Medical and surgical treatment options for lower extremity atherosclerosis

26th Feb 2021

Atherosclerotic peripheral arterial disease (PAD) can be treated with medication and / or surgery. Let’s review both of these treatment options and when each option is indicated.


Medication use for atherosclerotic PAD

The management of mild atherosclerosis with medication mainly consists of statin drug therapy. Statins lower cholesterol which reduces plaque buildup on the artery walls that leads to blockage. In 2006, statins were reported to clear plaque out of coronary arteries, and have been used with similar hopes in patients with atherosclerosis in the lower extremities. 

If the patient’s symptoms are not bothersome, management with medication can be an effective way to prevent further plaque buildup and potentially clear plaque out of the arteries. As well, it avoids an invasive surgical intervention. 

With mild atherosclerosis, surgeons employ a watchful waiting practice which includes serial visits to clinically track symptoms and perform ultrasounds. Ultrasounds provide information on the severity of the disease and its pace of advancement. 

Bottle of statin medication and list of indications for the treatment of atherosclerotic peripheral arterial disease (PAD) with statins. Illustration.

Figure 1. Using statins to treat atherosclerotic peripheral arterial disease (PAD) may be sufficient when symptoms are mild. This approach requires serial appointments to track symptoms and perform ultrasounds.

Sometimes, even with complete femoropopliteal occlusion, the symptoms are not severe enough for surgery. Collateral artery growth in response to chronic arterial blockage can provide adequate flow to the calf and foot, which prevents rest pain and ulcers. Collaterals act as a great collection of naturally grown bypass grafts. 

During the watchful waiting period, frequent and purposeful walking can help promote collateral circulation growth. 

Legs with magnifying glass highlighting an arterial blockage with collateral artery growth beside a list of collateral artery growth benefits. Illustration.

Figure 2. Collateral artery growth acts as a natural bypass graft for an arterial blockage, may prevent severe symptoms from developing, and can be promoted with frequent, purposeful walking.


Surgical treatment options for atherosclerotic PAD

Treatment to reopen or bypass the artery is usually elective until the patient experiences rest pain or ulcers, or if the ankle-brachial index (ABI) drops to 0.5 or less (regardless of symptoms).

Scalpel and legs with a magnifying glass highlighting an arterial blockage beside list of indications for surgical treatment options. Illustration.

Figure 3. Surgery for atherosclerotic peripheral arterial disease (PAD) is indicated if the patient experiences rest pain or ulcers, or has an ankle-brachial index (ABI) of 0.5 or less.

Surgical treatment for severe atherosclerosis consists of four options:

  1. Endarterectomy
  2. Angioplasty
  3. Stent placement
  4. Bypass graft 

Endarterectomy is the surgical removal of part of an artery’s inner lining along with the obstructive plaque. This procedure is also referred to as a roto-rooter procedure. On the other hand, angioplasty is the unblocking of a vessel using an expandable balloon catheter that pushes plaque up against the artery walls.

If a bypass graft surgery is anticipated, usually lower extremity ultrasound vein mapping is requested to measure the great saphenous vein (GSV) diameter. This helps you decide if the GSV is viable as an autologous graft to bypass the diseased artery. 

Legs with veins showing the location of the great saphenous vein. Illustration.

Figure 4. The great saphenous vein (GSV) runs along the length of the lower leg. It can be used as the source of an autologous graft to bypass a diseased artery.

Material for an autologous bypass graft is taken from the patient’s body, as opposed to an allogenic bypass graft which is taken from donated material. Autologous grafts are preferred over allogenic grafts because there is a lower risk of infection. 

Note that post-surgical patients will return for long-term follow-ups with serial ultrasounds after their surgery. Medmastery note.

It is very useful to perform a preoperative ABI as a baseline so that later ABI tests can be used to evaluate the surgery’s success and the healing progress. A preoperative ABI can be done alongside the ultrasound vein mapping. 

Unfortunately, sometimes advanced damage has already been done to the tissue that wasn’t receiving adequate blood flow. In this case, a surgical repair or bypass will not help, and amputation is unavoidable.

Clickable call to action, "Start learning for free", with direct link to sign up for a free Medmastery trial account.

Recommended reading

  • Aboyans, V, Criqui, MH, Abraham, P, et al. 2012. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association. Circulation126: 2890–2909. PMID: 23159553
  • Cervin, A, Wanhainen, A, and Björck, M. 2020. Popliteal aneurysms are common among men with screening detected abdominal aortic aneurysms, and prevalence correlates with the diameters of the common iliac arteries. Eur J Vasc Endovasc Surg59: 67–72. PMID: 31757587
  • Cleveland Clinic. 2021. Leg and foot ulcers. Cleveland Clinic
  • Cleveland Clinic. 2021. Marfan syndrome. Cleveland Clinic
  • Cleveland Clinic. 2021. Popliteal artery entrapment syndrome (PAES). Cleveland Clinic
  • Cleveland Clinic. 2021. Statin medications & heart disease. Cleveland Clinic
  • Collins, L and Seraj, S. 2010. Diagnosis and treatment of venous ulcers. Am Fam Physician81: 989–996. PMID: 20387775
  • Høyer, C, Sandermann, J, and Peterson, LJ. 2013. The toe-brachial index in the diagnosis of peripheral arterial disease. J Vasc Surg58: 231–238. PMID: 23688630
  • Jaoude, WA. 2010. Management of popliteal artery aneurysms. SUNY Downstate Department of Surgery
  • Johns Hopkins Medicine. 2021. Aneurysm. Johns Hopkins Medicine
  • Kassem, MM and Gonzalez, L. 2020. “Popliteal artery aneurysm”. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.
  • Moxon, JV, Parr, A, Emeto, TI, et al. 2010. Diagnosis and monitoring of abdominal aortic aneurysm: current status and future prospects. Curr Probl Cardiol35: 512–548. PMID: 20932435
  • Richert, DL. 2016. Gundersen/Lutheran Ultrasound Department Policy and Procedure Manual. Gundersen Health System
  • Rivera, PA and Dattilo, JB. 2020. “Pseudoaneurysm”. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.
  • Stanford Medicine 25. 2021. Measuring and understanding the ankle brachial index (ABI). Stanford Medicine 25
  • Teo, KK. 2019. Acute peripheral arterial occlusion. Merck Manuals Professional Edition
  • The Regents of the University of California. 2020. Diabetic foot ulcers. UCSF Department of Surgery
  • Zwiebel, WJ and Pellerito, JS. 2005. Introduction to Vascular Ultrasonography. 5th edition. Philadelphia: Elsevier Saunders. (Zwiebel and Pellerito 2005, 254–259)