The following are 10 points to remember about surgical intervention for peripheral arterial disease:

1. Revascularization of the limb plays a central role in the management of symptomatic peripheral arterial disease (PAD). Although the anatomic pattern of occlusive disease is a major factor in the revascularization strategy, it should be stressed that the physiological state of the patient and the status of the limb primarily determines the appropriateness and urgency of intervention for PAD.
2. Concomitant with advances in the pathogenesis, genetics, and medical management of PAD during the last 20 years, there has been an ongoing evolution of revascularization options.
3. The increasing application of endovascular techniques has resulted in dramatic changes in practice patterns and has refocused the question of which patients should be offered surgical revascularization. Choosing between open versus endovascular approaches takes into consideration a wide variety of factors, including but not limited to the pattern of occlusive disease, anesthetic risk, severity of comorbid conditions, durability of the intervention, extent of tissue loss, previous failed interventions, or other specific anatomic considerations.
4. Surgical therapy remains a cornerstone of management for advanced PAD, providing versatile and durable solutions to challenging patterns of disease.
5. Although there are little high-quality comparative effectiveness data to guide patient selection, existing evidence suggests that outcomes are dependent on definable patient factors such as distribution of disease, status of the limb, comorbid conditions, and conduit availability.
6. Aortoiliac disease is particularly well suited for endovascular interventions given the excellent durability in larger caliber vessels and the attendant risks of open aortic reconstruction. However, some situations call for open revascularization, such as a concomitant aortic aneurysm, prior failed interventions, or a significant burden of disease (i.e., aortic occlusion).
7. For femoropopliteal disease, technical success for initial treatment can almost always be accomplished with endovascular techniques; however, consideration should be given to the known specific factors that limit durability (lesion length, diameter of vessel, etc.).
8. The choice of revascularization is more complicated in tibioperoneal disease, as most patients with critical limb ischemia have significant comorbidities that translate into shorter life expectancy, and endoluminal interventions in tibioperoneal vessels have poor long-term durability (e.g., <40% primary patency at 1 year).
9. Neointimal hyperplasia is the end result of the prototypic response of blood vessels to injury. An inflammatory response, followed by activation of vascular smooth muscle cells, leads to a proliferative lesion with subsequent elaboration of extracellular matrix and fibrosis. Despite progress in the use of antiproliferative drugs to limit restenosis after endovascular interventions (drug-eluting stents and balloons), there is as yet no proven approach to attenuate neointimal hyperplasia in the surgical setting.
10. Patient-specific factors are critical in selecting the most efficacious and durable outcome, with particular importance placed on comorbid conditions, estimated life expectancy, functional status, pattern of disease, and availability of conduit.

Keywords: Aortic Aneurysm, Cardiac Surgical Procedures, Endovascular Procedures, Extracellular Matrix, Hyperplasia, Muscle, Smooth, Vascular, Neointima, Peripheral Arterial Disease, Vascular Surgical Procedures

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