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10.2 Results
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exclude other intra-abdominal disease. CTA features in MALS include focal narrowing of the proximal celiac artery with a characteristic hooked appearance.
Magnetic resonance angiography and digital subtraction angiography (DSA) can
provide similar appreciation of vessel stenosis as CTA. Magnetic resonance
angiography, DSA, and CTA should be performed in inspiration and expiration
to demonstrate the changes in celiac artery compression with the phases of respiration. Interestingly, a convincing correlation between degree of angiographic
stenosis and likelihood of being symptomatic from MALS is lacking.
• Management
Surgical management involves decompression of the median arcuate liga-
ment’s constriction of the celiac artery; robotic, laparoscopic, endoscopic retroperitoneal, and open surgical intervention can provide effective symptom relief,
but long-term follow-up data (>5years) are lacking. Patients treated nonoperatively appear to have worse outcomes.
• Evidence
The available evidence is highly suggestive that MALS exists. Despite no
denitive group consensus agreement as to the diagnostic criteria or management of MALS, patient presentation and radiologic signs appear generally consistent across the literature.
Kim etal. [4] reviewed the literature to dene an algorithm for accurate diagnosis
and successful treatment for patients with MAL syndrome. They concluded that
although diagnosis and treatment of MAL syndrome are unclear, symptom resolution has been achieved with multiple surgical modalities, including open, laparoscopic, or robotic ligament release as well as celiac ganglionectomy, which often
requires celiac artery revascularization. Based on current literature and own experience, they proposed an algorithm for diagnostic evaluation and intervention in
patients with MAL syndrome which is shown in Fig.10.1.
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10.2.2 Studies
10.2.2.1 Surgical Vs. Nonoperative Management
The only recent study describing the outcome after surgical decompression and
nonoperative management of MALS comes from Australia [5]. There were 67
patients, 43 (64%) treated surgically and 24 (36%) managed without surgery, with a
median follow-up of 25months and 24months, respectively. Laparoscopic decompression was performed in 38 cases (88%). One case (3%) was converted to an open
operation because of left gastric artery bleeding. Open decompression was performed in ve cases (12%). One patient had a percutaneous angioplasty and stent
insertion 1month after open decompression because of persistence of symptoms.
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Workup of abdominal pain
s
Coelia
Laparoscopic or robotic
Po
celi
Sy
Treatm
Consider reconstruction
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Right upper quadrant sonography
CT abdomen
Upper endoscopy
Hepatobiliary iminodiacetic acid (HIDA) scan
Normal findings Abnormal findings
-Duplex ultrasonography
-CT angiography abdomen
-MR angiography abdomen
-Angiography of coeliacartery
with pressure gradient
measurement
c stenosis
MALrelease and / or ganglionectomy
No coeliac stenosis Appropriate treatment of abdominal abnormalitie
10 Median Arcuate Ligament Syndrome (MALS)
Gastroenterology consult
stoperative duplex sultraonography ofSymptomsAngiography of celiac artery with
ac artery and follow-up persist pressure gradient measurement
mptoms resolve Residual stenosis
ent complete Symptoms resolve Angioplasty / stent of celiac artery
Symptoms persist
Fig. 10.1 Algorithm for diagnosis and management of median arcuate ligament (MAL) syndrome
proposed by Kim etal. [4]
One patient received a patch angioplasty during open decompression because the
celiac artery did not expand after decompression. After surgical treatment, 16 (37%)
patients were asymptomatic, 24 (56%) were partially improved, 3 (7%) had no
changes in symptoms, and none had worsening of symptoms. Postexertional
abdominal pain was associated with better surgical outcomes, whereas unprovoked
10.2 Results
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221
abdominal pain (i.e., abdominal pain that was not related to meals or exercise) and
vomiting were associated with poor surgical outcomes. There was no association
between postprandial pain and outcome.
After nonoperative management, 1 (4%) was asymptomatic, 7 (29%) were partially improved, 12 (50%) had no changes in symptoms, and 4 (17%) had worsening
of symptoms. The available evidence suggests that patients with postexertional
abdominal pain, without unprovoked abdominal pain, and without vomiting appear
more likely to achieve favorable surgical outcome. Other factors that were previously found to be predictive of surgical outcomes, such as gender, postprandial
abdominal pain, and weight loss of >9kg, were not found to be associated with
surgical outcomes in this study but should be taken into consideration.
