Peripheral Artery Disease (PAD) Guidelines 

Updated: Jan 06, 2020
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Screening

Because early detection of peripheral artery disease (PAD) in asymptomatic patients and subsequent treatment may reduce cardiovascular disease (CVD) in a potentially large group of individuals, screening guidelines have been addressed by a number of organizations, including the following:

  • US Preventive Services Task Force (USPSTF)
  • American College of Preventive Medicine (ACPM)
  • American College of Cardiology/American Heart Association (ACC/AHA)
  • Society for Vascular Surgery (SVS)
  • European Society of Cardiology (ESC)
  • ESC/European Society for Vascular Surgery (ESVS)
  • American Diabetes Association (ADA)

Currently, no organization recommends routine screening for PAD in asymptomatic patients. In 2013, the USPSTF changed its recommendation against screening to an indeterminate recommendation, due to insufficient evidence to assess the balance of benefits and harms. However, for individuals with known CVD or diabetes, the USPSTF recommends risk reduction interventions (eg, antiplatelet or lipid-lowering therapies). [1]

Recommendations for PAD screening are listed in Table 1, below.

Table 1. Recommendations for Peripheral Artery Disease Screening in Adults (Open Table in a new window)

Issuing organization

Year

Recommendation

US Preventive Services Task Force [1]

2013

Insufficient evidence that screening for peripheral artery disease (PAD) in asymptomatic adults leads to clinically important benefits. Risk reduction interventions (such as antiplatelet or lipid-lowering therapies) are recommended for high- risk individuals with known cardiovascular disease (CVD) or diabetes.

American College of Preventive Medicine [2]

2011

No routine screening is recommended but clinicians should be alert to symptoms of PAD in patients with risk factors (eg, age ≥50 years, history of smoking, diabetes mellitus).

American College of Cardiology/American Heart Association [3, 4, 5]

2005/2011/2016

Screen with ankle-brachial index (ABI) in patients at increased risk, including adults ≥65 years old, adults ≥50 years old with a history of smoking or diabetes, and adults of any age with exertional leg symptoms or nonhealing wounds.

 

A screening duplex ultrasound (DUS) for abdominal aortic aneurysm (AAA) is reasonable in patients with symptomatic PAD.

Society for Vascular Surgery [6]

2015

Screening is reasonable if used to improve risk stratification, preventive care, and medical management in asymptomatic patients at increased risk, (eg, adults >70 years old, smokers, individuals with diabetes, those with an abnormal pulse examination, or other established CVD).

European Society of Cardiology (ESC) [7]  and ESC/European Society for Vascular Surgery [8]

2011/2017

Consider screening with ABI in patients with coronary artery disease (CAD).

 

DUS screening for AAA should be considered.

 

In patients with CAD, ABI screening for LEAD may be considered for risk stratification.

 

Screening with electrocardiography is recommended in all patients and with imaging stress testing in patients with poor functional capacity and more than two of the following: history of CAD, heart failure, stroke or transient ischemic attack, chronic kidney disease, diabetes mellitus requiring insulin therapy.

American Diabetes Association [9]

2015

Screen with ABI in patients with diabetes who are symptomatic or are asymptomatic and >50 years old or have at least one other risk factor (eg, smoking, hypertension, hyperlipidemia, or duration of diabetes >10 years).

Next:

Lower Extremity PAD

The following organizations have released guidelines for the management of peripheral artery disease (PAD) in the lower extremities:

  • American College of Cardiology/American Heart Association (ACC/AHA)
  • Society for Vascular Surgery (SVS)
  • European Society of Cardiology (ESC)
  • ESC/European Society for Vascular Surgery (ESVS)
  • SVS, ESVS, and World Federation of Vascular Societies

Risk Factors

The ACC/AHA identifies the following as the most common risk factors for lower-extremity PAD [3] :

  • Age ≥70 years
  • Age 50-69 years and history of smoking or diabetes
  • Age < 50 years with diabetes and at least one of these additional atherosclerosis risk factor: smoking, hypertension, dyslipidemia, hyperhomocysteinemia
  • Known coronary, carotid, or renal atherosclerotic disease

The SVS and ESC guidelines concur that older age, smoking, and diabetes are associated with the highest relative risk of developing lower-extremity PAD. [6, 7]

Diagnosis

The guidelines recommend ankle-brachial index (ABI) determination as the first-line noninvasive test to establish a diagnosis of PAD, because of its high sensitivity and specificity. [3, 6, 7] The ACC/AHA recommends using the resting ABI in patients with any of the following:

  • Exertional leg symptoms
  • Nonhealing wounds
  • Age ≥70 years
  • Age ≥50 years and older with a history of smoking or diabetes

ABI diagnostic values are as follows [4, 5] :

  • ≤0.90: Abnormal (PAD)
  • 0.91-0.99: Borderline
  • 1.00-1.40: Normal
  • >1.40: Noncompressible (often due to diabetes or advanced age)

ACC/AHA and SVS recommend exercise ABI testing in patients with claudication or other risk factors whose ABI is borderline or normal. [3, 6] For patients with ABI >140, the ACC/AHA and ESC recommended toe-brachial index or pulse volume recording as alternative tests. [3, 7]

