2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS) : Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries

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2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Endorsed by: the European Stroke Organisation (ESO) Authors/Task Force Members: Michal Tendera (Chairperson) (Poland), Victor Aboyans (Co-Chairperson) (France), Marie-Louise Bartelink (The Netherlands), Iris Baumgartner (Switzerland), Denis Cle ́ment (Belgium), Jean-Philippe Collet (France), Alberto Cremonesi (Italy), Marco De Carlo (Italy), Raimund Erbel (Germany), F. Gerry R. Fowkes (UK), Magda Heras (Spain), Serge Kownator (France), Erich Minar (Austria), Jan Ostergren (Sweden), Don Poldermans (The Netherlands), Vincent Riambau (Spain), Marco Roffi (Switzerland), Joachim Ro ̈ ther† (Germany), Horst Sievert (Germany), Marc van Sambeek (The Netherlands), Thomas Zeller (Germany).

ESC Guidelines on the Diagnosis and Treatment of Peripheral Artery Diseases

2D
: two-dimensional
3D
: three-dimensional
ABI
: ankle–brachial index
ACAS
: Asymptomatic Carotid Atherosclerosis Study
ACCF
: American College of Cardiology Foundation
ACE
: angiotensin-converting enzyme
ACS
: acute coronary syndrome
ACST
: Asymptomatic Carotid Surgery Trial
ALI
: acute limb ischaemia
ASTRAL
: Angioplasty and Stenting for Renal Artery Lesions trial
BASIL
: Bypass versus Angioplasty in Severe Ischaemia of the Leg
BOA
: Dutch Bypass Oral Anticoagulants or Aspirin
CABG
: coronary artery bypass grafting
CAD
: coronary artery disease
CAPRIE
: Clopidogrel versus Aspirin in Patients at Risk for Ischaemic Events
CAPTURE
: Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events
CARP
: Coronary Artery Revascularization Prophylaxis
CAS
: carotid artery stenting
CASPAR
: Clopidogrel and Acetylsalicylic Acid in Bypass Surgery for Peripheral Arterial Disease
CASS
: Coronary Artery Surgery Study
CAVATAS
: CArotid and Vertebral Artery Transluminal Angioplasty Study
CEA
: carotid endarterectomy
CHARISMA
: Clopidogrel for High Atherothrombotic Risk and Ischaemic Stabilization, Management and Avoidance
CI
: confidence interval
CLEVER
: Claudication: Exercise Versus Endoluminal Revascularization
CLI
: critical limb ischaemia
CORAL
: Cardiovascular Outcomes in Renal Atherosclerotic Lesions
COURAGE
: Clinical Outcomes Utilization Revascularization and Aggressive Drug Evaluation
CPG
: Committee for Practice Guidelines
CREST
: Carotid Revascularization Endarterectomy vs. Stenting Trial
CT
: computed tomography
CTA
: computed tomography angiography
CVD
: cardiovascular disease
DECREASE-V
: Dutch Echocardiographic Cardiac Risk Evaluation
DRASTIC
: Dutch Renal Artery Stenosis Intervention Cooperative Study
DSA
: digital subtraction angiography
DUS
: duplex ultrasound/duplex ultrasonography
EACTS
: European Association for Cardio-Thoracic Surgery
EAS
: European Atherosclerosis Society
ECST
: European Carotid Surgery Trial
EPD
: embolic protection device
ESC
: European Society of Cardiology
ESH
: European Society of Hypertension
ESRD
: end-stage renal disease
EUROSCORE
: European System for Cardiac Operative Risk Evaluation
EVA-3S
: Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis
EXACT
: Emboshield and Xact Post Approval Carotid Stent Trial
GALA
: General Anaesthesia versus Local Anaesthesia for Carotid Surgery
GFR
: glomerular filtration rate
GRACE
: Global Registry of Acute Coronary Events
HbA1c
: glycated haemoglobin
HDL
: high-density lipoprotein
HOPE
: Heart Outcomes Prevention Evaluation
HR
: hazard ratio
IC
: intermittent claudication
ICSS
: International Carotid Stenting Study
IMT
: intima–media thickness
ITT
: intention to treat
LDL
: low-density lipoprotein
LEAD
: lower extremity artery disease
MACCEs
: major adverse cardiac and cerebrovascular events
MDCT
: multidetector computed tomography
MONICA
: Monitoring of Trends and Determinants in Cardiovascular Disease
MRA
: magnetic resonance angiography
MRI
: magnetic resonance imaging
NASCET
: North American Symptomatic Carotid Endarterectomy Trial
ONTARGET
: Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial
OR
: odds ratio
PAD
: peripheral artery diseases
PARTNERS
: Peripheral Arterial Disease Awareness, Risk, and Treatment: New Resources for Survival
PCI
: percutaneous coronary intervention
PET
: positron emission tomography
PRO-CAS
: Predictors of Death and Stroke in CAS
PTA
: percutaneous transluminal angioplasty
RAAS
: renin–angiotensin–aldosterone system
RADAR
: Randomized, Multicentre, Prospective Study Comparing Best Medical Treatment Versus Best Medical Treatment Plus Renal Artery Stenting in Patients With Haemodynamically Relevant Atherosclerotic Renal Artery Stenosis
RAS
: renal artery stenosis
RCT
: randomized controlled trial
REACH
: Reduction of Atherothrombosis for Continued Health
RR
: risk ratio
SAPPHIRE
: Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy
SCAI
: Society for Cardiovascular Angiography and Interventions
SIR
: Society of Interventional Radiology
SPACE
: Stent-Protected Angioplasty versus Carotid Endarterectomy
SPARCL
: Stroke Prevention by Aggressive Reduction in Cholesterol Levels Study
STAR
: Stent Placement in Patients With Atherosclerotic Renal Artery Stenosis and Impaired Renal Function
SSYLVIA
: Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries
SVMB
: Society for Vascular Medicine and Biology
TASC
: TransAtlantic Inter-Society Consensus
TIA
: transient ischaemic attack
UEAD
: upper extremity artery disease
VA
: vertebral artery

