Sandbox: Peripheral Arterial Disease
Template:Peripheral Arterial Disease
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]
==2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases (PAD), in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries Endorsed by: the European Stroke Organization (ESO) The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS)==
Changes in Recommendations
What is new in the 2017 PAD Guidelines
| 2011 | 2017 |
|---|---|
| 2017 Change in Recommendations: | |
| Carotid Artery Disease | |
| IIb - Embolic Protection Devices (EPDs)in Carotid Stenting | IIa - Embolic Protection Devices (EPDs)in Carotid Stenting |
| Asymptomatic 60-90% carotid stenosis | |
| IIa - Surgery for all | IIa - Surgery for high stroke risk |
| IIb - Stenting as an alternative | IIa - Stenting in high surgery risk |
| IIa - Stenting in average surgery risk | |
| 2017 New Recommendations: | |
| IIb - Coronary angiography before elective carotid surgery | |
| III - Routine prophylactic revascularization of asymptomatic carotid 70-99% stenosis in patients undergoing CABG. | |
| 2017 Change in Recommendations: | |
| Upper Extremity Artery Disease | |
| I - Revascularisation for symptomatic subclavian artery stenosis | IIa - Revascularisation for symptomatic subclavian artery stenosis |
| Subclavian stenosis revascularization | |
| I - Endovascular first | IIa - Stenting or surgery |
| IIb - Revascularization for asymptomatic subclavian stenosis in patients with/planned for CABG | IIa - Revascularization for asymptomatic subclavian stenosis in patients with/planned for CABG |
| Renal Artery Disease | |
| IIb - Stenting for symptomatic atherosclerotic stenosis >60% | III - Stenting for symptomatic atherosclerotic stenosis >60% |
| 2017 New Recommendations: | |
| Renal Artery Disease | |
| Fibromuscular dysplasia balloon angioplasty with bailout stenting | |
| 2017 Change in Recommendations: | |
| Lower Extremity Artery Disease (LEAD) | |
| Aorto-iliac lesions | |
| IIa - Primary endovascular therapy for 'TASC-D' | IIa - Surgery in aorta-iliac or -bi-femoral occlusions |
| IIb - Endovascular as an alternative in experienced centres. | |
| Infra-popliteal lesions | |
| IIa - Endovascular first | I - Bypass using GSV |
| IIa - Endovascular therapy | |
| 2017 New Recommendations: | |
| Lower Extremity Artery Disease (LEAD) | |
| I - Statins to improve walking distance | |
| I - LEAD + Atrial Fibrillation (AF): Anticoagulation if CHAD-VASc >2 | |
| IIa - Angiography in Chronic limb-threatening ischaemia (CLTI) with below-the-knee lesions | |
| IIa - Duplex screening for Abdominal Aortic Aneurysm (AAA) | |
| IIa - In case of CABG: screen LEAD with ABI, limit vein harvesting if LEAD | |
| IIb - Screening for LEAD in patients with coronary artery disease (CAD) | |
| IIb - Screening for LEAD in patients with heart failure (HF) | |
| IIb - Clopidogrel preferred over aspirin | |
| III - Antiplatelet therapy in isolated asymptomatic LEAD | |
| 2017 New Recommendations: | |
| Mesenteric Artery Disease | |
| IIa - D-dimers to rule out acute mesenteric ischaemia | |
| III - No delay for re-nuutrition in case of symptomatic Chronic Mesenteric Ischaemia | |
| 2017 New Recommendations: | |
| All Peripheral Arterial Diseases (PADs) | |
| IIa - Screening for heart failure (BNP, TTE) | |
| IIa - Stable PADs + other conditions requiring anticoagulants (e.g. AF): anticoagulation alone | |
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries Endorsed by: the European Stroke Organization (ESO) The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS)
Recommendations in Patients with Peripheral Arterial Diseases: Best Medical Therapy
| Class I |
| "1. Smoking cessation is recommended in all patients with PADs. (Level of Evidence: B) " |
| "2. Healthy diet and physical activity are recom- mended for all patients with PADs. (Level of Evidence: C) " |
| "3. Statins are recommended in all patients with PADs. (Level of Evidence: A) " |
| "4. In patients with PADs, it is recommended to reduce LDL-C to < 1.8 mmol/L (70 mg/dL) or decrease it by ≥50% if baseline values are 1.8–3.5 mmol/L (70–135 mg/dL). (Level of Evidence: C) " |
| "5. In diabetic patients with PADs, strict glycae- mic control is recommended. (Level of Evidence: C) " |
| "6. Antiplatelet therapy is recommended in patients with symptomatic PADs. (Level of Evidence: C) " |
| "7. In patients with PADs and hypertension, it is recommended to control blood pressure at < 140/90 mmHg. (Level of Evidence: A) " |
| Class IIa |
| "8. In patients with PADs and hypertension, it is recommended to control blood pressure at < 140/90 mmHg.. (Level of Evidence: B) " |
| ACEIs = angiotensin-converting enzyme inhibitors; ARBs = angiotensin-receptor blockers; LDL-C = low-density lipoprotein cholesterol; PADs = peripheral arterial diseases |
