of these scenarios will be necessary. "We expect this AUC to undergo frequent review and updates as new evidence becomes available," Bailey adds.

Keywords: Extremities, Ischemia, Intermittent Claudication, Critical Illness, Endovascular Procedures, Blood Vessel Prosthesis, Peripheral Arterial Disease, Peripheral Vascular Diseases, Therapeutics, Renal Artery Obstruction, Vascular Surgical Procedures, Veins, Radiology, Interventional, Constriction, Pathologic, Atherectomy, Lower Extremity, Risk Assessment, Arteries, Angiography, Stents

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