Are infra-inguinal angioplasty and surgery comparable?

PURPOSE

The indications for Percutaneous Transluminal Angioplasty (PTA) in the treatment of infrainguinal peripheral arterial occlusive disease are controversial. We have attempted to provide up to date data and compare the techniques of both conservative management and surgical approaches. REVIEW UNDERTAKEN: A literature review was undertaken after using the Medline database and an Ovid-based search engine on the Internet. The most recent reviews, meta-analyses and studies contributing the highest levels of evidence available were reviewed and cross-referenced.

EVIDENCE

The suitability of femoropopliteal disease for treatment with PTA depends on the severity of the patient's presentation and the extent of disease. Given the optimal pattern of disease, PTA can have equivalent initial technical success and medium term patency rates with the obvious advantages of lower in-hospital mortality, shorter hospital stay and lower inpatient costs. However, PTA has a higher secondary procedure rate and this negates many of the perceived benefits. In critical limb ischaemia (CLI) many lesions are unsuitable for PTA and require surgical procedures for limb salvage. Patients selected for the trials are often not from strictly stratified groups. These selection biases often interfere with direct comparison between the two techniques in all but a few prospective randomised-control studies.

CONCLUSIONS

There is still a lack of high level evidence to draw a consensus on the place for PTA in femoropopliteal occlusive disease. It is apparent that the most appropriate lesions make up only a small percentage of patient presentations. When limb salvage is required it is often a situation only amenable to surgical bypass and this is why the two techniques are not easily comparable.