Recommendations on Antithrombotic Therapy in Patients with Peripheral Arterial Diseases (PADs)
| Carotid artery disease |
| Class I |
| "1. In patients with symptomatic carotid stenosis, long-term SAPT is recommended. (Level of Evidence: A) " |
| "2. DAPT with aspirin and clopidogrel is recommended for at least 1 month after CAS. (Level of Evidence: B) " |
| Class IIa |
| "3. In patients with asymptomatic >50% carotid artery stenosis, long-term antiplatelet therapy (commonly low-dose aspirin) should be considered when the bleeding risk is low. (Level of Evidence: C) " |
| AF = atrial fibrillation; CAS = carotid artery stenosis; CHA2DS2-VASc = Congestive heart failure, Hypertension, Age >_75 (2 points), Diabetes mellitus, Stroke or TIA (2 points), Vascular disease, Age 65–74years, Sex category; DAPT = dual antiplatelet therapy; LEAD = lower extremity artery disease; OAC = oral anticoagulation; PADs = peripheral arterial diseases; SAPT = single antiplatelet therapy. |
Lower Extremities Artery Disease
| Class I |
| "1. Long-term SAPT is recommended in symptomatic patients. (Level of Evidence: A) " |
| "2. Long-term SAPT is recommended in all patients who have undergone revascularization. (Level of Evidence: C) " |
| "3. SAPT is recommended after infra-inguinal bypass surgery. (Level of Evidence: A) " |
| Class IIa |
| "1. DAPT with aspirin and clopidogrel for at least 1 month should be considered after infra-inguinal stent implantation. (Level of Evidence: C) " |
| Class IIb |
| "1. In patients requiring antiplatelet therapy, clopidogrel may be preferred over aspirin. (Level of Evidence: B) " |
| "2. Vitamin K antagonists may be considered after autologous vein infra-inguinal bypass. (Level of Evidence: B) " |
| "3. DAPT with aspirin and clopidogrel may be considered in below-the-knee bypass with a prosthetic graft. (Level of Evidence: B) " |
| Class III |
| "1. Because of a lack of proven benefit, antiplatelet therapy is not routinely indicated in patients with isolatedd asymptomatic LEAD. (Level of Evidence: A) " |
| AF = atrial fibrillation; CAS = carotid artery stenosis; CHA2DS2-VASc = Congestive heart failure, Hypertension, Age >_75 (2 points), Diabetes mellitus, Stroke or TIA (2 points), Vascular disease, Age 65–74years, Sex category; DAPT = dual antiplatelet therapy; LEAD = lower extremity artery disease; OAC = oral anticoagulation; PADs = peripheral arterial diseases; SAPT = single antiplatelet therapy. |
Antithrombotic Therapy for Peripheral Arterial Diseases (PADs) Patients Requiring Oral Anticoagulant
| Class I |
| "1.In patients with PADs and AF, OAC is recommended when the CHA2DS2-VASc score is ≥2. (Level of Evidence: A) " |
| Class IIa |
| "1.In patients with PADs and AF, OAC should be considered in all other patients.(Level of Evidence: B) " |
| "2.In patients with PADs who have an indication for OAC (e.g. AF or mechanical prosthetic valve), oral anticoagulants alone should be considered.(Level of Evidence: B) " |
| "3.After endovascular revascularization, aspirin or clopidogrel should be considered in addition to OAC for at least 1 month if the bleeding risk is low compared with the risk of stent/graft occlusion.(Level of Evidence: C) " |
| "4.After endovascular revascularization, OAC alone should be considered if the bleeding risk is high compared with the risk of stent/graft occlusion.(Level of Evidence: C) " |
| Class IIb |
| "1.OAC and SAPT may be considered beyond 1 month in high ischaemic risk patients or when there is another firm indication for long-term SAPT.(Level of Evidence: C) " |
| AF = atrial fibrillation; CAS = carotid artery stenosis; CHA2DS2-VASc = Congestive heart failure, Hypertension, Age >_75 (2 points), Diabetes mellitus, Stroke or TIA (2 points), Vascular disease, Age 65–74years, Sex category; DAPT = dual antiplatelet therapy; LEAD = lower extremity artery disease; OAC = oral anticoagulation; PADs = peripheral arterial diseases; SAPT = single antiplatelet therapy. |
Extracranial Carotid and Vertebral Artery Disease
Recommendations for Imaging of Extracranial Carotid Arteries
| Class I |
| "1.DUS (as first-line imaging), CTA and/or MRA are recommended for evaluating the extent and severity of extracranial carotid stenoses. (Level of Evidence: B) " |
| "2.When CAS is being considered, it is recommended that any DUS study be fol- lowed by either MRA or CTA to evaluate the aortic arch as well as the extra- and intracranial circulation. (Level of Evidence: B) " |
| "3.When CEA is considered, it is recom- mended that the DUS stenosis estimation be corroborated by either MRA or CTA (or by a repeat DUS study performed in an expert vascular laboratory)(Level of Evidence: B) " When CEA is considered, it is recommended that the DUS stenosis estimation be corroborated by either MRA or CTA (or by a repeat DUS study performed in an expert vascular laboratory). |
