New ESC/ESVS Guidelines for the Diagnosis and Treatment of Peripheral Arterial Diseases (PAD)
E. Stabile reviews the new ESC/EACTS Guidelines on PAD
The new joint ESC/ESVS guidelines for the Diagnosis and Treatment of Peripheral Arterial Diseases (PAD) have been profoundly updated thanks to the active collaboration between the European Society of Cardiology and the European Society for Vascular Surgery. In this document, the term ‘peripheral arterial diseases’ encompasses all arterial diseases other than coronary arteries and the aorta. In particular, the document addresses only PADs secondary to atherosclerosis, with a few exceptions in specific areas where nonatherosclerotic diseases are a frequent differential diagnosis (e.g. fibromuscular dysplasia in renal arteries) .
What's new in this edition?
In this 2017 edition there are several concepts that could be considered new or revised from the previous edition. In particular, it is now strongly recommended to set up a multidisciplinary Vascular Team, in healthcare centres, to make decisions for the management of patients with PADs. Similarly, best medical therapy (BMT), including drugs (i.e. statins, ACE-I/ARB, Antiplatelets) and non-pharmacological interventions (i.e. smoking cessation, increasing physical activity, weight loss) is recommended to achieve optimal outcome. There are also some recommendations on antithrombotic therapies, provided by a new specific chapter.
In detail, single antiplatelet therapy (SAPT) is indicated in all patients with carotid artery stenosis irrespective of clinical symptoms and revascularization; dual antiplatelet therapy (DAPT) should be given for at least 1month after carotid artery stenting. SAPT is indicated only if LEAD patients are symptomatic or have undergone revascularization, in this case clopidogrel is the preferred antiplatelet drug; chronic anticoagulation therapy is given only if there is a concomitant indication and may be combined with SAPT when there is a recent revascularization procedure.
Extracarnial Carotid and Vertebral Artery Disease
Carotid interventions should be performed within 14 days of symptom onset in recently symptomatic patients in order to gain maximum benefit. Given the improved prognosis with BMT, the management of asymptomatic carotid disease remains controversial. However, some subgroups of patients may benefit from revascularization (contralateral TIA or stroke, ipsilateral silent infarction, stenosis progression >20%, spontaneous embolization on transcranial Doppler, impaired cerebral vascular reserve, large plaques, echolucent plaques, increased juxta-luiminal hypoechogenic area, intraplaque haemorrhage, lipid rich necrotic core). An estimation of the perioperative risk of stroke can determine whether carotid endarterectomy or CAS is safer in individual patients, especially in the period very soon after the onset of symptoms and in patients >70 years of age. During CAS, the use of embolic protection devices is now recommended. The equivalence between carotid endarterectomy and CAS has been set in terms of perioperative late stroke rates. Vertebral artery stenosis should be treated medically, unless recurrent symptoms persist despite BMT.
Upper extremity artery disease (UEAD)
Upper extremity artery disease due to atherosclerosis is mostly situated at the level of the brachiocephalic trunk, the subclavian and axillary arteries. Revascularization can be proposed for severe/disabling symptoms, bilateral stenosis or stenosis with ipsilateral arteriovenous fistula for dialysis or in patients planned for coronary artery bypass grafting (CABG) or those already operated on with ipsilateral internal mammary artery grafted to coronary arteries with evidence of myocardial ischemia. When revascularization is considered, both endovascular and open surgical options can be proposed according to lesion characteristics and risk to the patient.
Mesenteric Artery Disease
Unfortunately mesenteric artery disease, acute or chronic, is still under-diagnosed and highly lethal. In many cases, endovascular surgery should be considered, since a less invasive option is preferred in these often frail patients. This is particular important in case of symptomatic multivessel chronic mesenteric ischemia (CMI) where any delay in revascularization should be avoided. In CMI, open surgery still has an advantage of better durability in patients with long expected survival. In acute embolic occlusion, open and endovascular surgery seem to have similar success rates.
Renal Artery Disease
Atherosclerotic renal artery disease (RAD) is the most common cause of ‘renovascular hypertension’. In clinical situations with high suspicion, the use of DUS, usually as first-line imaging, followed by MRA and/or CTA, is recommended for the establishment of a RAD diagnosis. Renal scintigraphy, plasma renin measurements before and after ACEI provocation and vein renin measurements are not recommended anymore for screening of atherosclerotic RAD.
Renal revascularization does not generally improve blood pressure, renal or CV outcomes in patients with atherosclerotic RAD. With few exceptions (i.e. hypertension and/or signs of renal impairment related to renal arterial fibromuscular dysplasia, unexplained recurrent congestive heart failure or sudden pulmonary oedema) medical therapy with antihypertensive agents, antiplatelet drugs and statins remains the cornerstone for
management of patients with RAD.
