Sandbox: Peripheral Arterial Disease

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AHA/ACC Guidelines on Management of Lower Extremity PAD

Guidelines for Clinical Assessment of Lower Extremity PAD

Guidelines for Diagnostic Testing for suspected PAD

Guidelines for Screening for Atherosclerotic Disease in Other Vascular Beds in patients with Lower Extremity PAD

Guidelines for Medical Therapy for Lower Extremity PAD

Guidelines for Structured Exercise Therapy for Lower Extremity PAD

Guidelines for Minimizing Tissue Loss in Lower Extremity PAD

Guidelines for Revascularization of Claudication in Lower Extremity PAD

Guidelines for Management of CLI in Lower Extremity PAD

Guidelines for Management of Acute Limb Ischemial in Lower Extremity PAD

Guidelines for Longitudinal Follow-up for Lower Extremity PAD

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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)

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)

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
"1. 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
"1. 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) "
"2.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) "
"2.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
"3.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 on the Management of Acute Mesenteric Ischaemia

Diagnosis
Class I
"1.In patients with suspected acute mesenteric ischaemia, urgent CTA is recommended.(Level of Evidence: C) "
Class IIa
"1.In patients with suspicion of acute mesenteric ischaemia, the measurement of D- dimer should be considered to rule out the diagnosis(Level of Evidence: B) "
Treatment
Class IIa
"1.In patients with suspicion of acute mesenteric ischaemia, the measurement of D-dimer should be considered to rule out the diagnosis(Level of Evidence: B) "(Level of Evidence: B) "
"1.In patients with acute embolic occlusion of the superior mesenteric artery, both endovascular and open surgery therapy should be considered.(Level of Evidence: B) "(Level of Evidence: B) "
CTA = computed tomography angiography

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 proximal 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

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 on the Management of Acute Mesenteric Ischaemia

Class I
Diagnosis
"1.In patients with suspected acute mesenteric ischaemia, urgent CTA is recommended.(Level of Evidence: C) "
Class IIa
"1.In patients with suspicion of acute mesenteric ischaemia, the measurement of D- dimer should be considered to rule out the diagnosis(Level of Evidence: B) "
Treatment
Class IIa
"1.In patients with suspicion of acute mesenteric ischaemia, the measurement of D-dimer should be considered to rule out the diagnosis(Level of Evidence: B) "(Level of Evidence: B) "
"1.In patients with acute embolic occlusion of the superior mesenteric artery, both endovascular and open surgery therapy should be considered.(Level of Evidence: B) "(Level of Evidence: B) "
CTA = computed tomography angiography

Recommendations for Management of Chronic Mesenteric Artery Disease

Diagnosis
Class I
"1.In patients with suspected CMI, DUS is recommended as the first-line examination.(Level of Evidence: C) "
Class IIa
"1.In patients with suspected CMI, occlusive disease of a single mesenteric artery makes the diagnosis unlikely and a careful search for alternative causes should be considered(Level of Evidence: B) "(Level of Evidence: C) "
Treatment
Class I
"1.In patients with symptomatic multivessel CMI, revascularization is recommended.(Level of Evidence: C) "
Class III
"1.In patients with symptomatic multivessel CMI, it is not recommended to delay revascularization in order to improve the nutri- tional status.(Level of Evidence: C) "

Recommendations for Diagnostic Strategies for Renal Artery Disease

Class I
"1.DUS (as first-line), CTAc and MRAd are rec- ommended imaging modalities to establish a diagnosis of RAD.(Level of Evidence: B) "
Class IIb
"1.DSA may be considered to confirm a diag- nosis of RAD when clinical suspicion is high and the results of non-invasive examinations are inconclusive(Level of Evidence: B) "(Level of Evidence: C) "
Class III
"1.Renal scintigraphy, plasma renin measure- ments before and after ACEI provocation and vein renin measurements are not recommended for screening of atherosclerotic RAD.(Level of Evidence: C) "
ACEI = angiotensin-converting enzyme inhibitor; CTA = computed tomography angiography; DSA = digital subtraction angiography; DUS = duplex ultrasound; eGFR = estimated glomerular filtration rate; MRA = magnetic resonance angiog- raphy; RAD = renal artery disease.

Recommendations for Treatment Strategies for Renal Artery Disease

Medical therapy
Class I
"1.ACEIs/ARBs are recommended for treatment of hypertension associated with unilateral RAS.(Level of Evidence: B) "
"2.Calcium channel blockers, beta-blockers and diuretics are recommended for treatment of hypertension associated with renal artery disease.(Level of Evidence: C) "
Class IIb
"1.ACEIs/ARBs may be considered in bilateral severe RAS and in the case of stenosis in a single functioning kidney, if well-tolerated and under close monitoring.(Level of Evidence: B) "(Level of Evidence: C) "
Revascularization
Class IIa
"1.In cases of hypertension and/or signs of renal impairment related to renal arterial fibromuscular dysplasia, balloon angioplasty with bailout stenting should be considered.(Level of Evidence: B) "(Level of Evidence: B) "
"2.In the case of an indication for revascularization, surgical revascularization should be considered for patients with complex anatomy of the renal arteries, after a failed endovascular procedure or during open aortic surgery.(Level of Evidence: B) "(Level of Evidence: B) "
Class IIb
"1.Balloon angioplasty, with or without stent- ing, may be considered in selected patients with RAS and unexplained recurrent congestive heart failure or sudden pulmonary oedema.(Level of Evidence: B) "(Level of Evidence: C) "
Class III
"1.Routine revascularization is not recommended in RAS secondary to atherosclerosis.(Level of Evidence: A) "
ACEIs = angiotensin-converting enzyme inhibitor; ARBs = angiotensin-receptor blockers; RAS = renal artery stenosis.

Clinical Stages of Lower Extremity Artery Disease

Clinical Stages of Lower Extremity Artery Disease
Fontain Classification Rutherford Classification
Stage Symptoms Grade Category Symptoms
I Asymptomatic 0 0 Asymptomatic
II IIa Non-disabling intermittent claudication I 1 Mild claudication
IIa Non-disabling intermittent claudication I 2 Moderate claudication
IIb Disabling intermittent claudication I 3 Severe claudication
III Ischeamic rest pain II 4 Ischeamic rest pain
IV Ulceration or gangrene III 5 Major tissue loss
Ulceration or gangrene III 6 Major tissue loss

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