Comments on the guidelines (2017) of the ESC on peripheral arterial diseases

Abstract

The European Society of Cardiology (ESC) guidelines on “Peripheral Arterial Diseases” (PAD) published in 2017 include recommendations on the diagnostics and treatment of atherosclerotic manifestations in peripheral arteries. The guidelines give recommendations for all arterial territories except the aorta and coronary arteries. The following comments are based on the pocket guidelines and focus on the recommendations for secondary prevention of lower extremity arterial disease (LEAD) and carotid artery stenosis. In the recommendations on secondary prevention atherosclerosis is considered as a disease of the whole vascular system. In general, a consistent discontinuance of cardiovascular risk factors is recommended including smoking cessation, statin therapy and control of blood pressure and blood glucose. In all patients with intermittent claudication, supervised exercise training is strongly recommended. A platelet aggregation inhibitor should be given when symptomatic LEAD is present or in the presence of other manifestations of atherosclerosis, such as coronary heart disease (CHD). If activities of daily life are severely compromised revascularization is recommended. If revascularisation is indicated, treatment shold be performed endovascular first on short lesions (e.g. femoro-popliteal < 25 cm). In long vascular occlusions or if the common femoral artery is involved, vascular surgery is indicated if the risk of an operation is justifiable. Despite a lack of data dual antiplatelet therapy is recommended for at least 1 month after endovascular revascularization. In patients with symptomatic stenosis of the internal carotid artery and low periprocedural risk, early revascularization is recommended if the degree of stenosis is more than 50%. In asymptomatic patients with carotid artery stenosis, revascularization should only be carried out if additional factors indicating an increased risk of stroke are present. Antiplatelet therapy is recommended in patients with a carotid artery stenosis of at least 50% and low bleeding risk. In general, a multidisciplinary treatment by a team of vascular specialists is recommended to make decisions for the management of patients with peripheral arterial diseases.