Vascular Surgery in North America: Current Perspectives in Peripheral Arterial Disease

Abstract

Over the course of the past several decades treatment of peripheral arterial disease (PAD) has changed in North America. Advent of new technology has led to a shift in the initial treatment of both intermittent claudication (IC) and critical limb ischemia (CLI) towards endovascular intervention—including percutaneous balloon angioplasty, stenting and atherectomy. Overall increase in interventions for PAD correlates with a surge in the number of endovascular procedures performed by interventional cardiologists, interventional radiologists and vascular surgeons. Changes in reimbursement patterns has led to a trend towards these procedures being performed in an outpatient or office setting. Although this has resulted in fewer cases being performed in the hospital potential cost saving has been offset by increased use of the more highly reimbursed atherectomy in the outpatient setting. With regard to recommendations on how to treat these patients the Society of Vascular Surgery (SVS) has recently published guidelines for the treatment of IC emphasizing the importance of initial conservative medical management. There continues to be significant equipoise in the treatment of CLI across North America leading to tremendous variability in the use of open surgery and endovascular therapy. Guidance for the future treatment of CLI is partially dependent upon the Best Endovascular versus Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial, a randomized, controlled trial currently accruing patients in North America.