For symptomatic patients who may undergo revascularization, the guidelines recommend imaging studies such as duplex ultrasound (DUS), computed tomography angiography (CTA), magnetic resonance angiography (MRA), and contrast arteriography. The use of segmental pressures and pulse volume recordings to assess localization and severity is also recommended. [3, 5, 6, 7]

The ESC/ESVS indicate DUS as a first-line imaging method to confirm lower extremity artery disease (LEAD). [8] DUS and/or CTA and/or MRA are indicated for anatomic characterization of LEAD lesions and guidance for optimal revascularization strategy. Data from anatomic imaging test should always be analyzed in conjunction with symptoms and hemodynamic tests prior to a treatment decision. [8]

Cardiovascular Disease Risk Reduction

Treatment of asymptomatic disease is directed at risk factor reduction. The following measures are recommended by the ACC/AHA and ESC [3, 4, 7] :

  • Smoking cessation
  • Beta-blocker (class I recommendation) or angiotensin-converting enzyme (ACE) inhibitor therapy to achieve a blood pressure of < 140/90 mm Hg, or < 130/80 mm Hg for adults with diabetes or chronic kidney disease
  • Statin therapy to achieve a low density lipoprotein (LDL) cholesterol level < 100 mg/dL, or < 70 mg/dL for those at very high risk for ischemic events
  • In patients with diabetes, proper foot care and glycemic control to reduce hemoglobin A1C to < 7%
  • Antiplatelet therapy with daily low-dose aspirin (75-325 mg)

The ESC/ESVS recommends a screening DUS in patients undergoing coronary artery bypass grafting (CABG) who have had a recent (< 6 months) history of transient ischemic attack (TIA)/stroke. [8] In patients without a recent history of TIA/stroke, DUS may be considered in those at least age 70 years, or in those with multivessel coronary artery disease (CAD), comcomitant LEAD, or carotid bruit. However, screening for carotid stenosis is not indicated in patients requiring urgent CABG with no recent stroke/TIA. [8]

Concomitant lower extremity artery disease and coronary artery disease

The ESC/ESVS recommends radial artery access as the first option for coronary angiography/intervention in patients with LEAD. [8] In patients with LEAD undergoing CABG, consider sparing the autologous great saphenous vein for potential future use for surgical peripheral revascularization.

Consider screening for LEAD in patients undergoing CABG and requiring saphenous vein harvesting. [8]

In patients with CAD, ABI screening for LEAD may be considered for risk stratification. [8]

In patients undergoing elective carotid endarterectomy (CEA), preoperative CAD screening, including coronary angiography, may be considered. [8]  ESC/ESVS recommendations regarding symptomatic carotid disease include the following [8] :

  • CEA is recommended in symptomatic patients with 70-99% carotid stenosis, provided the documented procedural death/stroke rate is below 6%.
  • Once the decision is made, revascularization of symptomatic 50-99% carotid stenoses is recommended to be performed as soon as possible (preferably within 14 days of symptom onset).
  • Revascularization is not recommended in patients with a less than 50% stenosis.

Intermittent Claudication—First-Line Intervention

Intermittent claudication (IC) is managed with exercise and medication to improve symptoms and impede progression of the disease. Endovascular and surgical revascularization are generally recommended when exercise and medication have failed. [3, 5, 6, 7, 8]

In addition to lifestyle modification for risk reduction, similar to those outlined above, the 2015 SVS guidelines for treatment of IC recommend the following first-line interventions [6] :

  • A supervised exercise program consisting of walking a minimum of three times per week (30-60 min/session) for at least 12 weeks
  • Home-based exercise, with a goal of at least 30 minutes of walking three to five times per week when a supervised exercise program is unavailable or for long-term benefit after a supervised exercise program is completed
  • Clopidogrel, 75 mg daily, as an effective alternative to aspirin for antiplatelet therapy (warfarin should not be used for the sole indication of reducing the risk of adverse cardiovascular events or vascular occlusions)
  • In patients who do not have chronic heart failure, consider a 3-month trial of cilostazol (100 mg twice daily) to improve pain-free walking; in patients who cannot tolerate cilostazol, pentoxifylline (400 mg thrice daily) may be considered
  • Ramipril (10 mg/d) may also be considered to improve pain-free and maximal walking times, but is contraindicated in individuals with known renal artery stenosis
  • Annual follow-up to assess compliance with lifestyle measures (eg, smoking cessation, exercise) and medical therapies as well as to assess for evidence of progression in symptoms or signs of PAD; ABI testing may be of value to provide objective evidence of disease progression

In general, the ACC/AHA and ESC recommendations are in agreement but include the following variations:

  • ACC/AHA finds the usefulness of unsupervised exercise programs to be not well established [3]
  • ESC recommends considering revascularization for patients who have poor improvement after 3-6 months of conservative therapy (risk factor reduction, exercise therapy, and pharmacotherapy) [6]
  • ESC recommends revascularization as a first-line therapy, along with risk factor management, for patients with severe intermittent claudication that impacts their activities of daily life [6]

