ESC Guidelines on the diagnosis and treatment of peripheral artery ...

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Page 16 of 56 increased risk of any stroke (RR 1.45; 95% CI 1.06–1.99), decreased risk of periprocedural myocardial infarction (RR 0.43; 95% CI 0.26–0.71), and non-significant increase in mortality (RR 1.40; 95% CI 0.85–2.33). 105 Recommendations for management of asymptomatic carotid artery disease Recommendations Class a Level b Ref c All patients with asymptomatic carotid artery stenosis should be treated with long-term antiplatelet therapy. All patients with asymptomatic carotid artery stenosis should be treated with long-term statin therapy. In asymptomatic patients with carotid artery stenosis ≥60%, CEA should be considered as long as the perioperative stroke and death rate for procedures performed by the surgical team is
<strong>ESC</strong> <strong>Guidelines</strong> Page 17 of 56 strategies in patients with VA disease, aspirin (or if not tolerated clopidogrel) and statins should be administered in all patients, irrespective of symptoms. Asymptomatic VA disease does not require intervention. In general, the need to intervene is tempered by the fact that the posterior circulation is supplied by the confluence of the two VAs, and a large proportion of patients remain asymptomatic despite an occlusion of one VA. However, in patients with recurrent ischaemic events under antiplatelet therapy or refractory vertebrobasilar hypoperfusion, revascularization may be considered. Although surgery of extracranial VA stenosis has been performed with low rates of stroke and mortality by surgeons with extensive experience, 112 in most centres the surgical approach has been replaced by endovascular techniques. However, data for VA revascularization are limited to retrospective and mainly single-centre studies. More information is provided in the online Appendix 2. Recommendations for revascularization in patients with VA stenosis Recommendations Class a Level b In patients with symptomatic extracranial VA stenosis, endovascular treatment may be considered for lesions ≥50% in the case of recurrent ischaemic events despite optimal medical management. Revascularization of an asymptomatic VA stenosis is not indicated, irrespective of the degree of severity. a Class of recommendation. b Level of evidence. VA ¼ vertebral artery. IIb C III C 4.2 Upper extremity artery disease 4.2.1 Definition and clinical presentation The subclavian artery and brachiocephalic trunk are the most common locations for atherosclerotic lesions in the upper extremities. However, UEAD can be caused by a number of conditions, involving different levels of the upper extremity arterial system (see online Appendix 3). The most common manifestation for subclavian arterial occlusive disease is unequal arm pressures. A difference of ≥15 mmHg is highly suspicious for subclavian stenosis. It is not uncommon to detect this occlusive disease in asymptomatic patients. Nevertheless, when the subclavian or brachiocephalic trunk becomes symptomatic, the clinical scenario can be diverse. Subclavian steal syndrome due to flow reversal in the VA, which is worsened by exercising the arm, can evoke symptoms of vertebrobasilar insufficiency (dizziness, vertigo, blurred vision, alternating hemiparesis, dysphasia, dysarthria, confusion, and loss of consciousness, drop attacks, ataxia or other postural disturbances including sensory and visual changes). Patients with coronary bypass with an internal mammary artery can develop symptoms of myocardial ischaemia as the manifestation of subclavian steal syndrome. Brachiocephalic occlusive disease can also lead to stroke related to the carotid and vertebral territories. Ischaemic arm symptoms are characterized by crampy pain on exercise— also referred to as arm claudication. In more severe cases— especially in more distal disease—rest pain and digital ischaemia with gangrene can develop. 4.2.2 Natural history Little is known about the natural history of subclavian stenosis, but the prognosis appears relatively benign. Only subclavian steal with myocardial ischaemia in patients revascularized using the internal mammary artery as well as symptomatic brachiocephalic atherosclerosis with stroke episodes can be considered as life-threatening clinical conditions. However, any symptomatic subclavian occlusive disease should be investigated and treated. Vertebrobasilar insufficiency related to subclavian artery stenosis can be recurrent even after revascularization procedures. It can be explained by numerous other conditions such as cardiac arrhythmias, or intracerebral small vessel disease that can mimic symptoms of vertebrobasilar insufficiency. The combination of proximal and distal arm occlusive disease can present a clinical challenge, with poor prognosis for the extremity. 4.2.3 Clinical examination Clinical diagnosis of upper limb ischaemia is based on history and physical examination including bilateral blood pressure measurement and assessment of the axillary, brachial, radial, and ulnar artery pulses. Auscultation is an important part of upper extremity examination and should begin in the supraclavicular fossa. Signs and symptoms, such as pulse deficit, arm pain, pallor, paraesthesia, coldness, and unequal arm pressures, warrant further investigation for occlusive artery disease of the upper limb. The Allen test should be performed in patients in whom the radial artery is instrumented or harvested for coronary revascularization. Adequate collateral flow via the ulnar artery is to be confirmed by this test. 4.2.4 Diagnostic methods 4.2.4.1 Duplex ultrasonography The proximal location of subclavian arterial occlusive disease makes DUS challenging. However, duplex scanning is of particular value in differentiating occlusion from stenosis, in determining the direction of the vertebral blood flow, and in screening for concurrent carotid artery stenosis. Subclavian steal can be present in the absence of retrograde vertebral flow at rest. Dynamic examination with cuff compression of the upper arm and consecutive hyperaemia after decompression can change the vertebral flow direction. 4.2.4.2 Computed tomography angiography Upper limb atherosclerosis can be imaged in excellent detail using CTA. To avoid misinterpretations, it is important to detect congenital abnormalities, in order to define precisely the four vessels perfusing the head. CTA should be analysed interactively, based on a combination of axial images and post-processed views. 4.2.4.3 Magnetic resonance angiography The use of MRI and contrast-enhanced MRA should also be considered because it enables acquisition of both functional and
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