10.2.2.2 Laparoscopic andOpen MAL Release
Using the National Inpatient Sampling database, Alnahhal etal. [6] identied all
patients surgically treated for MALS between 2008 and 2018 through conventional
open and laparoscopic approaches. A total of 630 patients were included and analyzed: 487 (77.3%) patients underwent open surgery while 143 (22.7%) patients
underwent laparoscopic decompression. The majority of the study population consisted of female patients (74.8%) with a mean age of 40.6±19years. Patients who
underwent laparoscopic decompression had signicantly less all-cause perioperative complications compared to their open surgery counterparts (0.7% vs. 9.9%;
P= 0.001). Additionally, prolonged hospitalization was noted in the open group
compared to the laparoscopic (5.8days vs. 3.5; P<0.001, respectively) with a signicantly higher mean of total hospital charges ($70,095.8 vs. 56,113.5; P=0.016).
This paper demonstrates the safety and improved outcomes during the index hospitalization of the laparoscopic approach as the standard of care. Although this work
shows that it can be done safely, it does not provide evidence on indications for
surgery, open or laparoscopic, and furthermore does not provide evidence on the
efcacy of the short or long-term symptom relief postoperatively.
The Vascular Low Frequency Disease Consortium is an international, multiinstitutional research consortium. Data on open, laparoscopic, and robotic MAL
release (MALR) performed from 2000 to 2020 were gathered by DeCarlo etal. [7].
Of 516 patients treated at 24 institutions, 227 (44.0%), 235 (45.5%), and 54 (10.5%)
had undergone open, laparoscopic, and robotic MALR, respectively. Of the 488
patients (94.6%) with follow-up data available, 287 (58.8%) had had full relief, 119
(24.4%) had had partial relief, and 82 (16.8%) had derived no benet from
MALR.The 3-year freedom from treatment failure for the overall cohort was 51.9%
(95% condence interval, 46.1%–57.3%). The factors associated with an increased
hazard of treatment failure included robotic MALR, a history of gastroparesis, a
history of abdominal cancer, dysphagia or odynophagia, no relief from a celiac
plexus block, and the number of pain locations. Age and an increasing number of
preoperative diagnostic gastrointestinal studies were associated with a lower hazard
of failure. No radiographic parameters were associated with differences in treatment
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10 Median Arcuate Ligament Syndrome (MALS)
failure. No difference was found in long-term failure after open vs laparoscopic
MALR; however, open release was associated with higher perioperative morbidity.
These results support the use of a preoperative celiac plexus block to aid in patient
selection. The overall rate of treatment failure was high, and operative candidates
for MALR should be counseled regarding the factors associated with treatment
failure.
Romero-Velez etal. [8] examined the trends in MAL release in the United States
in the past 10 years using the American College of Surgeons-National Surgical
Quality Improvement Project from 2010 to 2020. A total of 578 open cases (76%)
and 185 laparoscopic cases (24%) were identied. There was an increase adoption
of the laparoscopic approach, with 22% of the cases employing this technique at the
end of the study period, compared to 7% at the beginning of the study period. The
open group had a higher prevalence of hypertension (26% vs 18%, p=0.04) and
bleeding disorders (5% vs 2%, p0.03). Laparoscopic approach had a shorter length
of stay (2.3days vs 5.2days, p<0.0001), lower major complication rates (0.5% vs
4.0%, p=0.02) and lower reoperation rates (0% vs 2.6%, p=0.03). Overall mortality was 0.1%. Increased surgical treatment of MALS was detected in the past decade
in the United States.
Patel etal. [9] described 32 patients who underwent laparoscopic MAL release.