Critical Limb Ischemia

The ACC/AHA guidelines include the following recommendations for management of CLI [3, 4, 5] :

  • Emergent evaluation of patients with acute limb ischemia (ALI) by a clinician experienced in assessing limb viability and implementing appropriate therapy. Administer systemic anticoagulation with heparin unless contraindicated.
  • In patients with suspected ALI, the initial evaluation should rapidly assess limb viability and salvage potential; imaging is not required.
  • In patients with combined inflow and outflow disease, inflow lesions should be treated first; if symptoms of CLI or infection persist after inflow revascularization, an outflow revascularization procedure is required
  • Balloon angioplasty is reasonable when an autogenous vein conduit is not available for patients with limb-threatening CLI and life expectancy ≤2 years
  • Bypass surgery, when possible and an autogenous vein conduit is available, is reasonable as initial treatment for patients with limb-threatening CLI and life expectancy >2 years

The 2016 ACC/AHA guidelines include the following recommendations for revascularization for ALI and CLI [5] :

  • The revascularization strategy of patients with ALI should be determined by local resources and patient factors (eg, etiology, degree of ischemia).
  • Catheter-based thrombolysis is effective for patients with ALI and a salvageable limb. Amputation should be performed as the first procedure in those with a nonsalvageable limb. Percutaneous mechanical thrmobectomy can be useful as adjunctive therapy to thrombolysis in patients with ALI and a salvageable limb.
  • Monitor and treat (eg, fasciotomy) postrevascularization ALI patients for compartment syndrome.
  • Surgical thrombectomy can be effective in patients with ALI due to embolism and who have a salvageable limb.
  • The usefulnes of ultrasound-accelerated catheter-based thrombolysis for patients with ALI and a salvageable limb is unknown.
  • Patients with CLI should undergo revascularization when possible to minimize tissue loss.
  • Prior to amputation in patients with CLI, an interdisciplinary team should evaluate for revascularization options.
  • Endovascular or surgical procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene. Use of angiosome-directed endovasculary therapy may be reasonable for patients with CLI and nonhealing wounds or gangrene.
  • A staged endovascular or surgical approach is reasonable in patients with ischemic rest pain.
  • Evaluation of lesion characteristics can be useful in selecting the endovascular approach for CLI.
  • When surgery is performed for CLI, bypass to the popliteal or infrapopliteal arteries (eg, tibial, pedal) should be constructed with a suitable autologous vein.
  • When endovacular revascularization has failed and a suitable autologous vein is not available, prosthetic material can be effective for bypass to the below-knee popliteal and tibial arteries in patients with CLI.

The ACC/AHA guideline recommends evaluation for primary amputation of the leg in patients with any of the following [3, 4] :

  • Significant necrosis of weight-bearing portions of the foot
  • Uncorrectable flexion contracture
  • Paresis of the extremity
  • Refractory ischemic rest pain
  • Sepsis
  • Limited life expectancy

The ESC recommends revascularization whenever feasible for limb salvage. [7, 8]  Endovascular therapy is preferred, if technically possible. [7]

The ESC/ESVS recommend urgent revascularization in the setting of acute limb ischemia with neurologic deficit. [8]  In the absence of neurologic deficit, revascularization is indicated within hours after the initial imaging on a case-by-case basis. Heparin and analgesics are indicated as soon as possible. [8]

In 2014, the Society for Cardiac Angiography and Interventions (SCAI) issued a consensus statement on the treatment of infrapopliteal arterial disease. The statement provided the following recommendations [10] :

  • Invasive intervention for infrapopliteal disease is appropriate in patients with two- or three-vessel disease and (1) moderate-to-severe claudication with a focal arterial lesion; (2) ischemic foot pain during rest (Rutherford classification 4); or (3) minor and major (skin necrosis, gangrene) tissue loss.
  • Primary amputation should be the preferred intervention in nonambulatory patients with a limited life expectancy and extensive necrosis or gangrene.
  • Consider surgical bypass and evaluate its associated risks for ambulatory patients with a patent infrapopliteal artery that has direct flow to the foot and an adequate autologous venous conduit.
  • Use balloon angioplasty for clinically significant infrapopliteal arterial disease; consider bailout bare-metal and drug-eluting stents for tibial arterial disease that is refractory to treatment with balloon angioplasty.
  • Endovascular intervention is not appropriate for most single-vessel, mildly symptomatic, or asymptomatic blockages of infrapopliteal vessels.
  • It is not appropriate to treat most cases of moderate-to-severe claudication or major tissue loss in one-vessel disease and mild claudication in one-, two-, or three-vessel disease.

In 2019, the SVS, ESVS, and World Federation of Vascular Societies released guidelines on chronic limb-threatening ischemia (CLTI), as follows. [11]

Definitions and nomenclature

Evaluate for ischemia and determine its severity using objective hemodynamic tests in all patients with suspected CLTI.

Grade wound extent, degree of ischemia, and infection severity with a lower-extremity threatened-limb classification staging system to guide clinical treatment in all patients with suspected CLTI.