Guidelines summarize and evaluate all available evidence, at the time of the writing process, on a particular issue with the aim of assisting physicians in selecting the best management strategies for an individual patient, with a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes but are complements for textbooks and cover the ESC Core Curriculum topics. Guidelines and recommendations should help the physicians to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible physician(s).

A large number of Guidelines have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for the development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines can be found on the ESC website (http://www.escardio.org/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx). ESC Guidelines represent the official position of the ESC on a given topic and are regularly updated.

Members of this Task Force were selected by the ESC to represent professionals involved with the medical care of patients with this pathology. Selected experts in the field undertook a comprehensive review of the published evidence for diagnosis, management, and/or prevention of a given condition according to ESC Committee for Practice Guidelines (CPG) policy. A critical evaluation of diagnostic and therapeutic procedures was performed including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger populations were included, where data exist. The level of evidence and the strength of recommendation of particular treatment options were weighed and graded according to pre-defined scales, as outlined in Tables 1 and 2 . …

https://www.siapav.it/pdf/ESC%20Guidelines.pdf

ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC).

Initially, a set of guidelines for the use of ultrasound contrast agents was published in 2004 dealing only with liver applications. A second edition of the guidelines in 2008 reflected changes in the available contrast agents and updated the guidelines for the liver, as well as implementing some non-liver applications. Time has moved on, and the need for international guidelines on the use of CEUS in the liver has become apparent. The present document describes the third iteration of recommendations for the hepatic use of contrast enhanced ultrasound (CEUS) using contrast specific imaging techniques. This joint WFUMB-EFSUMB initiative has implicated experts from major leading ultrasound societies worldwide. These liver CEUS guidelines are simultaneously published in the official journals of both organizing federations (i.e., Ultrasound in Medicine and Biology for WFUMB and Ultraschall in der Medizin/European Journal of Ultrasound for EFSUMB). These guidelines and recommendations provide general advice on the use of all currently clinically available ultrasound contrast agents (UCA). They are intended to create standard protocols for the use and administration of UCA in liver applications on an international basis and improve the management of patients worldwide.

Guidelines and good clinical practice recommendations for Contrast Enhanced Ultrasound (CEUS) in the liver - update 2012: A WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS.

A b s t r ac t BACKGROUND Drug-eluting stents reduce restenosis in coronary arteries, but clinical trials have failed to prove their efficacy in peripheral arteries. We investigated the use of paclitaxel-coated angioplasty balloons and paclitaxel dissolved in the angiographic contrast medium during angioplasty of the leg. METHODS In a small, multicenter trial, we randomly assigned 154 patients with stenosis or occlusion of a femoropopliteal artery to treatment with standard balloon catheters coated with paclitaxel, uncoated balloons with paclitaxel dissolved in the contrast medium, or uncoated balloons without paclitaxel (control). The primary end point was late lumen loss at 6 months. RESULTS The mean (±SD) age of the patients was 68±8 years, 24% were smokers, and 49% had diabetes. Twenty-seven percent of the lesions were total occlusions, and 36% were restenotic lesions. The mean lesion length was 7.4±6.5 cm. There were no significant differences in baseline characteristics between the groups. There were no adverse events attributable to the paclitaxel-coated balloons. At 6 months, the mean late lumen loss was 1.7±1.8 mm in the control group, as compared with 0.4±1.2 mm (P<0.001) in the group treated with paclitaxel-coated balloons and 2.2±1.6 mm (P = 0.11) in the group treated with paclitaxel in the contrast medium. The rate of revascularization of target lesions at 6 months was 20 of 54 (37%) in the control group, 2 of 48 (4%) in the group treated with paclitaxel-coated balloons (P<0.001 vs. control), and 15 of 52 (29%) in the group treated with paclitaxel in the contrast medium (P = 0.41 vs. control); at 24 months, the rates increased to 28 of 54 (52%), 7 of 48 (15%), and 21 of 52 (40%), respectively. CONCLUSIONS Use of paclitaxel-coated angioplasty balloons during percutaneous treatment of femoropopliteal disease is associated with significant reductions in late lumen loss and target-lesion revascularization. No significant benefit is seen with the use of a paclitaxel-containing contrast medium. (ClinicalTrials.gov number, NCT00156624.)

https://www.nejm.org/doi/pdf/10.1056/NEJMoa0706356

Local delivery of paclitaxel to inhibit restenosis during angioplasty of the leg.

