Page 8 - Carotid and peripheral vascular interventions textbook

CAROTID AND PERIPHERAL VASCULAR INTERVENTIONS: STEP-BY-STEP

with an exercise program to augment collateral f ow rather either approach depending on factors such as physician
than undergoing intervention therapy for femoropopliteal experience, the patient status, and technical resources
disease. Fewer than one-fourth of these patients will available. In patients with comorbidities and high risk
progress to the stage of developing more disabling for surgery, an endovascular approach should be applied
symptoms or a threatened limb, which mandate therapy. irrespective of anatomy. Patients with rest pain or
Once revascularization is indicated, deciding disabling claudication and having multiple levels of disease
whether to choose a surgical or an endovascular may receive a staged approach with an endovascular-
approach is based on the TASC II recommendation. f rst approach as one stage. In-f ow disease may be
The TransAtlantic Inter-Society Consensus (TASC) corrected f rst, and out-f ow disease may be corrected
(16) has classif ed femoropopliteal disease into four in a staged manner, when needed. Patients whose veins
types (i.e., A-D) based on the number of lesions, have been harvested for prior coronary artery bypass
lesion length, and the presence of stenosis or occlusion surgery without suitable remaining autologous veins to
(Fig. 12-5). The classif cation has def ned lesion length apply for conduits, should be considered for endovascular
as follows: focal (<10cm), intermediate (10-20 cm), revascularization.
and diffuse (>20 cm). This classif cation also proposed For non-operable severe claudication patients
treatment strategies and recommendations for the because of unfavorable anatomy or medical comorbidities,
management of the lesions. Type A and type B are advised only medication treatment is appropriate. Amputation
for initial endovascular revascularization, type D lesions can ameliorate ischemic rest pain and is required
advised for surgical revascularization and type C for when gangrene and signif cant tissue loss is present.

Figure 12-5. The TransAtlantic InterSociety Consensus (TASC) II classif cation for the management of femoropopliteal lesions.
(Redrawn from Jaff MR, White CJ, Hiatt WR, et al. An update on methods for revascularization and expansion of the TASC lesion classif cation
to include below-the-knee arteries. J Endovasc Ther. 2015;20:465-478, with permission from SAGE Publications.)

TASC A lesions
• Single stenosis <10 cm in length
• Single occlusion <5 cm in length

TASC B lesions
• Multiple lesions (stenoses or occlusions), each
<5 cm
• Single stenosis or occlusion <15 cm not
involving the infrageniculate popliteal artery
• Heavily calcified occlusion <5 cm in length
336 • Single popliteal stenosis

TASC C lesions
• Multiple stenoses or occlusion totaling >15 cm
with or without heavy calcification
• Recurrent stenoses or occlusions after failing
treatment

TASC D lesions
• Chronic total occlusions of CFA or SFA (>20
cm, involving the popliteal artery)
• Chronic total occlusion of popliteal artery and
proximal trifurcation vessels

CFA, common femoral artery; SFA, superf cial femoral artery.