Diagnosis and limb staging

A detailed history should be performed in all patients with suspected CLTI to determine symptoms, cardiovascular risk factors, and medical history .

A complete cardiovascular physical examination should be performed in all patients with suspected CLTI.

A complete foot examination should be performed in all patients with pedal tissue loss and suspected CLTI, including a neuropathy assessment and a probe-to-bone test of any open ulcers.

Ankle pressure (AP) and ankle-brachial index (ABI) should be measured as first-line noninvasive testing in all patients with suspected CLTI.

Toe pressure (TP) and toe-brachial index (TBI) should be measured in all patients with tissue loss and suspected CLTI.

High-quality angiographic imaging of the lower limb (including the ankle and foot) should be performed in all patients with suspected CLTI who may be candidates for revascularization.

Medical management

Cardiovascular risk factors should be evaluated in all patients with suspected CLTI.

Modifiable risk factors should be managed in all patients with suspected CLTI.

Antiplatelet therapy should be administered to all patients with CLTI.

Systemic vitamin K antagonists should be avoided in the treatment of lower extremity atherosclerosis in patients with CLTI.

Statin therapy (moderate- or high-intensity) should be administered to patients with CLTI to reduce the likelihood of all-cause and cardiovascular mortality.

Hypertension should be modified to target levels of < 140 mm Hg systolic and < 90 mm Hg diastolic in patients with CLTI.

Metformin is the primary hypoglycemic agent in patients with type 2 diabetes mellitus (DM) and CLTI.

Smoking-cessation interventions should be offered to all patients with CLTI who use tobacco products.

Smokers or former smokers with CLTI should be inquired about the status of tobacco use at every visit.

Analgesics should be prescribed to patients with CLTI who have ischemic rest pain of the lower extremity and foot until pain resolves following revascularization.

Chronic severe pain should be treated with acetaminophen in combination with opioids in patients with CLTI.

Global Limb Anatomic Staging System

An integrated limb-based anatomic staging system (eg, Global Limb Anatomic Staging System [GLASS]) should be used to define the complexity of a preferred target artery path (TAP) and to aid in revascularization (EBR) in patients with CLTI.

Strategies for evidence-based revascularization

A vascular specialist should be consulted in all cases of suspected CLTI to consider limb salvage except when major amputation is considered medically urgent.

Patients with a limited life expectancy, unsalvageable limb, or poor functional status should be offered primary amputation or palliation after shared decision-making.

The periprocedural risk should be assessed and life expectancy estimated in patients with CLTI who are candidates for revascularization.

All patients with CLTI who are candidates for limb salvage should be staged with an integrated threatened limb classification system.

Urgent surgical drainage and debridement (including minor amputation, if needed) should be performed and antibiotic therapy initiated in all patients with suspected CLTI who have wet gangrene or deep-space foot infection.

Limb staging should be repeated following surgical drainage, debridement, minor amputation, or correction of inflow disease (aortoiliac [AI], common and deep femoral artery disease) and before subsequent major treatment decisions.

Revascularization should not be performed in patients without significant ischemia (Wound, Ischemia, and foot Infection [WIfI] ischemia grade 0) unless an isolated region of poor perfusion in conjunction with major tissue loss (eg, WIfI wound grade 2 or 3) can be effectively targeted and the wound progresses or fails to decrease in size by 50% or more within 4 weeks despite appropriate infection control, wound care, and offloading.

Revascularization should be offered to all average-risk patients with advanced limb-threatening conditions (eg, WIfI stage 4) and significant perfusion deficits (eg, WIfI ischemia grades 2 and 3).

High-quality angiographic imaging with dedicated views of foot and ankle arteries should be performed for anatomic staging and procedural planning in all patients with CLTI who are candidates for revascularization.

The anatomic pattern of disease and preferred TAP should be defined with an integrated lib-based staging system in all patients with CLTI who are candidates for revascularization.

When available, ultrasonographic vein mapping should be performed in all patients with CLTI who are candidates for surgical bypass.

The ipsilateral great saphenous vein (GSV) and small saphenous vein should be mapped to plan the surgical bypass.

Veins in the contralateral leg and both arms should be mapped if the ipsilateral vein is insufficient.

A patient with CLTI should not be considered as unsuitable for revascularization until imaging studies are reviewed and the patient is clinically evaluated by a qualified vascular specialist.

Inflow disease should be corrected first in patients with CLTI who have both inflow and outflow disease.

The decision for staged versus combined inflow and outflow revascularization should be based on risk and limb threat.

Inflow disease alone should be corrected in patients with CLTI who have multilevel disease and low-grade ischemia (eg, WIfI ischemia grade 1) or limited tissue loss (eg, WIfI wound grade 0 or 1) and whenever the risk-benefit of additional outflow reconstruction is high or initially unclear.

The limb should be restaged and hemodynamic assessment repeated following inflow correction in patients with CLTI who have both inflow and outflow disease.

An endovascular-first approach should be used to treat patients with CLTI who have moderate to severe (eg, GLASS stage IA) aortoiliac (AI) disease.

