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)==

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.

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.