The average age of the patients at time of treatment was 37.8 years (range,
22–60years). No operative complications occurred, and none required conversion
to open surgery. Technical success rate, dened as origin of the celiac artery being
visually free of external stricture and with improvement in intraoperative DUS
velocity, was 100%. There were 29 patients (91%) who completed follow-up with a
1-year clinical evaluation. 19 patients (66%) reported improvement in symptoms,
and 18 (62%) decreased their use of analgesics. No celiac artery DUS nding (peak
celiac artery velocity, angle of deection, or change in preoperative to postoperative
velocity) was predictive of successful clinical outcomes (P > .05). Similarly, no
CTA nding (characteristic morphology, cross-sectional area, diameter, or location
of the focal stenosis of the celiac artery) was associated with clinical outcomes
(P> .05). This small series of patients who underwent laparoscopic MAL release
experienced good outcomes comparable to those reported in the literature. However,
no DUS or CTA ndings were able to predict response to treatment. MALS is a
complex condition that may be multifactorial in etiology, including both vascular
and neurogenic components. This study did not conrm a vascular etiology for
median arcuate ligament syndrome. The leading alternative pathophysiologic
mechanism for MALS involves neurogenic pain from compression of the celiac
nerve plexus.
In a single-center, 52 consecutive MALS patients were followed-up, prospectively, after transperitoneal laparoscopic decompression. All operations were performed by one surgeon [10]. Mean age of the patients was 47±21years, and 65%
were females. Complete (67%) or partial (23%) relief from symptoms was found in
47 patients (90%) after 3–6months of follow-up. Five patients (10%) had operative
complications. Only two patients had recurrent symptoms requiring intervention
during a mean follow-up period of 2.4 years. Despite controversies about its
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223
pathophysiology, laparoscopic decompression of the celiac artery seems to provide
persistent relief from symptoms in most patients with median arcuate ligament
syndrome.
Long-term results in 100 patients with MALS (mean age, 38±18years; 75%
female) were presented by Pather etal. [11]. Open surgical release was performed
in 81 and laparoscopic release in 19 patients. There was no mortality. Major adverse
events at 30days had occurred in 21 patients (open 19, laparoscopic 2) including
myocardial infarction (n=1), pancreatitis (n=2), respiratory failure (n=4), estimated blood loss of more than 1L (n=8), and postoperative ileus (n=8). A crosssectional questionnaire using the Visick score, the Gastrointestinal Quality of Life
Index, and Short Form (SF)-12v2 questionnaires was performed to assess long-term
outcomes. Forty-six patients responded to the questionnaire with a mean follow-up
of 8 ± 4 years. Initial symptom resolution or improvement was reported by 38
patients (83%), whereas eight patients (17%) reported treatment failure. Seven of
the 38 patients (18%) with initial treatment success reported symptom recurrence.
The estimated 5-year freedom from symptoms was 67 ± 7%. Forty respondents
(87%) reported that they would still undergo operative management if given the
choice, including all respondents who reported symptom recurrence.
10.2.2.3 Open Surgery forAbdominal Compression Syndromes
An observational study was undertaken on 169 patients who underwent 196 open
operations for abdominal compression syndromes (CS) between 2010 and 2020 by
Sandmann etal. [12]. Arising not only in the abdomen and causing pain (median
arcuate ligament syndrome [MALS] and superior mesenteric artery syndrome
[SMAS]), CS also occur in the retroperitoneum and the pelvis (nutcracker syndrome and May-Turner syndrome), these latter conditions causing chronic pelvic
congestion syndrome (PCS). Out of 169 patients with CS, 132 (78.1%) were female,
37 (21.9%) were male. The mean age was 31.36years (female 33.82years, male
29.44years). The majority (n=123, 72.8%) of 169 patients presented with multiple
types of CS.Eighty-one patients were operated for primary or recurrence of MALS,
that is 47.9% of the total number of patients undergoing surgery for abdominalretroperitoneal and pelvic CS. 122 patients with either MALS as a mono-lesion or
in combination with other CS underwent partial resection of the MAL.In all but 4
patients, the typical symptoms disappeared or had signicantly improved after 2 to
3weeks. A subgroup of 43 (25.4%) patients underwent superior mesenteric artery
transposition (SMATX) from suprarenal into the infrarenal aorta for treatment of
SMAS. Thirty-eight (90.5%) patients in this SMAS subgroup having undergone
SMASTX reported pain-free eating and weight gain within 6months post operation. Based on their experience, the authors argued against the laparoscopic approach
for MALS, which could either—performed too close to the aorta—lead to bleeding
that is difcult to control or- if the procedure is too cautious—may leave bres in
place that make decompression incomplete. Just dividing but not resecting a segment of the MAL can cause recurrence due to strong scar tissue.