Open common femoral artery (CFA) endarterectomy with patch angioplasty should be performed, with or without extension into the profunda femoris artery (PFA), in patients with CLTI who have hemodynamically significant disease of the common and deep femoral arteries (>50% stenosis).

Endovascular treatment should be considered for significant CFA disease in patients who are deemed to be at high surgical risk or to have a hostile groin.

Stents should be avoided in the CFA, and they should not be placed across the origin of a patent deep femoral artery.

Hemodynamically significant disease of the proximal deep femoral artery should be corrected, when technically feasible.

Decisions concerning endovascular intervention versus open surgical bypass should be based on the severity of the limb threat (eg, WIfI grade), the anatomic disease pattern (eg, GLASS), and the availability of autologous vein in average-risk patients with CLTI.

The preferred conduit for infrainguinal bypass surgery is autologous vein in patients with CLTI.

Intraoperative imaging (angiography, duplex ultrasonography, or both) should be performed upon completion of open bypass surgery for CLTI and significant technical defects corrected, if feasible, during the index operation.

Nonrevascularization treatments

Vasoactive drugs and defibrinating agents (ancrod) should not be offered to patients in whom revascularization is not possible.

Hyperbaric oxygen therapy (HBOT) should not be offered to improve limb salvage in patients with CLTI who have severe uncorrected ischemia (eg, WIfI ischemia grade 2 or 3).

Optimal wound care should be continued until the lower extremity wound has completely healed or amputation is performed.

Biologic and regenerative medicine approaches

Therapeutic angiogenesis should be restricted for patients with CLTI who are enrolled in a registered clinical trial.

Minor and major amputations

After shared decision-making, primary amputation should be offered to patients with CLTI who have an unsalvageable or pre-existing dysfunctional limb, a short life expectancy, or poor functional status.

A multidisciplinary rehabilitation team should be involved from the time of decision to amputate through successful completion of rehabilitation.

Patients with CLTI who have undergone amputation should be monitored at least yearly to track disease progression in the contralateral limb, to maintain optimal medical therapy, and to manage risk factors.

Postprocedural care and surveillance following infrainguinal revascularization

Following lower-extremity revascularization, optimal medical therapy for peripheral artery disease (PAD), including long-term antiplatelet and statin therapies, should be continued.

Smoking cessation should be promoted to all patients with CLTI who have undergone lower-extremity revascularization.

Patients who have undergone lower-extremity vein bypass for CLTI should be observed regularly for at least 2 years. The clinical surveillance program should include interval history, pulse examination, and assessment of resting APs and TPs. Duplex ultrasonography should also be considered.

Patients who have undergone lower-extremity prosthetic bypass for CLTI should be observed regularly for at least 2 years, with interval history, pulse examination, and measurement of resting APs and TPs.

Patients who have undergone infrainguinal endovascular interventions for CLTI should be observed in a surveillance program that includes clinical visits, pulse examination, and noninvasive testing (resting APs and TPs).

Additional imaging should be considered in patients with lower-extremity vein grafts whose ABI has decreased ≥0.15 and whose symptoms have recurred or pulse status changed to evaluate for vein graft stenosis.

Intervention should be offered if vein graft lesions are detected on duplex ultrasonography in patients with an associated peak systolic velocity (PSV) of >300 cm/s and a PSV ratio >3.5 or grafts with low velocity (midgraft PSV < 45 cm/s) to maintain patency.

Long-term surveillance, including duplex ultrasonographic graft scanning, should be maintained following surgical or catheter-based revision of a vein graft to evaluate for recurrent graft-threatening lesions.

Mechanical offloading should be provided as a primary component of care in all patients with CLTI who have pedal wounds.

Counseling on protection of the healed wound and foot should be provided, including appropriate shoes, insoles, and monitoring of inflammation.

Revascularization

ACC/AHA guidelines recommend endovascular revascularization as second-line therapy for patients with lifestyle- or vocation-limiting disability when there is a reasonable likelihood of symptomatic improvement with treatment, and pharmacologic or exercise therapy, or both, have failed.

Aortobifemoral bypass is appropriate for patients who are unsuitable for endovascular repair; iliac endarterectomy and aortoiliac or iliofemoral bypass for surgical treatment of unilateral disease may be considered if aortobifemoral bypass is not possible. Axillofemoral-femoral bypass should not be considered except in very limited settings. [3]

SVS guidelines recommend an individualized approach to selection of invasive treatment. The SVS advises, however, that endovascular procedures are generally preferred over open surgery. [6]

ESC guidelines recommend an endovascular approach. An experienced team is required in patients with multivessel disease and severe comorbidities. Stent implementation should be considered for femoropopliteal lesions classified as type B according to the Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC B lesions). [7]

In its 2014 consensus statement on femoral-popliteal arterial intervention, the Society for Cardiac Angiography and Interventions (SCAI) advised that endovascular treatment is appropriate care for patients who have any of the following [12] :

  • Chronic total occlusion (CTO) with lifestyle- or vocation-limiting claudication despite pharmacological therapy and/or walking therapy
  • CTO with critical limb ischemia (CLI)
  • CTO and the clinical need for vascular access (eg, access needed for transaortic valvular repair)

The SCAI advises that endovascular treatment may be appropriate care for CTO with severe claudication or CLI, but is rarely appropriate care for most mildly symptomatic or asymptomatic blockages.

