Peripheral arterial disease Microchapters |
Differentiating Peripheral arterial disease from other Diseases |
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Diagnosis |
Treatment |
Case Studies |
AHA/ACC Guidelines on Management of 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 Acute Limb Ischemial in Lower Extremity PAD |
Guidelines for Longitudinal Follow-up for Lower Extremity PAD |
Sandbox: Peripheral Arterial Disease On the Web |
American Roentgen Ray Society Images of Sandbox: Peripheral Arterial Disease |
Directions to Hospitals Treating Peripheral arterial disease |
Risk calculators and risk factors for Sandbox: Peripheral Arterial Disease |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Arzu Kalayci, M.D. [2]
2011 | 2017 |
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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 |
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 |
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. |
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. |
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. |
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. |
Class IIa |
"1.The use of embolic protection devices should be considered in patients undergoing carotid artery stenting.(Level of Evidence: C) " |
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 |
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 |
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 |
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) " |
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 |
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 |
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 |
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) " |
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. |
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 | |||||
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 |