01Purpose and principlesWhat the treatment does and how it fits into care.
Revascularisation seeks a clinical benefit: longer useful walking in selected claudication, relief of ischaemic rest pain, wound healing, infection control or preservation of a functional limb in CLTI. A stenosis on imaging is neither a symptom nor an automatic indication. Before intervening, confirm the syndrome, objective PAD, effect on life or tissue, response to best medical treatment, procedural fitness, life expectancy and the outcome the person values. Discuss the realistic chance and duration of benefit, reintervention burden and possibility that an apparently successful procedure may not restore function.
Angioplasty passes a wire across disease and dilates it with a balloon. It is less invasive than bypass and often allows rapid recovery, but technical success can be limited by inability to cross the lesion, recoil, flow-limiting dissection, residual stenosis, calcification or distal embolisation; later restenosis or occlusion may require surveillance and reintervention. A stent provides scaffolding or a covered channel. Device choice depends on arterial segment and lesion rather than a universal stent rule. NICE CG147 retains 2012 recommendations against routine primary stenting for most aorto-iliac stenoses and femoropopliteal disease, while ESVS 2024 gives more segment-specific contemporary recommendations, such as balloon angioplasty with selective stenting for iliac stenosis and selective drug-eluting stenting after suboptimal femoropopliteal angioplasty. Apply the current vascular service’s device governance and multidisciplinary interpretation rather than mixing recommendations across eras.
Bypass creates an alternative route from adequate inflow to a distal artery beyond the disease. It can provide durable flow across long or complex occlusive segments, but requires an operation, suitable inflow and outflow, a conduit, physiological reserve and wound-healing capacity. Autologous vein is preferred whenever possible for infrainguinal bypass. Map the great and small saphenous veins and alternatives before surgery. Prosthetic grafts may be used in selected settings, but distal target, infection risk and anticipated patency alter the balance.
The treatment choice differs by presentation. For intermittent claudication, NICE requires reinforced risk-factor advice, an unsatisfactory response to supervised exercise and suitable anatomy before angioplasty, and restricts bypass to severe lifestyle limitation when angioplasty is unsuccessful or unsuitable. ESVS similarly demands disabling symptoms despite exercise-based best treatment and careful consideration of comorbidity, procedural risk and expected durability. For CLTI, the Global Vascular Guidelines use PLAN: Patient risk, Limb severity and ANatomic complexity, supported by WIfI, GLASS and vein availability. High-risk patients or less complex disease may favour endovascular treatment; average-risk patients with advanced limb threat, high anatomical complexity and good vein may gain from bypass. These are decision structures, not automatic algorithms.
Key points
- Treat the patient’s syndrome and goals, not a percentage stenosis or an attractive technical image.
- Stable claudication usually needs risk reduction and supervised exercise before invasive treatment is justified.
- NICE offers angioplasty for claudication only after non-invasive treatment is unsatisfactory and imaging confirms suitability.
- NICE reserves bypass for severe lifestyle-limiting claudication when angioplasty has failed or is unsuitable and bypass anatomy is appropriate.
- For limb-threatening ischaemia, choose endovascular or bypass treatment after multidisciplinary review of patient risk, limb severity, anatomy and vein availability.
- Balloon angioplasty enlarges the lumen; stents scaffold recoil, dissection or selected lesions but introduce fracture, restenosis and thrombosis considerations.
- Use autologous vein whenever possible for infrainguinal bypass because conduit quality materially affects durability.
- Surveillance must link symptoms, wounds, pulses and haemodynamics; a patent reconstruction without clinical benefit is not success.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Disabling symptoms persist despite risk-factor care and supervised exercise, anatomy is suitable, and the person accepts procedural and reintervention risk.
Objective ischaemia accompanies rest pain or tissue loss, the limb remains reconstructible, and meaningful healing or function is achievable.
Frailty, severe cardiac, pulmonary or kidney disease, limited life expectancy or hostile operative fields may shift strategy or support palliation.
Good-quality autologous vein increases the feasibility and expected durability of infrainguinal bypass and should be mapped before choice.
New pain, pulse loss, sensory change, weakness or wound deterioration after treatment suggests thrombosis, embolisation or inadequate perfusion.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Clinical and physiological confirmationFirst step - Why
- Confirm that PAD explains symptoms or tissue threat before selecting anatomy-driven treatment.
- Interpretation and limitations
- Integrate symptom pattern, pulse examination, Doppler waveforms, ankle pressure and toe pressure where needed. Discordant or calcified-vessel results require vascular-laboratory interpretation rather than automatic intervention.
- 02
Duplex and cross-sectional arterial imaging - Why
- Define inflow, lesion morphology, outflow and target zones for the proposed reconstruction.
- Interpretation and limitations
- NICE uses duplex first when revascularisation is considered, then contrast MRA or CTA as appropriate. Imaging must be adequate through the foot in CLTI, and stenosis severity alone does not establish indication.
- 03
WIfI and GLASS assessment - Why
- Structure limb severity and anatomical complexity in chronic limb-threatening ischaemia.
- Interpretation and limitations
- WIfI grades wound, objective ischaemia and foot infection; GLASS describes a preferred target arterial path and expected endovascular complexity. Use them with patient risk and goals, not as stand-alone procedure orders.
- 04
Autologous vein mapping - Why
- Identify a usable conduit before an infrainguinal bypass decision is finalised.
