In an article published in the Journal of the American College of Cardiology, the American College of Cardiology (ACC), in collaboration with the American Heart Association (AHA)/Society for Cardiovascular Angiography and Interventions/Society of Interventional Radiology/Society for Vascular Medicine, released a new report on appropriate use criteria for peripheral artery intervention.
In their report, the multiorganization committee provided a detailed account of peripheral artery intervention appropriate use criteria by indication, including renal artery stenosis (RAS), lower extremity disease, critical limb ischemia, and asymptomatic artery disease, in an effort to guide interventional cardiologists, as well as clinicians who are in the position to refer patients for revascularization.
Appropriate Use Criteria for RAS
The randomized CORAL trial (Stenting and Medical Therapy for Atherosclerotic Renal-Artery Stenosis) partly provided expert consensus for appropriate use criteria for RAS. The CORAL trial recommended best medical therapy as the first treatment strategy for a patient with a new diagnosis. Optimal medical therapy, as defined by both the ACC/AHA 2005 Guidelines for the Management of Patients with Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) and the 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease, should comprise 3 antihypertensive drugs, of which 1 should be a diuretic.
Renal artery stenting can be considered in patients who have both hemodynamically significant RAS and intolerance to the 3 antihypertensive agents. In addition, renal stenting may be appropriate in patients “with an accelerating decline in renal function and bilateral or solitary significant RAS (e.g., severe RAS [≥70% diameter stenosis]) or moderate RAS (50% to 69% diameter stenosis)] with translesional gradients that exceed threshold measurements,” the writing committee stated. Conversely, renal stenting is rarely appropriate, according to the committee, in patients with incidentally discovered RAS.
These patients should be treated with optimal medical therapy as the initial treatment strategy.
Appropriate Use Criteria for Lower Extremity Disease
Based on the 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease, expert consensus was revascularization for patients with intermittent claudication should be considered only after excluding nonvascular causes of limb symptoms.
In the new statement by the ACC and collaborating organizations, the selection of candidates who may likely experience benefit from revascularization should be based on evaluations that demonstrate substantial flow limitation with exercise ankle-brachial index testing, segmental Doppler pressures, and/or measurement of translesional gradients. Patients who continue to experience “lifestyle-limiting claudication” despite noninvasive approaches should undergo arterial revascularization, the committee wrote.
Appropriate Use Criteria for Critical Limb Ischemia
In patients with critical limb ischemia and limb loss, surgical or endovascular revascularization is essential and appropriate for reducing morbidity and mortality, the report recommended.
Appropriate Use Criteria for Asymptomatic Artery Disease
In the instance where peripheral artery interventions may be necessary to access the arteries before other necessary procedures, endovascular treatment is considered appropriate. Endovascular revascularization is particularly appropriate in clinical situations in which there exists a need for access for coronary intervention, hemodynamic support, and/or large vascular or valvular intervention. Surgical access may also be appropriate for coronary interventions. “It is emphasized that these revascularizations are not undertaken for the management of [peripheral artery disease], per se,” the committee wrote, “but to facilitate care that is deemed necessary and is dependent upon suitable vascular access.”
The ACC/AHA/Society for Cardiovascular Angiography and Interventions/Society of Interventional Radiology/Society for Vascular Medicine collaboration published their paper with the intent to support clinical decision making, especially in regard to the appropriateness of care that’s delivered to the individual patient. “Ideally, this document will serve as an educational and quality improvement tool for addressing Rarely Appropriate revascularizations either performed or referred by individual clinicians,” the committee concluded. “Future studies to evaluate implementation of these [appropriate use criteria] in clinical settings will be useful not only in identifying any deficiencies in the current document, but also in defining patterns of care for individual practitioners and understanding variations in the delivery of care.”
Bailey SR, Beckman JA, Dao TD, et al. ACC/AHA/SCAI/SIR/SVM 2018 Appropriate use criteria for peripheral artery intervention. JACC. 2018. doi: 10.1016/j.jacc.2018.10.002