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10 Median Arcuate Ligament Syndrome (MALS)
10.2.2.4 Robotic Surgery
Gerull etal. [13] presented a retrospective cohort study analyzing adult patients who
underwent robotic median arcuate ligament release (MALR) performed by a single
surgeon at a tertiary academic hospital from 2014 to 2021. A total of 74 patients
underwent robotic MALR during the study period. The mean age was 27.3±7.9years
and the majority of patients were female (n=60/74, 81.1%). The most common
presenting symptom was post-prandial abdominal pain (n = 65/74, 87.7%). The
mean operative time was 52.6±18.1min. There were no conversions to open surgery and minimal blood loss (mean=13.9±8.4mL). At 3-months, 12% (n=9/74)
of patients had persistent abdominal pain and underwent additional imaging. 5 of
these 9 patients had persistently elevated DUS expiratory PSV and were referred for
angioplasty. At 1-year follow up, 90.3% (n=56/62) continued to have no abdominal
pain. The robotic approach to MALR is safe and feasible, with good patient
outcomes.
In a retrospective study, Khrucharoen et al. [14] compared surgical outcomes
between laparoscopic and robotic-assisted MAL release. A total of 16 laparoscopic
and 18 robotic cases were included. Median operative time was shorter in the robotic
group (106 vs. 179.5min). The rates of conversion to open procedure in both groups
were similar (6.3% in the laparoscopic group and 5.6% in the robotic group).
Postoperative complication rates were similar (12.5% vs. 16.7%, p=0.99), major
complications were not seen in either group. There was no difference in the immediate postoperative outcome. Complete abdominal pain relief was found in 37.5%
(laparoscopic group) and 44.4% (robotic group), respectively, and no improvement
in 12.5% and 16.7%. This study demonstrated that laparoscopic and robotic-assisted
MAL release offer comparable surgical outcomes and similar short- and
intermediate- term clinical outcomes. Robotic MAL release can be associated with
a substantially shorter operative time than laparoscopic MAL release with the
hypothesis of improved dexterity offered by the robotic instrument’s multiarticulated joints.
In another retrospective study, the results of 26 robotic MALR and 24 laparoscopic MALR performed by a single surgeon were reported [15]. In this study, the
mean operative time was signicantly shorter for laparoscopic surgery (86 min)
compared to robotic surgery (134min; p<0.0001). There were no open conversions
and mean length of hospital stay was 1day for both groups. While robotic MALR
had signicantly higher reduction of chronic abdominal pain postoperatively (76.9%
vs 50%) there were no signicant differences in other postoperative symptom relief
between groups. In comparison with laparoscopic MALR, robotic MALR cases
were associated with more junior rst assistants, fewer second assistants, and longer
operative times. Both approaches are safe and feasible for well-selected patients in
experienced centers.
10.3 Conclusions forClinical Practice
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10.2.2.5 MALS inthePediatric Population
Mak etal. [16] prospectively evaluated 46 pediatric patients (42 females, 4 males;
ages 8.6–20.5years; median 16.6; mean 16.2±0.5years). All patients had previously been diagnosed with chronic functional abdominal pain (CFAP). Patients
were evaluated for celiac artery compression by duplex ultrasound and diagnosis
was conrmed by computed tomography. All patients underwent a technically satisfactory laparoscopic surgical release resulting in a signicant improvement in
blood ow through the celiac artery. There were no deaths and a total of 9 complications, 8 requiring a secondary procedure; 33 patients were administered QOL surveys. Eighteen patients completed the survey with 15 (83%) patients reporting
overall improvement in the QOL.Overall, 31/46 patients (67%) reported improvement of symptoms since the time of surgery. Laparoscopic release of the celiac
artery can be performed safely in the pediatric population. Surgical release of the
artery and resultant neurolysis resulted in signicant improvement in the blood ow,
symptoms, and overall QOL in this cohort. The overall improvement in QOL outcome measures after surgery leads the authors to conclude that MALS might be
earlier diagnosed and possibly treated in patients with CFAP.
