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I've had the pleasure of participating in debates like the one outlined in Nancy Walsh's cover article (continued below) that took place at the last Veith meeting. You know the drill: The speaker advocating surgery will usually show slide after slide of data from the often-quoted BASIL trial and many other studies demonstrating the superiority of bypass surgery in terms of durability and limb salvage while the speaker advocating endovascular surgery will mumble some words about how frequently patients die quickly with critical limb ischemia, rarely have an "ideal" outcome, whatever that means, while showing a picture of an intact leg with a Band-Aid on the groin next to one with a 3-foot-long open incision. The endovascular proponent wins every time.

Frank Pomposelli, M.D.

As a surgeon who's made much of his living and academic reputation by treating lower-extremity ischemia by conventional surgery, you might think I'd be a staunch defender of bypass surgery who gets nauseous at the sight of a self-expanding stent in the superficial femoral artery. Certainly, organizers of these debates seem to think so, since I rarely get the chance to show the pretty picture of the groin with the Band-Aid next to the bloody leg when I'm a participant in these events. The truth is, however, that endovascular therapy for lower-extremity ischemia is here to stay in my practice and in yours, too, whether you like it or not. So while these debates are interesting and entertaining, they also are almost totally irrelevant and obscure--the more important point is that surgery and angioplasty are neither exchangeable nor mutually exclusive; both are critical components of a comprehensive treatment strategy for limb ischemia.

So why the argument? Proponents of "angioplasty first" at all times ignore the fact that, in some circumstances, this approach is both excessively costly and results in the worst of both possible outcomes: a string of multiple reinterventions that is ineffective and leads ultimately to bypass anyway. Moreover, in my experience, the resultant bypass all too often extends to a target more distal than would have been required had it been done as the first procedure. Haven't we all had the unpleasant experience of attempting angioplasty that neither works nor adequately restores foot perfusion, until you are unable to save the limb and regret not having done a bypass in the first place? And while mercifully rare in my own experience, determining how often this does occur is nearly impossible to glean from administrative data sets like the ones mentioned in the preceding article.

The naysayers who deny the utility of angioplasty in any circumstance of limb-threatening ischemia seem to overlook a very important fact that I've appreciated in my practice--that it works! With less morbidity (but not mortality) than performing a bypass, it is preferred by patients and achieves similar rates of limb salvage. And who among us wouldn't prefer a Band-Aid to a 3-foot-long incision? The results of the BASIL trial outlined in the preceding article are important and well known to all vascular surgeons. What is not usually emphasized is that many patients evaluated by the BASIL investigators apparently got no medical therapy (rare in my patients) and that the severity of the lesions treated were not stratified according the Transatlantic Intersociety Consensus (TASC) criteria. Consequently, it has been difficult to use the data to make clinical decisions in our practice. Our experience has been that severe TASC D disease is more difficult to treat with angioplasty and results in lower rates of technical success and worse durability. Many, but by no means all, of these patients ultimately come to bypass. On the other hand, TASC A and B disease does very well with angioplasty, both in the immediate and long term although it might not be encountered as often in patients with critical limb ischemia.

In approaching these patients, having options always is beneficial. That is, for me, the biggest advantage of angioplasty in the hands of a vascular surgeon--it adds another option. No one can deny the severe morbidity of bypass in "bad" legs: those that are morbidly obese, with severe venous stasis changes, patients on high-dose steroids, etc. The ability to treat these patients with angioplasty has been a most welcome addition to my treatment strategy. I have similar feelings about the very elderly and/or frail patient with critical ischemia for whom I know a bypass will save the limb but often at a high cost in terms of recovery, rehabilitation, and occasionally, mortality. What about the patient with no conduit who needs a prosthetic graft to a target below the knee? In my experience, angioplasty works at least as well and is more easily revised. On the other hand, is angioplasty really the best approach in a relatively intact patient with TASC D disease who has a beautiful distal target and an excellent saphenous vein? I'm not so sure. I have had patients like this in my practice whom I treated 10 or 15 years ago with patent bypasses that never have been revised. In many studies, patients treated with critical limb ischemia with intact saphenous vein have primary patency exceeding 70% at 5 years and secondary patency exceeding 80%, with limb salvage of 90%. And while as many as 50% may die in less than 5 years, it is important to remember that an equal percentage live at least that long, with most returning to their baseline level of function and a good resolution of their symptoms. Durability and cost-effectiveness, common in bypass in these circumstances, are not two words you usually associate with lower-extremity angioplasty. So, for me, the conundrum was and is trying to predict who is best served by bypass or, rather, by endovascular therapy? The answer to that question is far more important than arguing about the one modality over the other; besides, this will never be answered by anyone but a vascular specialist--who already has both approaches available anyway.

As our experience with angioplasty broadens, I suspect it ultimately will find its rightful place in our treatment strategy. At our current level of knowledge, however, determining the proper role of angioplasty requires flexibility, good judgment, and clinical experience. In my own practice, angioplasty has replaced bypass surgery in 60%-70% of my patients. While we should not abandon our roots as traditional vascular surgeons, we must not deny our predominance as the only "true" vascular specialists. We should continue to apply all of our skills, both open and endovascular, and dispassionately select the best treatment for each individual patient. To not do so makes us no better than the peripatetic tradesman whose only tool is a hammer--and you know what they say about him.