January 15, 2019
New Appropriate Use Criteria Address Peripheral Artery Interventions
January 16, 2019—The American College of Cardiology (ACC) announced that the "2018 Appropriate Use Criteria for Peripheral Artery Intervention" document was published by Steven R. Bailey, MD, et al online in Journal of the American College of Cardiology.
The new guidance for clinicians to determine the role of different revascularization options for patients with peripheral artery disease (PAD) was developed by the ACC, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, and Society for Vascular Medicine.
According to the ACC, the writing group used published guidelines, trial data, and expert opinion to identify 45 common clinical scenarios within the field of PAD. An independent rating panel then scored the scenarios to rank each as "appropriate," "may be appropriate," or "rarely appropriate."
The indication topics include renal artery stenosis, lower extremity disease, critical limb ischemia, asymptomatic artery disease, options for endovascular treatment when deemed appropriate or may be appropriate, and secondary treatment options for lower extremity disease.
ACC noted that the rating panel deemed patients with cardiac destabilization such as recurrent heart failure or uncontrolled unstable angina despite maximal medical therapy and severe renal artery stenosis as "may be appropriate" for renal stenting.
For patients with PAD and intermittent claudication who have already completed a guideline-directed medical therapy and structured exercise strategy, surgical or endovascular randomization will depend on the risk-benefit ratio unique to each patient. In patients with critical limb ischemia, either endovascular or surgical revascularization "is critical for the reduction of high morbidity and mortality rates."
ACC advised that the document also points out several areas where research is lacking, including:
- Asymptomatic artery disease
- Risks and benefits of atherectomy in femoropopliteal lesions
- Comparing treatment modalities for in-stent stenosis, venous graft failures, and arterial graft failures
The writing group explained that although appropriate use criteria (AUC) are evidence-based, they are "not a replacement for clinical judgement and practice experience in determining the best options for individual patients."
The authors concluded, "Future studies to evaluate implementation of these AUC in clinical settings will be useful." Noting that as the field of PAD is continuously evolving, they advise that a regular review of these scenarios will be necessary.
Dr. Bailey commented in the ACC announcement, "AUC are designed to provide an assessment of care decisions in aggregated patient populations, not to determine reimbursement or coverage decisions for the treatment of individual patients." He added, "We expect this AUC to undergo frequent review and updates as new evidence becomes available."