In another retrospective study, six pediatric patients underwent laparoscopic
release for MALS [17]. 5 patients were female (83.3%), with an average age of
15.7±1.5years. Presenting symptoms lasted on average 16.5±12.7months prior
to treatment. Average pre- and postsurgical ultrasound celiac artery peak velocities
with inspiration were 332.0±34.1cm/s and 224.3±31.2cm/s, respectively, with a
statistically signicant decrease of 107.67cm/s (P=0.03). The results demonstrated
that laparoscopic MALR in the pediatric population is safe and effective. In carefully selected patients, laparoscopic release for MALS without additional celiac
artery reconstruction normalizes blood ow in the celiac artery and improves physical and psychosocial quality of life for the child and his or her parents.
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10.3 Conclusions forClinical Practice
1. MALS is a controversial disease; this applies to pathogenesis and treatment.
There are no guidelines, meta-analyses, or controlled trials, so that evidencebased treatment recommendations cannot be made.
2. Despite no denitive group consensus agreement as to the diagnostic criteria or
management of MALS, patient presentation and radiologic signs appear generally consistent across the literature. The available evidence is highly suggestive
that MALS exists.
3. Celiac artery compression in MALS can be diagnosed by inspiration/expiration
duplex ultrasound, CTA or CE-MRA.
4. Surgical management involves decompression of the median arcuate ligament’s
constriction of the celiac artery; robotic, laparoscopic, endoscopic retroperitoneal, and open surgical intervention can provide effective symptom relief, but
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10 Median Arcuate Ligament Syndrome (MALS)
long-term follow-up data (>5years) are lacking. Patients treated nonoperatively
appear to have worse outcomes.
5. Percutaneous transluminal angioplasty with stent placement is the second-line
intervention in patients with recurrent or persistent symptoms despite surgical
decompression and where there is evidence of celiac artery narrowing.
6. A mental disorder is not uncommon in these patients and must be carefully ruled
out before any intervention.
References
1. Fidelman N, AbuRahma AF, Cash BD, Kapoor BS, Knuttinen MG, Minocha J, Rochon PJ,
Shaw CM, Ray CE Jr, Lorenz JM.ACR appropriate ness Criteria® Radiologic Management
of Mesen teric Ischemia. J Am Coll Radiol. 2017;14:S266–71.
2. Terlouw LG, Moelker A, Abrahamsen J, etal. European guidelines on chronic mesenteric ischaemia—joint United European Gastroenterology, European Association for Gastroenterology,
Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology,
Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology,
Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric
Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with
chronic mesenteric ischaemia. United European Gastroenterol J. 2020;8:371–95.
3. Goodall R, Langridge B, Onida S, Ellis M, Lane T, Davies AH.Median arcuate ligament syndrome. J Vasc Surg. 2020;71:2170–6.
4. Kim EN, Lamb K, Relles D, Moudgill N, DiMuzio PJ, Eisenberg JA.Median arcuate ligament
syndrome-review of this rare disease. JAMA Surg. 2016;151:471–7.
5. Ho KKF, Walker P, Smithers BM, Foster W, Nathanson L, O'Rourke N, Shaw I, McGahan
T.Outcome predictors in median arcuate ligament syndrome. J Vasc Surg. 2017;65:1745–52.
6. Alnahhal KI, Tedesco A, Khan ZZ, Irshad A, Salehi P.Median arcuate ligament syndrome:
comparing the safety of open and laparoscopic management in a large cohort. Ann Vasc Surg.
2023; https://doi.org/10.1016/j.avsg.2023.04.021. S0890-5096(23)00242-X, Epub ahead
of print
7. DeCarlo C, Woo K, van Petersen AS, etal. Factors associated with successful median arcuate
ligament release in an international, multi-institutional cohort. J Vasc Surg. 2023;77:567–77.