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Renal Arterial Stenosis

The following organizations have released guidelines for the management of renal artery stenosis (RAS):

  • American College of Cardiology (ACC)/American Heart Association(AHA)
  • European Society of Cardiology (ESC)
  • ESC/European Society for Vascular Surgery (ESVS)
  • Society for Cardiovascular Angiography and Interventions (SCAI)

Diagnosis

The 2005 ACC/AHA and 2014 ESC guidelines recommend performing diagnostic studies to identify RAS in patients with any of the following [3, 7] :

  • Onset of hypertension before the age of 30
  • Onset of severe hypertension after the age of 55
  • Accelerated hypertension (sudden and persistent worsening of previously controlled hypertension)
  • Resistant hypertension (failure of blood-pressure control despite full doses of an appropriate three-drug regimen including a diuretic
  • Malignant hypertension (hypertension with coexistent end-organ damage; ie, acute kidney injury, flash pulmonary edema, hypertensive left ventricular failure, aortic dissection, new visual or neurological disturbance, and/or advanced retinopathy)
  • New azotemia or worsening renal function after the administration of an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB)
  • Unexplained atrophic kidney or size discrepancy of greater than 1.5 cm between the kidneys
  • Unexplained renal failure

The ACC/AHA guidelines also include patients with sudden, unexplained pulmonary edema in its class I recommendations. [3] In its 2014 SCAI Expert Consensus Statement for Renal Artery Stenting Appropriate Use, the SCAI utilized the ACC/AHA recommendations. [13]

The ESC has additional recommendation for patients with hypertension and abdominal bruit as well as those with hypertension and hypokalemia in particular when receiving thiazide diuretics. [7]

Class I recommendations for establishing a diagnosis of RAS generally concur and include the following [3, 7] :

  • Duplex ultrasonography (DUS) is the first-line test
  • Computed tomography angiography (CTA) in patients with creatinine clearance >60 mL/min
  • Magnetic resonance angiography (MRA) in patients with creatinine clearance >30 mL/min

When the clinical index of suspicion is high and the results of noninvasive tests are inconclusive, ACC/AHA recommends catheter angiography, [3] while ESC recommends digital subtraction angiography. [7]

Both guidelines are in agreement that captopril renal scintigraphy, selective renal vein renin measurements, plasma renin activity, and the captopril test are not recommended as useful screening tests for RAS (class III). [3, 7]

The ESC/ESVS guidelines recommend the imaging modalities DUS (first line), CTA, and MRA to establish a diagnosis of renal artery disease (RAD). [8] Digital subtraction angiography (DSA) may be considered to confirm a diagnosis of RAD when there is a high clinical suspicion and the findings of noninvasive evaluations are inconclusive. However, renal scintigraphy, plasma renin measurements before and after angiotensin-converting enzyme inhibitor (ACEI) challenge and vein renin measurements are not recommended for screening of atherosclerotic RAD. [8]

SCAI recommends renal angiography as the gold standard for invasive assessment of hemodynamically significant RAS and categorizes stenosis severity as follows [13] :

  • Mild: < 50%
  • Moderate: 50–70%
  • Severe: >70%

Severe angiographic stenosis is considered hemodynamically significant. Moderate angiographic stenosis is considered hemodynamically significant only when the patient also has a resting mean pressure gradient >10 mm Hg or systolic hyperemic pressure gradient >20 mm Hg or renal fractional flow reserve (FFR) ≤0.8. Mild and moderate stenosis that is not hemodynamically significant should only rarely be considered for revascularization. [13]

Medical Therapy

ACC/AHA, ESC, and SCAI all prefer medical therapy as the first-line treatment for RAS. [3, 7, 13] ACC/AHA and ESC recommend ACE inhibitors (ACEIs), ARBs, and calcium channel blockers (CCBs) for unilateral RAS, [3, 7] but ESC considers ACE inhibitors and ARBs contraindicated for the treatment of bilateral severe RAS and in the case of a single functional kidney. [7] ACC/AHA also recommends beta-blockers for treatment of hypertension associated with RAS.

However, the 2017 ESC/ESVS guidelines recommend ACEIs and ARBs for unilateral RAS. [8] For treatment of hypertension associated with RAD, CCBs, beta blockers, and diuretics are recommended. ACEIs/ARBs may be considered in bilateral severe RAS and in the setting of a single functioning kidney, if these agents are well tolerated and the patients are closely monitored. [8]

Revascularization

The ACC/AHA guidelines recommend percutaneous revascularization in patients with hemodynamically significant RAS and any of the following [3] :

  • Recurrent congestive heart failure or sudden unexplained pulmonary edema (class I)
  • Unstable angina (class IIa)
  • Accelerated, resistant, or malignant hypertension or hypertension with unexplained unilateral small kidney and intolerance to medication (class IIa)
  • Asymptomatic bilateral or single functioning kidney; however, this treatment is clinically unproven in asymptomatic unilateral hemodynamically significant RAS in a viable kidney (class IIb)

