Redefining the Treatment of Peripheral Artery Disease Role of Percutaneous Revascularization

T he application of a catheter-based approach to the treatment of arterial occlusion of the lower extremities was proposed by Dotter and Judkins1 nearly 30 years ago; 13 years later, Gruentzig2 demonstrated that similar techniques could be used to achieve nonoperative revascularization in patients with obstructed coronary arteries. Before even one decade had elapsed following Gruentzig's seminal work, the demonstrated utility of percutaneous transluminal coronary angioplasty (PTCA) altogether redefined the management of patients with coronary artery disease (CAD). In contrast, despite three decades of research and development, the role of percutaneous transluminal angioplasty (PTA) in the management of patients with peripheral artery disease (PAD) has remained uncertain, controversial, and the subject of exhaustive debate. Such contrary attitudes regarding the respective roles of PTCA and PTA in the management of vascular disease are counterintuitive. The relative risks of attempting to revascularize those arteries supplying the electrical and contractile machinery of the heart pose significantly greater risk than attempts to reestablish patency of the arteries supplying muscles of the hips, buttocks, legs, and feet. The risks of PTCA have in most centers required that an operating room and surgical team be kept free for emergency bypass surgery until revascularization has been completed3; in contrast, the lesser risks of PTA have at no time required such a contingency.4 While restenosis rates as high as 50%5 have from the outset been regarded as an eminently retreatable complication of PTCA, restenosis following PTAtreatable by repeat PTAhas been implicitly equated with graft failure -typically requiring reoperation. The reasons for such disparate use of percutaneous revascularization within the chest versus below the belt are complicated and many, and the explanation of same would almost certainly defy any meaningful consensus. Only one thing is clear: the future will be different. Thrombolytic therapy is being used on an increasingly