ESC Congress 2017 In Review -- Main Edition - 6

Main Session

The ankle-brachial index measurement is recommended for diagnosis of asymptomatic at-risk patients
and patients with clinical suspicion or at risk for LEAD.
Among asymptomatic patients, the guidelines individualised a subset of patients with "Masked LEAD" (ie,
generally old patients with other comorbidities limiting walking so that the classical symptoms cannot be
revealed) with the risk of sudden severe presentation.
For management of patients with claudication, the
guidelines recommend cardiovascular disease prevention and exercise therapy with or without revascularisation. Patients with chronic limb-threatening ischaemia
should be referred to a vascular team for risk stratification and management (Table 2).
Renal artery disease (RAD) is a strong independent
predictor of mortality. Medical therapy with ACE inhibitors or ARBs is recommended for treatment of hypertension in patients with bilateral severe or unilateral renal
artery stenosis and in some cases of stenosis in a single
functioning kidney. Revascularisation is not recommended for RAD secondary to atherosclerosis but may be considered in patients with significant stenosis and particular clinical scenarios such as flash pulmonary oedema.
For patients with asymptomatic extracranial carotid
artery disease, optimal medical therapy reduces the risk

Table 2. Management of Chronic Limb-Threatening Ischaemia
Recommendations

Class

Level

In patients with CLTI and diabetes, optimal glycaemic
control is recommended.

For limb salvage, revascularisation is indicated whenever
feasible.

In patients with CLTI with below-the-knee lesions, angiography including foot runoff should be considered prior
to revascularisation.

IIa

Early recognition of tissue loss and/or infection and
referral to the vascular team is mandatory to improve
limb salvage.
In patients with CLTI, assessment of the risk of amputation is indicated.

CLTI, chronic limb-threatening ischaemia.
Reprinted from Valgimigli M et al. 2017 ESC focused update on dual antiplatelet
therapy in coronary artery disease developed in collaboration with EACTS. Eur
Heart J. 2017. doi:10.1093/eurheartj/ehx419. By permission of Oxford University
Press on behalf of the European Society of Cardiology.

of stroke [Abbott AL et al. Int J Stroke. 2007; Naylor AR
et al. Semin Vasc Surg. 2008]. Best medical treatment is
recommended for all asymptomatic patients; and with a
60-99% stenosis, carotid endarterectomy should be considered in the presence of clinical and/or more imaging
characteristics that may be associated with an increased

Figure 3. Management of Extracranial Carotid Artery Disease

Recent (< 6 months) symptoms of stroke/TIA
No

Yes
Imaging of carotid artery disease
by duplex ultrasound,
CTA and/or MRA

Imaging of carotid artery disease
by duplex ultrasound,
CTA and/or MRA

Carotid
stenosis
60-99%

Carotid
stenosis
< 60%

Life expectancy > 5 yrs?
Favourable anatomy?
≥ I feature suggesting
higher stroke risk
on BMT?b
Yes
CEA + BMT
should be considered
Class IIa B
CAS + BMT
may be considered
Class IIb B

Occlusion or
near
occlusiona

BMT
Class I A

Carotid
stenosis
< 50%

Carotid
stenosis
50-65%

Carotid
stenosis
70-99%

Yes

CEA + BMT
should be
considered
Class IIa B

CEA + BMT
is
recommended
Class I A

CAS + BMT
may be
considered
Class IIb B

CAS + BMT
*should be
considered if
high-risk for
CEA
Class IIa B
**otherwise
may be
considered
Class IIb B

BMT, best medical therapy; CAS, carotid artery stenting; CEA, carotid endarterectomy; CTA, computed tomography angiography; MRA, magnetic resonance angiography; TIA, transient ischaemic attack.
a
With post-stenotic internal carotid artery narrowed to the point of near occlusion.
b
Ipsilateral silent brain infarction, stenosis progression > 20%, embolisation on transcranial Doppler, large plaques (> 40 mm2), echolucent plaques, intraplaque haemorrhage.
Reprinted from Valgimigli M et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur Heart J.
2017. doi:10.1093/eurheartj/ehx419. By permission of Oxford University Press on behalf of the European Society of Cardiology.

October 2017

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