2018 Appropriate Use Criteria for Peripheral Artery Intervention

Bailey SR, Beckman JA, Dao TD, et al.
ACC/AHA/SCAI/SIR/SVM 2018 Appropriate Use Criteria for Peripheral Artery Intervention: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, and Society for Vascular Medicine. J Am Coll Cardiol 2018;Dec 17:[Epub ahead of print].

The following are key points to remember from the 2018 ACC/AHA/SCAI/SVM/SIR Appropriate Use Criteria for Peripheral Artery Intervention:

  1. The patient scenarios are not intended to be comprehensive, but instead to address scenarios common in clinical practice with associated assumptions and definitions. A total of 45 clinical scenarios with up to six intervention options each were developed. A separate, independent rating panel then evaluated each indication using a scoring scale from 1-9, with scores of 7-9 corresponding to “appropriate,” scores from 4-6 corresponding to “may be appropriate,” and scores of 1-3 corresponding to “rarely appropriate.”
  2. An appropriate treatment is one where the potential survival or health outcomes benefits exceed the potential negative consequences of the treatment strategy. “May be appropriate” suggests that a treatment should be contingent on individual patient circumstances and shared decision making based on patient and provider preferences. Multiple therapies may be required in an individual patient, and “rarely appropriate” is not equivalent to “inappropriate” or “never appropriate.”
  3. Emphasis was placed on adhering to and exhausting medical therapy to achieve maximal benefit in situations where symptom management was desired or incidental disease was discovered. Other factors that were considered included symptom burden, anatomic distribution, and ischemic burden.
  4. Factors to consider when evaluating appropriateness for intervention for hemodynamically significant renal artery stenosis include: the indication (i.e., chronic kidney disease, hypertension, cardiac destabilization, or incidentally discovered), the severity of symptoms (including the rapidity of decline in renal function and/or response to antihypertensive medications), and whether renal artery stenosis is unilateral versus bilateral or affecting a solitary viable kidney.
  5. Factors to consider when evaluating appropriateness of lower extremity intervention for claudication include: previous medical therapy, lesion location (aortoiliac, femoral-popliteal, or below knee), and whether the lesion is stenotic versus a chronic total occlusion.
  6. Both endovascular and surgical treatment for critical limb ischemia were considered "appropriate" by the rating panel for all anatomic subsets (aortoiliac, femoral-popliteal, or below knee). Continuation or intensification of medical therapy is not considered a reasonable treatment in patients with this diagnosis.
  7. Appropriate peripheral procedures for asymptomatic disease were based on expert consensus and included specific scenarios where arterial access would facilitate other necessary cardiovascular procedures, some of which may be life-saving (e.g., transcatheter aortic valve replacement, hemodynamic support devices, etc.).
  8. Factors that should be considered when choosing between endovascular treatment options include the anatomic location and length of the lesion, and presence of discrete/focal stenosis, diffuse stenosis, or chronic total occlusion.
  9. Factors that should be considered when evaluating appropriateness of secondary lower extremity intervention for in-stent restenosis or bypass failure include presence of diffuse versus focal stenosis, whether the bypass is stenotic versus thrombosed, and whether the bypass graft is a vein or prosthetic conduit.

Keywords: Antihypertensive Agents, Asymptomatic Diseases, Cardiology Interventions, Constriction, Pathologic, Coronary Occlusion, Endovascular Procedures, Hemodynamics, Hypertension, Ischemia, Peripheral Vascular Diseases, Renal Artery Obstruction, Renal Insufficiency, Chronic, Secondary Prevention, Stents, Transcatheter Aortic Valve Replacement, Vascular Diseases

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