What’s New in the European Guidelines on Peripheral Arterial Disease

Since the last version of the European guidelines on the diagnosis and treatment of peripheral arterial disease in 2011, there have been many trials and registries that warrant guideline adjustments in many aspects. The first novelty is the teamwork that gave way to these guidelines, which were written in collaboration with the European Society of Vascular Surgery. The result was a document that balances the opinions of the best general practitioners, surgeons, and interventional cardiologists.

There have been changes on several topics:

• General items: the document emphasizes the need for multidisciplinary work with a vascular team.

• Prevention: the new guidelines gave statins the status of cornerstone of primary and secondary prevention. The document now presents a specific chapter on antithrombotic therapy in different clinical scenarios. Single antiplatelet therapy, preferably clopidogrel, is proposed for most cases with symptomatic lower-extremities disease. For asymptomatic lower-extremities disease, aspirin is not indicated given its lack of proven efficacy.

• Carotid artery disease: since 2011, most trials and registries have confirmed surgery as the first option when revascularization is indicated. Angioplasty is just an alternative. The indications for revascularization of asymptomatic carotid disease are now more restrictive than in previous guidelines, and the document provides high-risk criteria where revascularization is indicated.
• Upper-extremities disease: the document provides information on potential benefits of revascularization in some specific asymptomatic cases, such as the need for conduits for myocardial revascularization surgery, arteriovenous fistula, or bilateral subclavian stenosis.

• Mesenteric artery disease: D-dimers can be useful when acute mesenteric ischemia is suspected. In patients with suspected chronic mesenteric ischemia, occlusive disease of a single mesenteric artery renders diagnosis very unlikely. When the disease involves multiple arteries, revascularization should not be delayed in order to avoid malnutrition.

• Renal artery disease: routine revascularization is not recommended anymore in renal artery stenosis secondary to atherosclerosis.

• Lower-extremities disease: the document emphasizes specific clinical patterns such as ‘asymptomatic’ disease, which is actually masked by other symptoms such as dyspnea or angina. These guidelines strongly favor supervised exercise therapy alone, or, when necessary, in combination with revascularization. The transatlantic consensus (TASC) classification for the decision between revascularization strategies is definitely a thing of the past.

The term ‘critical lower-limb ischemia’ will be replaced by ‘chronic lower-limb-threatening ischemia’ and the recent Wound, Ischemia, and foot Infection (WIfI) classification.

Original title: The 2017 ESC Guidelines on PADs: What’s New?

Reference: Aboyans V et al. Eur Heart J. 2018 Mar 1;39(9):720-729.

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