Iliac femoropopliteal district: decision-making and current statement—steno-occlusive disease

Peripheral artery disease (PAD) is the most common localization of atherosclerosis, and vascular surgeons are commonly involved in decision-making processes related to PAD. The recent shift from traditional open vascular interventions toward endovascular solutions is debated because of lack of firm evidence. Open surgery is still considered the gold standard technique, above all in complex lesions; however, the continuous improvement in technology and materials makes endovascular procedures safe and feasible in the majority of cases. Surgical choices are influenced by multiple factors and the decisionmaking process is driven by surgeons’ skills and experiences. In this chapter, the authors purpose is to match clinical practice guidelines indications with real-world scenarios of daily surgeons’ experience to underline the surgical approach to iliac!femoral or femoropopliteal diseased patients. Lower extremities arterial disease (LEAD) represents the full clinical spectrum of atherosclerotic stenoocclusive PAD that involves the infrarenal aorta until the tibial and pedal arteries. The arterial tree of the lower extremities should be divided into multiple segments of distribution of the disease. Iliac!femoral and femoropopliteal districts have a crucial relevance in the lower extremity arterial downstream and they are known as the inflow and outflow environments, respectively. The decision to treat a LEAD patient relies on several clinical and technical aspects: severity of disease, comorbidities, and fit-for-surgery status. Nowadays, the choice between open surgical repair (OSR) or endovascular repair (EVR) is the most common and important debate in this type of patient. The 2007 Trans-Atlantic Inter-Society Consensus(TASC) traditionally indicated EVR for A-B lesions and OSR for C-D aortoiliac obstructive lesions [1]. The 2019 Global guidelines remark the new concept of chronic limb-threatening ischemia for LEAD infrainguinal patients with an integrated system of indications, both clinically and technically based [2]. The aim of vascular interventions on lower extremities, as in all other vascular obstructions, is to regain the perfusion of an arterial segment with in-line blood flow from a healthy-tohealthy segment. The challenge is to choose the correct intervention strategy in each situation.