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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1357 interventions for common femoral artery disease vary according to the underlying anatomy (eg, bifurcation lesion versus not, involvement of branch arteries versus common femoral artery only) and the device(s) used for revascularization.33,37,39,40 Further, patients selected for endovascular common femoral artery revascularization are often those in whom wound healing would be suboptimal after a surgical approach, such as those treated with radiation therapy or previous surgery to the local area, or with severe obesity.40 Further evaluation of patient and treatment factors are necessary to better define the role of endovascular approaches to common femoral artery disease and its safety and effectiveness relative to endarterectomy. In cases where endovascular approaches to the common femoral artery adversely affect needed profunda femoris artery pathways (ie, collaterals), open surgical revascularization (ie, endarterectomy that preserves profunda femoris artery branches) is preferred. Revascularization for Claudication: Infrapopliteal Disease 8 Most studies of endovascular revascularization for infrapopliteal disease have been conducted in the population of patients with CLTI. Isolated infrapopliteal disease is an uncommon cause of claudication. The long-term patency of infrapopliteal endovascular procedures is lower than for aortoiliac or femoropopliteal lesions, making infrapopliteal endovascular procedures more appropriate for the treatment of CLTI where short-term patency may be sufficient for wound healing.41 There are no RCTs of endovascular revascularization versus medical therapy and structured exercise for treatment of isolated infrapopliteal disease in patients with claudication, and thus the effectiveness of these procedures in this setting is unknown. 9. Isolated infrapopliteal disease is an uncommon cause of claudication, and treatment of isolated infrapopliteal disease is typically reserved for patients with CLTI. No RCTs have evaluated surgical revascularization versus medical therapy and exercise for patients with isolated infrapopliteal disease. In a registry-based study from VQI of patients with claudication who were treated with surgical revascularization, infrainguinal bypass to the infrapopliteal vessels was associated with higher rates of perioperative complications and MALE at 1-year follow-up compared with bypass to the popliteal arteries.42 Accordingly, the effectiveness of surgical revascularization for isolated infrapopliteal disease in patients with claudication is unknown. 9.2 Conduit for Surgical Revascularization for Femoropopliteal Disease Recommendation for Conduit for Surgical Revascularization for Femoropopliteal Disease Referenced studies that support the recommendation are summarized in the Online Data Supplement. COR LOE Recommendation 1 A 1 In patients who are undergoing surgical revascu- larization for functionally limiting claudication and hemodynamically significant femoropopliteal disease, bypass to the popliteal artery with autogenous vein is recommended in preference to prosthetic graft material.1–5 Synopsis The superficial femoral and proximal popliteal arteries are common anatomic sites of stenosis or occlusion among patients with PAD across the clinical subsets. Femoral-popliteal bypass is therefore one of the most common surgical revascularization procedures when surgical revascularization is undertaken for functionally limiting claudication and is performed under general or regional anesthesia (see Section 9.1, “Revascularization for Claudication”). The type and size of conduit and site of popliteal artery anastomosis (above versus below knee) are major determinants of outcomes associated with femoral-popliteal bypass.1–4 Note, this recommendation pertains to conduit for surgical revascularization for femoropopliteal disease only; prosthetic conduits perform well for aortoiliac reconstruction. Recommendation-Specific Supportive Text 1 Multiple RCTs, systematic reviews, and meta-anal- yses have identified a clear and consistent primary patency benefit for autogenous vein versus prosthetic conduit for femoral-popliteal artery bypass.1–3,5 Thus, autogenous vein, generally the great saphenous vein, should be the first choice of conduit when bypass is performed for functionally limiting claudication with inadequate response to GDMT with hemodynamically significant femoropopliteal disease. 10 MANAGEMENT OF CLTI Patients with CLTI have an advanced form of PAD that manifests as rest pain or minor or major tissue loss (see Section 2.1, “Recognizing Clinical Subsets of PAD”). Team-based, multispecialty care is optimal for the care of patients with CLTI. Revascularization is considered the standard treatment for patients with CLTI, rather than the exception, to minimize tissue loss and preserve a functional limb and ambulatory status. Therapies for wound care, management of infection, and pressure offloading are important adjunctive components of care for CLTI in addition to revascularization (Figures 6 and 7). Downloaded from http://ahajournals.org by on October 7, 2026