ESC Focus on Interventions & PC - 6

Main Session

Mesenteric Artery Disease
Sebastian Debus, MD, University Heart Center HamburgEppendorf, Hamburg, Germany, noted that the 2017
guidelines have been expanded to cover both acute and
chronic mesenteric ischaemia (CMI) and arterial and
venous ischaemia. Duplex ultrasound is recommended
as first line examination for suspected CMI (I C), once
diagnosed, those with symptomatic CMI should undergo
revascularisation (I C). A novel recommendation is on
the use of d-dimers to rule out acute mesenteric ischaemia when the levels are normal (IIa B)
Upper Extremity Artery Disease (UEAD)
Atherosclerotic UEAD affects mostly proximal arteries.
It can be detected by inter-arm blood pressure difference
(> 15 mm Hg) and is associated with increased CVD risk
and mortality. Marianne Brodmann, MD, University of
Graz, Graz, Austria, discussed some of the new guidelines for UAED. For patients with symptomatic subclavian
artery stenosis/occlusion revascularisation (stenting or
surgery) should be considered (IIa C) based on the lesion
characteristics and the patient's risk. Revascularisation
should also be considered for some patients with asymptomatic proximal stenosis undergoing CABG, post-graft,
or in patients who also have ipsilateral arteriovenous fistula for dialysis (IIa C) or in the case of bilateral stenosis
to be able to accurately monitor blood pressure (IIb C).
Lower Extremity Artery Disease (LEAD)
Prof Brodmann also covered the ESC recommendations
for LEAD. Although the Fontaine and Rutherford classi-

Table 3. Imaging in Patients With LEAD
Recommendations

Class

Level

DUS is indicated as first-line imaging method to
confirm LEAD lesions

DUS and/or CTA and/or MRA are indicated for anatomical characterisation of LEAD lesions and guidance for optimal revascularisation strategy

Data from an anatomical imaging test should
always be analysed in conjunction with symptoms
and haemodynamic tests prior to treatment decision
DUS screening for AAA should be considered

I
IIa

C
C

AAA, abdominal aortic aneurysm; CTA, computed tomography angiography;
DUS, duplex ultrasound; LEAD, lower extremity artery disease; MRA, magnetic
resonance angiography.
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.

October 2017

fication systems for LEAD should still be used, the 2017
Guidelines introduced the concept of 'masked LEAD' to
account for asymptomatic patients who are only asymptomatic because another condition limits their ability to or
prevents them from walking. Prof Brodmann reiterated the
value of the ABI but noted that in the case of incompressible ankle arteries or ABI > 1.40, alternative methods such
as the toe-brachial index, Doppler waveform analysis, or
pulse volume recording are indicated (I C). Imaging recommendations for patients with LEAD are shown in Table 3.
The recommendations for the management of patients
with intermittent claudication are detailed in Table 4.
Multisite Artery Disease (MSAD)
MSAD is common in patients with atherosclerotic involvement in 1 vascular bed, ranging from 10% to 15% in
patients with CAD to 60% to 70% in patients with severe
carotid stenosis or LEAD. Patients with MSAD have a 1.5to 2-fold increase in the risk of major cardiac events both
in-hospital and at 1 and 3 years, versus single-site disease
[Steg PG et al. JAMA. 2007; Alberts MJ et al. Eur Heart J.
2009; Subherwal S et al. Circ Cardiovasc Qual Outcomes.
2012; Wilson WM et al. Am J Cardiol. 2011]. The guidelines
for MSAD were presented by Marco De Carlo, MD, PhD,
Pisa University Hospital, Pisa, Italy. In patients with any
presentation of PADs, clinical assessment of symptoms
and physical signs of other localisations and/or CAD is
necessary, and in case of clinical suspicion, further tests
may be planned. The indications for screening for associated atherosclerotic disease in additional vascular territories are shown in Figure 4.

Table 4. Recommendations for the Management of Patients With
Intermittent Claudication
Recommendations

Class

Level

* supervised exercise training is recommended

* unsupervised exercise training is recommended
when supervised exercise training is not feasible
or available

When daily life activities are compromised despite
exercise therapy, revascularisation should be
considered

IIa

When daily life activity is severely compromised,
revascularisation should be considered, in
association with exercise therapy

IIa

On top of general prevention, statins are indicated
to improve walking distance
In patients with intermittent claudication:

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.

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