In addition, percutaneous revascularization is reasonable for patients with progressive chronic kidney disease (CKD) and bilateral RAS or a RAS to a single functioning kidney and can be considered for unilateral RAS with chronic renal insufficiency. [3]

The ESC/ESVS do not recommend routine revascularization in RAS due to atherosclerosis. [8]  They indicate ballon angioplasty with bailout stenting should be considered in cases of hypertension and/or signs of renal impairment related to renal arterial fibromuscular dysplasia. Balloon angioplasty, with or without stenting, may be considered in selected patients with RAS and unexplained recurrent congestive heart failure or sudden pulmonary edema. When revascularization is indicated, surgical revascularization should be considered for patients with complex anatomy of the renal arteries, after a failed endovascular procedure, or during open aortic surgery. [8]

ACC/AHA and ESC recommend renal stent placement for ostial atherosclerotic RAS (class I). [3]

ACC/AHA gives a class I recommendation for balloon angioplasty with bailout stent placement if necessary for fibromuscular dysplasia lesions, [3] whereas ESC recommends considering balloon angioplasty with or without stenting for patients with RAS and recurrent congestive heart failure or sudden pulmonary edema and preserved left ventricular systolic function (class IIb). [7]

Based on an expert panel review of scientific data, the SCAI concluded that patients with the following are most likely to benefit from renal artery stenting [13] :

  • Cardiac disturbance syndromes (flash pulmonary edema or acute coronary syndrome)
  • Hypertension that has not been controlled by three or more medications at maximal tolerated doses
  • Blockages in both kidneys or severe blockages in a single functioning kidney when blood pressure or renal dysfunction cannot be managed medically

The SCAI concluded that patients with any of the following are typically not good candidates for renal artery stenting [13] :

  • Mild or moderate blockages (less than 70%)
  • Long-standing loss of blood flow
  • Complete blockage of the renal artery

ACC/AHA gives class I recommendations to surgical revascularization for the following indications [3] :

  • Fibromuscular dysplasia, especially in those exhibiting complex disease or macroaneurysms
  • Atherosclerotic RAS and multiple small renal arteries or early primary branching of the main renal artery
  • Atherosclerotic RAS in combination with pararenal aortic reconstruction

ESC gives a class IIb recommendation to consider surgical revascularization in patients undergoing repair of the aorta or with complex anatomy of renal arteries or after failure of endovascular treatment. [7]

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Abdominal Aortic Aneurysms (AAA)

Screening

Screening guidelines for abdominal aortic aneurysms (AAA) have been released by the following organizations:

  • US Preventive Services Task Force (USPSTF)
  • American College of Preventive Medicine(ACPM)
  • American College of Cardiology (ACC)/American Heart Association(AHA)
  • Society for Vascular Surgery (SVS)
  • European Society of Cardiology (ESC)
  • European Society of Vascular Surgery (ESVS)

Because most AAA are asymptomatic until they rupture but the risk for death with AAA rupture is as high as 75-90%, all the organizations recommend a one-time screening with ultrasound for high-risk men >65 years old. Because of the relatively low risk in women, including those who have smoked, the guidelines vary from recommending against screening to recommending it for in specific higher-risk populations. A comparison of all screening recommendations for AAA is outlined in Table 2, below.

Table 2. Abdominal aortic aneurysm screening recommendations (Open Table in a new window)

One-time abdominal screening with ultrasound

USPSTF (2014)   [14]

ACPM (2011)   [2]

ACC/AHA (2005/2011)   [3, 4]

SVS (2009)   [15]

ESC (2014)   [16]

ESVS (2011)   [17]

All men

65-74 years old (offer selectively)

   

≥65 years old

>65 years old

≥65 years old

Men who have smoked

65-74 years old

65-74 years old

65-74 years old

   

Consider < 65 years old

Men with family history of AAA

   

≥60 years old

≥55 years old

 

Consider < 65 years old

All women

Recommend against in women who have never smoked

Recommend against

   

Recommend against in absence of family history or smoking

Not beneficial

Women who have smoked

Insufficient evidence

   

≥65 years old

>65 years old (consider)

Requires further investigation

Women with a family history of AAA

     

≥65 years old

   

SVS guidelines do not recommend rescreening patients for AAA if an initial ultrasound scan performed on patients 65 years of age or older demonstrates an aortic diameter of < 2.6 cm. [15] ESVS guidelines recommend considering rescreening in those initially screened at a younger age or at higher risk for AAA. [17]

Asymptomatic AAA

ACC/AHA, SVS, ESC and ESVS guidelines agree that in asymptomatic patients with AAA < 5.5 cm, surveillance and smoking cessation are recommended; surgical repair is indicated for AAA ≥5.5 cm or if growth exceeds 1.0 cm/year. [3, 15, 16, 17]  In addition, for patients with AAA < 5.5 cm, ACC/AHA and ESC recommend monitoring and controlling blood pressure and serum lipids. [3, 16] However, the SVS guidelines find doxycycline, roxithromycin, ACE inhibitors, and ARBs of uncertain benefit in reducing the risk of AAA expansion and rupture, and that use of beta- blockers is not recommended. [15]

All the guidelines recommend that the interval for monitoring by ultrasound for expansion of AAAs should shorten as the AAA enlarges. ACC/AHA guidelines recommend that with AAA < 4.0 cm, monitoring should take place every 2 to 3 years and with AAA 4.0-5.4cm, every 6 to 12 months. [3] A comparison of the intervals recommended by the other three guidelines is shown in Table 3, below.

