In a patient with critical limb ischemia (CLI) and an ankle-brachial index of 0.3 with non-healing heel ulcer, duplex ultrasound identifies a 8 cm occlusion of the superficial femoral artery (SFA) with good run-off. Which revascularization strategy is most appropriate as per TASC-II classification?
- A Primary amputation without revascularization attempt
- B Percutaneous transluminal angioplasty (PTA) with stenting
- C Femoro-popliteal bypass with autologous vein graft
- D Endovascular-first approach (subintimal angioplasty) or bypass depending on anatomy ✓
Explanation
Per TASC-II classification, SFA occlusions 5–15 cm are TASC-II Category C lesions. Current guidelines (ESVS 2019) recommend an 'endovascular-first' approach for most CLI patients due to lower procedural morbidity, while reserving surgical bypass for endovascular failure or complex anatomy. An 8 cm SFA occlusion is amenable to subintimal angioplasty or drug-coated balloon angioplasty. However, in good-risk surgical patients with an available great saphenous vein, femoro-popliteal bypass achieves superior long-term patency and may be preferable when life expectancy justifies the procedure. The answer D acknowledges this nuance. Primary amputation without revascularization is inappropriate when revascularization is feasible.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.