- Interpretation and limitations
- Map ipsilateral great and small saphenous vein and alternatives when needed. Diameter, continuity, previous harvest and thrombosis affect suitability; available vein can shift the open-versus-endovascular balance.
- 05
Cardiopulmonary, renal and anaesthetic assessment - Why
- Estimate peri-procedural harm and identify factors requiring optimisation or a different strategy.
- Interpretation and limitations
- Assess frailty, function, cardiac and respiratory disease, renal function, bleeding, infection and medicines. High risk does not automatically prohibit treatment but changes expected benefit and invasiveness.
- 06
Baseline wound and functional measurement - Why
- Define the clinical outcome against which technical treatment should be judged.
- Interpretation and limitations
- Record walking limitation and patient goal for claudication; in CLTI document pain, wound dimensions, infection, offloading and perfusion so patency is not mistaken for clinical success.
04Treatment approachPreparation, options, escalation and aftercare.
01Management selectionChoose a revascularisation strategyFirst stepPAD causes disabling claudication or limb threat and a procedure may improve a meaningful outcome.+
- 1Confirm the clinical indication, objective ischaemia, patient goal and response to appropriate non-invasive treatment before reviewing the angiogram.
- 2Assess physiological reserve, life expectancy, wound and infection severity, lesion distribution, distal target, conduit and centre capability.
- 3For claudication, favour angioplasty when NICE criteria and anatomy are met; reserve bypass for severe limitation when angioplasty is unsuitable or has failed.
- 4For CLTI, integrate PLAN, WIfI, GLASS and vein availability to select endovascular, open, hybrid, amputation or palliative care through shared decision-making.
- 5Verify success using symptoms, perfusion, wound progress and function, while arranging the reconstruction-specific surveillance plan.
02Endovascular procedurePerform angioplasty with selective adjunctsAn endovascular approach offers an acceptable likelihood of benefit and durability for the target anatomy.+
- 1Plan access, target vessel, device options, contrast limitation, radiation, bailout strategy and post-procedure antithrombotic plan before puncture.
- 2Cross and dilate the lesion while protecting branch vessels and watching for recoil, residual stenosis, dissection, perforation or embolisation.
- 3Use stenting selectively or primarily only where current segment-specific evidence, device approval and service policy support it.
- 4Document completion imaging, distal perfusion and access haemostasis, then monitor for bleeding and acute limb deterioration.
03Open bypassConstruct and protect a durable conduitOpen reconstruction offers an appropriate benefit over endovascular treatment and operative risk is acceptable.+
- 1Confirm inflow, distal target, adequate runoff and mapped conduit, and agree the expected functional or wound-healing goal.
- 2Use autologous vein whenever possible for infrainguinal bypass and handle it without twist, tension or anastomotic defect.
- 3Perform completion assessment and correct a significant technical defect during the index operation when feasible.
- 4Protect the graft through wound care, cardiovascular prevention, prescribed antithrombotic therapy and symptom-linked duplex surveillance.
04Post-procedure emergencyRespond to acute deteriorationPain, pulse, neurology, haemoglobin, access site or systemic observations worsen after revascularisation.+
- 1Reassess limb colour, temperature, capillary return, motor and sensory function and Doppler signals while calling the vascular team.
- 2Use ABCDE, obtain access, crossmatch and activate haemorrhage support for shock or expanding access-site bleeding.
- 3DefinitiveReturn urgently to definitive imaging or theatre when thrombosis, embolisation, compartment syndrome or active bleeding is suspected.
05Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Document a post-procedure pulse, Doppler, neurological and access-site baseline, then escalate any change immediately.
- For CLTI, measure pain and wound healing with infection control and offloading; patency without healing needs reassessment.
- Follow the vascular service’s duplex schedule for the treated segment or bypass and investigate recurrent symptoms between planned visits.
- Continue secondary cardiovascular prevention and smoking treatment; revascularisation does not cure systemic atherosclerosis.
- Review renal function or bleeding according to contrast exposure, procedure and the individual antithrombotic plan.
- Audit whether the agreed walking, healing, analgesia or limb-function goal was achieved and whether repeat intervention remains proportionate.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Technical success is intermediate
Opening a vessel matters only if it improves perfusion enough to relieve symptoms, heal tissue or preserve useful function.
Guidelines have eras
NICE 2012 device recommendations and ESVS 2024 segment-specific evidence differ; cite the exact source and use current multidisciplinary governance.
Vein changes the option set
A good single-segment autologous vein can make durable distal bypass feasible, whereas absent conduit may favour a different target or endovascular plan.
Failure can close options
An endovascular attempt may alter landing zones or delay bypass, while an open operation can consume conduit, so sequencing deserves deliberate planning.
Function frames durability
A long-patency reconstruction has limited value when comorbidity prevents walking or an irreparable foot cannot become functional.
07Common pitfallsFrequent interpretation and management errors.
- 01
Offering a procedure for anatomical stenosis without proving a meaningful clinical indication.
- 02
Skipping supervised exercise and risk-factor treatment before intervening for stable claudication.
- 03
Presenting angioplasty, stenting and bypass as interchangeable operations with identical hazards and durability.
- 04
Quoting an older universal stent rule without naming its source date, arterial segment and current device governance.
- 05
Choosing infrainguinal prosthetic conduit without first assessing usable autologous vein.
- 06
Calling a reconstruction successful because it is patent despite persistent pain, infection or non-healing tissue.
- 07
Missing acute thrombosis, bleeding or compartment syndrome after revascularisation because routine observations appear acceptable.