8. Romero-Velez G, Barajas-Gamboa JS, Pantoja JP, Corcelles R, Rodriguez J, Navarrete S, Park
WM, Kroh M.A nationwide analysis of median arcuate ligament release between 2010 and
2020: a NSQIP study. Surg Endosc. 2023;37:140–7.
9. Patel MV, Dalag L, Weiner A, Skelly C, Lorenz J.Inability of conventional imaging ndings to
predict response to laparoscopic release of the median arcuate ligament in patients with celiac
artery compression. J Vasc Surg. 2019;69:462–9.
10. Kazmi SSH, Sa N, Berge ST, Kazmi M, Sundhagen JO, Hisdal J.Laparoscopic surgery for
median arcuate ligament syndrome (MALS): a prospective cohort of 52 patients. Vasc Health
Risk Manag. 2022;18:139–51.
11. Pather K, Kärkkäinen JM, Tenorio ER, Bower TC, Kalra M, DeMartino R, Colglazier J,
Oderich GS.Long-term symptom improvement and health-related quality of life after operative management of median arcuate ligament syndrome. J Vasc Surg. 2021;73:2050–8.
12. Sandmann W, Scholbach T, Verginis K. Surgical treatment of abdominal compression syndromes: the signicance of hypermobility-related disorders. Am J Med Genet C Semin Med
Genet. 2021;187:570–8.
References
https://t.me/medicina_free
13. Gerull WD, Sherrill W, Awad MM. Robotic median arcuate ligament release: management algorithm and clinical outcomes from a large minimally invasive series. Surg Endosc.
2023;37:3956–62.
14. Khrucharoen U, Juo YY, Chen Y, Jimenez JC, Dutson EP.Short- and intermediate-term clinical outcome comparison between laparoscopic and robotic-assisted median arcuate ligament
release. J Robot Surg. 2020;14:123–9.
15. Shin TH, Rosinski B, Strong A, Fayazzadeh H, Fathalizadeh A, Rodriguez J, El-Hayek
K.Robotic versus laparoscopic median arcuate ligament (MAL) release: a retrospective comparative study. Surg Endosc. 2022;36:5416–23.
16. Mak GZ, Speaker C, Anderson K, Stiles-Shields C, Lorenz J, Drossos T, Liu DC, Skelly
CL. Median arcuate ligament syndrome in the pediatric population. J Pediatr Surg.
2013;48:2261–70.
17. Joyce DD, Antiel RM, Oderich G, Gloviczki P, Tung J, Grothe R, Absah I, Zarroug AE.Pediatric
median arcuate ligament syndrome: surgical outcomes and quality of life. J Laparoendosc Adv
Surg Tech A. 2014;24:104–10.
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Chapter 11
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Intermittent Claudication
11.1 Guidelines
11.1.1 European Society ofCardiology (ESC)/European
Society forVascular Surgery (ESVS)
The European Society of Cardiology in collaboration with the European Society for
Vascular Surgery (ESVS) guidelines [1] recommend for the management of intermittent claudication (IC):
• On top of general prevention, statins are indicated to improve walking distance.
(Class I recommendation/Level of evidence A).
• In patients with intermittent claudication supervised exercise training is recom-
mended. (Class I recommendation/Level of evidence A).
• Unsupervised exercise training is recommended when supervised exercise train-
ing is not feasible or available. (Class I recommendation/Level of evidence C).
• When daily life activities are compromised despite exercise therapy, revascular-
ization should be considered. (Class IIa recommendation/Level of evidence C).
• When daily life activities are severely compromised, revascularization should be
considered in association with exercise therapy. (Class IIa recommendation/
Level of evidence B).
The recommendations on revascularization of aorto-iliac occlusive lesions and the
recommendations on revascularization of femoro-popliteal occlusive lesions in this
guideline apply for patients with intermittent claudication and severe chronic limb
threatening ischemia and are given in Chap. 12.
Switzerland AG 2023
E. S. Debus, R. T. Grundmann, Evidence-based Therapy in Vascular Surgery,
https://doi.org/10.1007/978-3-031-47397-5_11
229© The Author(s), under exclusive license to Springer Nature
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