Table 3. Recommendations for monitoring of abdominal aortic aneurysms (Open Table in a new window)

Monitoring Interval

 Aneurysm size (cm)

SVS (2009)  [15]

ESC (2014)  [16]

ESVS (2011)  [17]

5 years

2.6 to < 3.0

   

4 years

 

2.5 to < 3.0

 

3 years

3.0 to < 3.5

3.0 to < 4.0

 

2 years

 

4.0 to ≤4.5

3.0 to < 4.0

12 months

3.5 to < 4.5

>4.5

4.0 to < 4.5

6 months

≥4.5

 

4.5 to ≤5.0

According to the ESVS guidelines, surgery may be indicated for AAA ≥5.0 cm in women or in men at higher risk of rupture due to smoking, hypertension, or chronic airway disease. Patients should be referred to a vascular surgeon for risk assessment when the AAA reaches 5.0 cm. [17]

Rupture Prevention/Repair

The ACC/AHA and ESC guidelines recommend endovascular or open aortic repair for patients with large aneurysms who are good surgical candidates. [4, 16] ACC/AHA further recommends that for patients who have undergone endovascular repair, long-term imaging surveillance should be performed to monitor for endoleak, document shrinkage or stability of excluded aneurysm sac, and to determine if further intervention is needed. Open repair is a reasonable option for those patients who cannot comply with long-term surveillance. [4]

Symptomatic AAA

ACC/AHA guidelines recommend immediate surgical evaluation of patients presenting with abdominal and/or back pain, pulsatile abdominal mass and hypotension. Surgical repair is indicated for all symptomatic AAAs regardless of size. [3]

ESC and ESVS guidelines recommend emergency repair for ruptured AAA and urgent repair for nonruptured symptomatic AAA. [16, 17] In addition, ESVS finds no evidence to support endovascular repair of ruptured AAA. However, SVS guidelines recommend considering emergent endovascular repair if anatomically feasible. [15]

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Questions & Answers

Overview

Which organizations have issued screening guidelines for peripheral artery disease (PAD)?

What are the screening guidelines for peripheral artery disease (PAD)?

Which organizations have released treatment guidelines for peripheral artery disease (PAD) in the lower extremities?

What are the risk factors for lower extremity peripheral artery disease (PAD) identified by ACC/AHA guidelines?

According to the ACC/AHA guidelines, when is ankle-brachial index (ABI) indicated for diagnosis of peripheral artery disease (PAD) in the lower extremities?

What are the ankle-brachial index (ABI) diagnostic values for peripheral artery disease (PAD) in the lower extremities?

According to guidelines, which tests should be performed in the workup of peripheral artery disease (PAD) based on ABI results?

What are the guidelines for symptomatic patients with peripheral artery disease (PAD) in the lower extremities who may undergo revascularization?

What are the guidelines on risk reduction in asymptomatic peripheral artery disease (PAD) in the lower extremities?

What are the guidelines on the treatment of intermittent claudication (IC) in peripheral artery disease (PAD) of the lower extremities?

What are the guidelines on revascularization for treatment of peripheral artery disease (PAD) in lower extremities?

According to SCAI guidelines, when is endovascular treatment indicated for peripheral artery disease (PAD) in the lower extremities?

What are the ACC/AHA guidelines on the treatment of critical limb ischemia in peripheral artery disease (PAD) of the lower extremities?

What are the ESC, ESC/ESVS, and SVS/ESVS guidelines on the treatment of critical limb ischemia in peripheral artery disease (PAD) of the lower extremities?

What are the SCAI guidelines on the treatment of critical limb ischemia in peripheral artery disease (PAD) of the lower extremities?

Which organizations have released treatment guidelines for renal artery stenosis (RAS)?

What are the ACC/AHA and ESC guidelines on the diagnosis of renal artery stenosis (RAS)?

What are the SCAI guidelines on the diagnosis of renal arterial stenosis (RAS)?

What are guidelines on medical therapy for renal artery stenosis (RAS)?

What are the guidelines on percutaneous revascularization for the treatment of renal artery stenosis (RAS)?

What are the guidelines on renal artery stenting for the treatment of RAS?

What are the guidelines on surgical revascularization to treat RAS?

What are guidelines on monitoring asymptomatic abdominal aortic aneurysms (AAA)?

Which organizations have released screening guidelines for abdominal aortic aneurysms (AAA)?

What are the guidelines for abdominal aortic aneurysms (AAA) screening?

What are the guidelines on abdominal aortic aneurysms (AAA) repair?

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