ESC Focus on Interventions & PC - 5

ESC Congress 2017

In Review

Interventions &
Peripheral Circulation
Symptomatic patients should receive long-term SAPT
(I A). Patients who have undergone percutaneous coronary intervention (PCI) should receive short-term DAPT
then long-term SAPT (both IIa C) while those who have
received carotid surgery should be treated with longterm SAPT or a vitamin K antagonist (VKA; both IIb B).
The recommendations for LEAD patients who require
anticoagulation are shown in Figure 2.
Figure 2. Antithrombotic Therapy in Patients With LEAD Requiring Oral
Anticoagulation
LEAD in Patients Requiring Long-term Oral Anticoagulation
(A)symptomatic

Percutaneous
Interventions

Surgery

Bleeding Risk Lowb

Time Delay

0
1 mo.

Bleeding Risk Highb

DAT

OACa
Monotherapy
O

Class I

O A or C
Class IIa

OACa
Monotherapy

DAT
O A+C

O
O

Class IIb

Class IIa

OAC

Monotherapy

1 year

Class IIb

Long Term
DAT may be considered in high ischaemic rick
patients (ST, ALI on OAC, CAD.
Compared to the risk for stroke/CLTI due to
stent/graft occlusion.
a

Clopidogrel 75 mg/day

Oral Anticoagulation

Aspirin 75-100 mg/day

ALI, acute limb ischaemia; CAD, coronary artery disease; CLTI, chronic limbthreatening ischaemia; DAT, dual antithrombic therapy; OAC, oral anticoagulation;
ST, stent thrombosis.
Reprinted from Aboyans V, Ricco JB et al. 2017 ESC Guidelines on the Diagnosis
and Treatment of Peripheral Arterial Diseases. Eur Heart J. 2017; doi:10.1093/eurheartj/ehx095. By permission of Oxford University Press on behalf of the European
Society of Cardiology.

Table 2. Revascularisation in Patients With Renal Artery Disease
Recommendations

Class

Level

Routine revascularisation is not recommended in
RAS secondary to atherosclerosis

III

Balloon angioplasty, with or without stenting, may be
considered in selected patients with RAS and unexplained recurrent CHF or flash pulmonary oedema

IIb

In patients with hypertension and/or signs of renal
impairment related to renal FMD, balloon angioplasty with bailout stenting should be considered

IIa

When there is an indication for revascularisation,
surgical revascularisation should be considered
for patients with complex anatomy of the renal
arteries, after a failed endovascular procedure, or
during open aortic surgery

IIa

Patients With Renal Artery Disease (RAD) or
Extracranial Carotid Disease
Charalambos Vlachopoulos, MD, University of Athens
Medical School. Athens, Greece, reviewed the new recommendations for patients with RAD.
In the case of RAD and hypertension associated with
unilateral renal artery stenosis (RAS) the recommendation is for ACEIs/ARBs (I B). These therapies may also be
considered for bilateral severe RAS and in the case of stenosis in a single functioning kidney, if well tolerated and
under close monitoring (IIb B). For hypertension associated with RAD, the recommendation is for calcium channel blockers, β-blockers, and diuretics (I C). The recommendations for revascularisation are shown in Table 2.
Jean-Baptiste Ricco, MD, PhD, University of Poitiers,
Poitiers, France, presented the guidelines for the management of patients with extracranial carotid disease (ECD).
Optimal medical treatment reduces the risk of
stroke in asymptomatic patients with ECD but some
risk remains. In "average surgical risk" patients with
an asymptomatic 60% to 99% stenosis whose clinical characteristics may put them at an increased risk
of late ipsilateral stroke, carotid artery stenting (CAS)
may be an alternative to carotid endarterectomy provided documented perioperative stroke/death rates are
< 3% and the patient's life expectancy is > 5 years (IIb B).
Recommendations for revascularisation in patients with
symptomatic ECD are shown in Figure 3. The guidelines
also provide specific recommendations for screening and treating patients undergoing coronary artery
bypass graft (CABG).
Figure 3. Revascularisation in Patients With Symptomatic ECD
Occlusion
or near
Occlusion
BMT
Class I A

Carotid
Stenosis
< 50%

Carotid
Stenosis
50-69%
CEA + BMT
should be
considered
Class IIa B
CAS + BMT
may be
considered
Class IIb B

Carotid
Stenosis
70-99%

CEA + BMT
recommended
Class I A
CAS + BMT
should be
considered if
"high-risk" for
CEA
Class IIa B
otherwise may
be considered
Class IIb B

CHF, congestive heart failure; FMD, fibromuscular dysplasia; RAS, renal artery stenosis.

BMT, best medical therapy; CAS, carotid artery stenting; CEA, carotid
endarterectomy.

Reprinted from Aboyans V, Ricco JB et al. 2017 ESC Guidelines on the Diagnosis
and Treatment of Peripheral Arterial Diseases. Eur Heart J. 2017; doi:10.1093/
eurheartj/ehx095. By permission of Oxford University Press on behalf of the
European Society of Cardiology.

Adapted from Aboyans V, Ricco JB et al. 2017 ESC Guidelines on the Diagnosis
and Treatment of Peripheral Arterial Diseases. Eur Heart J. 2017; doi:10.1093/
eurheartj/ehx095. By permission of Oxford University Press on behalf of the
European Society of Cardiology.

Official Peer-Reviewed Highlights From ESC Congress 2017

Table of Contents for the Digital Edition of ESC Focus on Interventions & PC