A 55-year-old diabetic smoker with critical limb ischaemia (CLI) and ABI 0.35 has extensive femoropopliteal occlusion (TASC II Class D lesion) on angiography. Crural vessels show single vessel run-off (peroneal artery). According to TASC II and BASIL trial evidence, which revascularisation strategy should be considered as first-line for suitable surgical candidates?
- A Endovascular therapy (angioplasty/stenting) as less invasive and first choice regardless of TASC class
- B Femoro-distal bypass surgery (using autologous vein graft) as preferred for TASC C/D lesions when bypass is feasible ✓
- C Primary amputation as CLI with single vessel run-off has no revascularisable option
- D Lumbar sympathectomy to improve collateral flow as an equivalent alternative to bypass
Explanation
TASC II guidelines recommend surgery (bypass) as preferred revascularisation for TASC C and D femoropopliteal lesions (complex, long occlusions) when surgical risk is acceptable. The BASIL trial (Bypass versus Angioplasty in Severe Ischaemia of the Leg) showed that in CLI patients fit for surgery, bypass with autologous vein graft offered superior amputation-free survival at 2 years compared to angioplasty, particularly for patients with expected survival > 2 years. Single vessel run-off (peroneal) is not a contraindication to distal bypass. Autologous great saphenous vein is the conduit of choice (synthetic grafts have poor patency below-knee). Primary amputation is premature when revascularisation is technically feasible.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.