Lower extremity artery disease (LEAD)
In patients with intermittent claudication, CV prevention and exercise training are the cornerstones of management. If daily life activity is severely compromised, revascularization can be proposed, along with exercise therapy. In particular, in case of aorto-iliac lesions, an endovascular-first strategy is recommended for short (i.e. <5 cm) occlusive lesions. In patients fit for surgery, aorto-(bi)femoral bypass should be considered in aorto-iliac occlusions. An endovascular-first strategy should be considered in long and/or bilateral lesions in patients with severe comorbidities and may be considered if done by an experienced team and if it does not compromise subsequent surgical options. Primary stent implantation rather than provisional stenting should be considered. Open surgery should be considered in fit patients with an aortic occlusion extending up to the renal arteries. In the case of ilio-femoral occlusive lesions, a hybrid procedure combining iliac stenting and femoral endarterectomy or bypass should be considered. Extra-anatomical bypass may be indicated for patients with no other alternatives for revascularization.
In the case of femoropoliteal lesions, an endovascular-first strategy is recommended in short (i.e. <25 cm) lesions. Primary stent implantation should be considered in short (i.e. <25 cm) lesions, while drug-eluting balloons/stents may be considered. Drug-eluting balloons may be considered for the treatment of in-stent restenosis. In patients who are not at high risk for surgery, bypass surgery is indicated for long (i.e. >_25 cm) superficial femoral artery lesions when an autologous vein is available and life expectancy is > 2 years. When above-the-knee bypass is indicated, the use of a prosthetic conduit should be considered in the absence of any autologous saphenous vein. In patients unfit for surgery, endovascular therapy may be considered in long (i.e. >_25 cm) femoro-popliteal lesions.
The task force propose to stratify the risk of patients with chronic limb-threatening ischaemia according to the severity of ischaemia, wounds and infection. Early recognition of tissue loss and/or infection and referral to a vascular specialist is mandatory for limb salvage by a multidisciplinary approach. Revascularization is indicated whenever feasible. Acute limb ischaemia with neurological deficit mandates urgent revascularization.
Multisite artery disease
Multisite artery disease (MSAD) is common in patients with atherosclerotic involvement in one vascular bed, ranging from 10 to 15% in patients with CAD to 60 to 70% in patients with severe carotid stenosis or LEAD.
MSAD is invariably associated with worse clinical outcomes; however, screening for asymptomatic disease in additional vascular sites has not been proven to improve prognosis. In some situations the identification of asymptomatic lesions may affect patient management. This is the case for patients undergoing CABG, where ABI measurement may be considered, especially when saphenous vein harvesting is planned, and carotid screening should be considered in a subset of patients at high risk of CAD.
In patients scheduled for CABG with severe carotid stenosis, prophylactic carotid revascularization should be considered in recently symptomatic cases and may be considered in asymptomatic cases after multidisciplinary discussion. In patients with a recent (<6 months) history of TIA/stroke who are scheduled for CABG: CEA should be considered in patients with 50–99% carotid stenosis. In neurologically asymptomatic patients scheduled for CABG, routine prophylactic carotid revascularization in patients with a 70–99% carotid stenosis is not recommended. Differently it may be considered in patients with bilateral 70–99% carotid stenosis or 70–99% carotid stenosis with contralateral occlusion.
Carotid revascularization may be considered in patients with a 70–99% carotid stenosis in the presence of one or more characteristics that may be associated with an increased risk of ipsilateral stroke in order to reduce stroke risk beyond the perioperative period.
Finally, in patients planned for carotid artery revascularization for asymptomatic stenosis, preoperative coronary angiography for detection (and revascularization) of CAD may be considered.
Cardiac conditions in peripheral arterial diseases
Cardiac conditions other than CAD are frequent in patients with PADs. This is especially the case for heart failure and atrial fibrillation in patients with LEAD. In patients with symptomatic PADs, screening for heart failure should be considered. In patients with heart failure, screening for LEAD may be considered. Full vascular assessment is indicated in patients planned for heart transplantation or a cardiac assist device.
In patients with stable PADs who have AF, anticoagulation is the priority and suffices in most cases. In the case of recent endovascular revascularization, a period of combination therapy (anticoagulant and antiplatelet therapies) should be considered according to the bleeding and thrombotic risks. The period of combination therapy should be as brief as possible.
In patients undergoing transcatheter aortic valve implantation (TAVI) or other structural interventions, screening for LEAD and UEAD is indicated.