Objective:
The aim of the study was to assess the clinical value of contrast-enhanced intraoperative ultrasound (CE-IOUS) as a novel tool in the hepatic staging of patients undergoing liver resection.

Potential value of contrast-enhanced intraoperative ultrasonography during partial hepatectomy for metastases: an essential investigation before resection?

Modern liver imaging of cancer patients requires an imaging modality that is not only highly sen- sitive in detecting lesions but also provides reliable characterisation of lesions and thus allows differentia- tion of metastases from frequently found benign lesions. Conventional ultrasound (US) has a relatively poor sensitivity and specificity for imag- ing liver metastases and US used to be inferior to CT and MRI mainly due to a lack of contrast agents. This has changed with the advent of mi- crobubble contrast agents for US. The use of recent contrast agents such as SonoVue (Bracco, Italy) combined with low mechanical index contrast- specific imaging techniques such as Contrast Pulse Sequencing provides dynamic real time imaging of focal liver lesions in the arterial, portal venous and delayed phase. This im- proves lesion detection and charac- terisation. To investigate the benefit of SonoVue for detecting liver me- tastases we studied 40 cancer patients with liver lesions on reference imag- ing (CT or MRI), 37 of them had metastases. The mean number of ref- erence confirmed metastases per patient increased from 1.85 ± 1.79 on conventional ultrasound to 2.73 ± 2.50 post SonoVue (p < 0.05). CEUS showed more individual metastases than baseline in 12 (34%) patients. Using CT or MRI as the reference, the mean sensitivity to individual metastases increased from 69% on baseline US to 90% post contrast (p < 0.0005). The role of SonoVue in characterisation of focal liver lesions was evaluated in 63 patients. One lesion was studied per patient. Based on standardised dynamic enhance- ment criteria for each lesion type, the number of correctly diagnosed le- sions improved from 41 (65%) on baseline US to 58 (92%) post contrast (p < 0.001). On CEUS all 27 metas- tases were correctly diagnosed, while baseline US misinterpreted 2 of these. The number of correctly diag- nosed benign lesions (n = 28) in- creased from 12 (43%) on baseline to 25 (89%) post SonoVue. In con- clusion, detection and characterisa- tion of focal liver lesions by US are markedly improved by the use of SonoVue. Contrast agents add a new dimension to sonography allowing it to rival CT and MRI, especially for lesion characterisation.

Detection and characterisation of liver metastases

AIM SonoVue is the first ultrasound contrast agent which allows repeated continuous examination of the liver in real time. The aim of this study was to compare low mechanical index (MI) real time contrast enhanced ultrasound of the liver, using the contrast agent SonoVue, with conventional B-mode sonography for the detection of hepatic metastases. METHOD 40 patients with known malignancy and at least one liver lesion on conventional B-mode sonography were included. Conventional B-mode sonography was performed followed by contrast enhanced ultrasound (CEUS) of the liver in the arterial ( 120 sec) after injection of SonoVue. CEUS was performed using contrast specific imaging and low MI (< 0.3). Number, location and size of metastases on baseline and CEUS were compared with CT or MRI (blinded reader). RESULTS 37 patients had 128 metastases on CT or MRI. Baseline US showed 74 metastases confirmed by reference examination (69%), while CEUS yielded 109 metastases (sensitivity 90%) (p < 0.001). On CEUS, 35 additional metastases not seen on baseline but confirmed by reference imaging were detected in 14 patients (36%). In 8 patients, CEUS showed 13 metastases not seen on reference imaging. CONCLUSION Detection of hepatic metastases is substantially improved by low MI real time contrast enhanced ultrasound with SonoVue compared to conventional B-mode sonography.

Detection of hepatic metastases with low MI real time contrast enhanced sonography and SonoVue.

We report two children who sustained traumatic parenchymal splenic injury and were monitored with contrast-enhanced ultrasound (CEUS). In both cases, unenhanced US failed to diagnose splenic haematoma, but the injury was well demonstrated after injection of contrast agent. In one case agreement with CT was excellent; in the other, CT was not performed due to the comprehensive information provided by CEUS.

A. Oldenburg

Papers

Local delivery of paclitaxel to inhibit restenosis during angioplasty of the leg.

Potential value of contrast-enhanced intraoperative ultrasonography during partial hepatectomy for metastases: an essential investigation before resection?

Detection and characterisation of liver metastases

Detection of hepatic metastases with low MI real time contrast enhanced sonography and SonoVue.

Imaging of paediatric splenic injury with contrast-enhanced ultrasonography