| CAS = carotid artery stenting; CEA = carotid endarterectomy; CTA = computed tomography angiography; DUS = duplex ultrasound; MRA = magnetic resonance angiography. |
Recommendation on the Use of Embolic Protection Device During Carotid Stenting
| Class IIa |
| "1.The use of embolic protection devices should be considered in patients undergoing carotid artery stenting.(Level of Evidence: C) " |
Recommendations for management of asymptomatic carotid artery disease
| Class IIa |
| "1.In ‘average surgical risk’ patients with an asymptomatic 60–99% stenosis, CEA should be considered in the presence of clinical and/or more imaging characteristics that may be associated with an increased risk of late ipsilateral stroke, provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy is > 5 years.(Level of Evidence: B) " |
| "2.In asymptomatic patients who have been deemed ‘high risk for CEA’d and who have an asymptomatic 60–99% stenosis in the presence of clinical and/or imaging characteristicsc that may be associated with an increased risk of late ipsilateral stroke, CAS should be considered, provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy is > 5 years.(Level of Evidence: B) " |
| Class IIb |
| "1.In ‘average surgical risk’ patients with an asymptomatic 60–99% stenosis in the presence of clinical and/or imaging characteristics that may be associated with an increased risk of late ipsilateral stroke, CAS may be an alternative to CEA provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy is > 5 years.(Level of Evidence: B) " |
| BP = blood pressure, CAS = carotid artery stenting, CEA = carotid endarterectomy |
Recommendations on Revascularization in Patients with Symptomatic Carotid Disease
| Class I |
| "1.CEA is recommended in symptomatic patients with 70–99% carotid stenoses, provided the documented procedural death/ stroke rate is < 6%. (Level of Evidence: A) " |
| "1.When decided, it is recommended to perform revascularization of symptomatic 50–99% carotid stenoses as soon as possible, preferably within 14 days of symptom onset. (Level of Evidence: A) " |
| Class IIa |
| "1.CEA should be considered in symptomatic patients with 50–69% carotid stenoses, provided the documented procedural death/ stroke rate is < 6%.(Level of Evidence: A) " |
| "1.In recently symptomatic patients with a 50–99% stenosis who present with adverse anatomical features or medical comorbidities that are considered to make them ‘high risk for CEA’, CAS should be considered, provided the documented procedural death/stroke rate is < 6%.(Level of Evidence: B) " |
| Class IIb |
| "1.When revascularization is indicated in ‘average surgical risk’ patients with symptomatic carotid disease, CAS may be considered as an alternative to surgery, provided the documented procedural death/stroke rate is < 6%.(Level of Evidence: B) " |
| Class III |
| "1.Revascularization is not recommended in patients with a < 50% carotid stenosis. (Level of Evidence: A) " |
| Symptomatic Carotid Disease: Stroke or TIA occurring within 6 months |
Recommendations for Management of Vertebral Artery Stenoses
| Class IIa |
| "1.In patients with symptomatic extracranial vertebral artery stenoses, revascularization may be considered for lesions >_50% in patients with recurrent ischaemic events despite opti- mal medical management.(Level of Evidence: B) " |
| Class III |
| "1.Revascularization of asymptomatic vertebral artery stenosis is not indicated, irrespective of the degree of severity.(Level of Evidence: C) " |
Recommendations on the Management of Subclavian Artery Stenosis
| Class IIa |
| "1.In symptomatic patients with subclavian artery stenosis/occlusion, revascularization should be considered.(Level of Evidence: C) " |
| "2.In symptomatic patients with a stenotic/ occluded subclavian artery, both revasculariza- tion options (stenting or surgery) should be considered and discussed case by case according to the lesion characteristics and patient’s risk.(Level of Evidence: C) " |
| "3. In asymptomatic subclavian artery stenosis, revascularization:
- should be considered in the case of proxi- mal stenosis in patients undergoing CABG using the ipsilateral internal mammary artery - should be considered in the case of proximal stenosis in patients who already have the ipsilateral internal mammary artery grafted to coronary arteries with evidence of myocardial ischaemia - should be considered in the case of subcla- vian artery stenosis and ipsilateral arterio-venous fistula for dialysis.(Level of Evidence: C) " |
| Class IIb |
| "1.In asymptomatic subclavian artery stenosis, revascularization may be considered in the case of bilateral stenosis in order to be able to monitor blood pressure accurately.(Level of Evidence: C) " |
| CABG: Coronary artery bypass grafting |