Surgical Revascularization in Peripheral Arterial Disease

Transcript: Deepak L. Bhatt, MD, MPH: I’ll turn back to the surgical arena here, Matt. What advances have there been in revascularization? We talked about drug-coated balloons and drug-eluting stents. But what is there in terms of surgical revascularization conduits? Has there been anything exciting going on? I don’t know if you saw the RADIAL[Radial Artery Database International Alliance] meta-analysis just presented as a late breaker at ACC [American College of Cardiology meeting] by Mario Gaudino—a cardiac surgeon from Weill Cornell Medicine in New York, New York—showing better outcomes with radial conduits after coronary artery bypass grafting versus saphenous vein grafting. While post hoc, there was even a lower rate of all-cause mortality. It was quite a provocative finding. Have we made any advances in terms of what type of conduit we’re using for lower limb revascularization?

Matthew T. Menard, MD: Great question, Deepak. Historically, one of the criticisms of the surgical world is that we haven’t really kept pace and we haven’t really innovated as the endovascular world is busy with new iterations of devices. In the endovascular world, we talked about drug elution. There’s a whole slew of atherectomy devices that we are continually trying to improve and get right. There is something called lithoplasty, which uses ultrasonic technology to break up significantly calcified plaque. That’s gaining traction and is particularly effective in the iliac bed and lower down as well. That’s just coming on to the market. On the surgical side of things, I think we have ample data that get repeated time and again showing that the best conduit is a single segment of saphenous vein from either leg. That’s always been associated with the best outcomes.

Once that has been used up in the heart or in prior leg revascularization, other autogenous venous options are available. We could use a good segment of cephalic vein, basilic vein, or even brachial vein if needed, as well as the short saphenous veins. These are all options. If one wants to go outside of the venous options bucket, we can use prosthetics. Over the years, the prosthetic technology has definitely improved. We now have options that are lined with heparin. There’s something magical about 6 mm. We don’t have any conduits that are shorter than 6 mm, and therefore using a prosthetic conduit below the knee is still a challenge and the results are not particularly good.

There are two other options that we use occasionally. We could use cadaveric vein. It does not have a very good long-term patency rate, but in certain circumstances, that’s an option. For the first time, we can use cadaveric artery, which is very early on in experience but promising. It’s still an area that needs a lot of development and hasn’t moved too far over the years, but it’s definitely better than 20 years ago.

Deepak L. Bhatt, MD, MPH: I think there’s been a lot of surgical innovation. The cadaveric arteries in particular could be really promising, given that arterial conduits seem to behave better, at least in the coronary bypasses. I’m looking forward to seeing all those data eventually.

Transcript Edited for Clarity