Angioplasty can be easily repeated in the case of restenosis or reocclusion or be performed after the failure of bypass surgery [2], [119], [120] and [121]. The considerable industrial effort that

has been made to create new instruments (very long, low-profile balloons, drug-eluting balloons, atherotomes, medicated and non-medicated stents, etc.) means that angioplasty can be increasingly proposed even in extreme situations and assures the better long-term selleckchem patency of the treated vessels [121], [122], [123], [124], [125] and [126]. When patients can be treated either surgically or percutaneously, the fundamental rule of an ‘angioplasty first strategy’ is to respect the so-called surgical ‘landing zones’. It can generally be said that the failure of angioplasty

does not preclude subsequent bypass surgery [127], but there are reports indicating that a distal bypass procedure is more difficult after the failure of percutaneous revascularisation and associated with more complications and failures [128] and [129]. It is therefore imperative that percutaneous revascularisation procedures be carried out by experts capable of Z-VAD-FMK correctly identifying and technically respecting the ‘landing zones’ required for a subsequent distal bypass salvage operation. It is also necessary to use stents very carefully because any restenosis/reocclusion makes subsequent (surgical or percutaneous) treatment difficult or impossible. By the same token, the use of open surgery should not compromise the possibility of future percutaneous treatment: Tolmetin for example, ligation of the superficial femoral artery makes

it impossible to perform a subsequent percutaneous intervention to restore its patency in the case of bypass failure. Even in the context of an ‘angioplasty first’ approach, there are some forms of vascular obstruction that should preferentially be treated surgically. Obstructive disease of the common femoral artery and its bifurcation are generally not related to diabetic arterial disease [130], and can be resolved by means of relatively trauma-free surgery requiring little anaesthesia in almost all cases. Another example is an extremely long occlusion of the femoro-popliteal and infra-popliteal axes, although there is no consensus concerning the length of the obstruction and local expertise is particularly important: the percutaneous treatment of such lesions is currently burdened by a high incidence of restenosis and repeat procedures [115], [130] and [131], whereas a distal bypass in an autologous vein is a more effective and longer-lasting solution [114], [115] and [132]. Surgical revascularisation by means of a bypass should be performed after having visualised the vascular tree by means of Doppler ultrasonography, angio-CT, angio-MR or angiography, and considered a series of important variables that condition the success of the procedure and its complications (see flow chart in Fig. 1).