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

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disease, especially in the case of carotid plaque with nonsignificant
stenosis, which is the most frequent situation.
(iii) The benefits of CEA in asymptomatic patients were proven in
RCTs performed before the modern era of cardiovascular
prevention, when medical therapy was almost non-existent
and patients .80 years of age were excluded; thus, both
CEA and CAS need to be evaluated against current optimal
medical therapy in asymptomatic carotid stenosis, with a particular
focus on elderly patients.
(iv) The efficacy of EPDs during CAS has not been studied in adequately
powered RCTs, and the available evidence is
conflicting.
(v) The optimal duration of dual antiplatelet therapy after CAS is
not well established.
Vertebral artery disease
(i) Almost no data are available on the clinical benefit of revascularization
of symptomatic VA stenosis, and on the comparison
between surgical and endovascular revascularization.
Upper extremity artery disease
(i) Almost no data are available on the clinical benefit of revascularization
of symptomatic subclavian artery stenosis/occlusion,
and on the comparison between surgical and endovascular
revascularization.
(ii) Little is known about the natural course in UEAD.
Mesenteric artery disease
(i) No data are available on the comparison between surgical and
endovascular revascularization for symptomatic mesenteric
artery disease.
(ii) No data are available on the potential benefits of revascularization
for asymptomatic mesenteric artery disease involving
two or more main visceral vessels.
Renal artery disease
(i) Large-size trials are still necessary to clarify the potential
benefits of RAS in patients with different clinical presentations
of renal artery disease.
(ii) Appropriate treatment of in-stent renal artery restenosis is not
yet defined, although several trials are under way.
Lower extremity artery disease
(i) The benefits of statins in LEAD patients derive mainly from
small studies or from subgroup analyses of large RCTs
focused on CAD patients; thus, the treatment goals for
LDL cholesterol levels in LEAD patients cannot be defined
clearly.
(ii) Data on the benefits of the combination of ‘supervised exercise
training’ and medical therapy are lacking.
(iii) Data on the potential benefit of endovascular revascularization
over supervised exercise for intermittent claudication
are limited.
(iv) The role of primary stenting vs. provisional stenting in aortoiliac
disease needs to be evaluated.
(v) In the superficial femoral artery, the role of primary stenting
in TASC II type C lesions, the potential benefit of covered
stents for long superficial femoral artery occlusions, and
the optimal treatment of in-stent restenosis need to be
investigated.
(vi) The role of drug-eluting stents and drug-eluting balloons in
superficial femoral artery and below-the-knee interventions
has to be established.
(vii) Optimal treatment for popliteal artery stenosis needs to be
addressed.
(viii) The role of self-expanding stents for below-the-knee interventions
is unclear.
(ix) Benefits and/or adverse effects of b-blockers in CLI must be
further evaluated.
(x) Optimal duration of dual antiplatelet therapy after LEAD
stenting, as well as potential benefit of long-term dual antiaggregation
therapy in patients with advanced CLI should be
further investigated.
(xi) The role of gene or stem cell therapy in CLI needs further
studies.
Multisite disease
(i) The need for prophylactic carotid revascularization in patients
with asymptomatic carotid stenosis scheduled for CABG is
still unclear.
(ii) The preferred timing of CABG associated with carotid revascularization
(synchronous or staged) is still unclear.
(iii) If future studies confirm the benefits of carotid revascularization
in patients undergoing CABG, the optimal treatment
method (CAS vs. CEA) should be determined.
Acknowledgements
<strong>ESC</strong> <strong>Guidelines</strong>
We thank Nathalie Cameron, Veronica Dean, Catherine Després,
Jennifer Franke, Sanne Hoeks, Tomasz Jadczyk, Radoslaw Parma,
Wojciech Wańha, and Piotr Wieczorek for their excellent technical
assistance.
The CME text ‘<strong>ESC</strong> <strong>Guidelines</strong> on the diagnosis and treatment of peripheral artery diseases’ is accredited by the European Board for Accreditation in Cardiology (EBAC). EBAC
works according to the quality standards of the European Accreditation Council for Continuing Medical Education (EACCME), which is an institution of the European Union of
Medical Specialists (UEMS). In compliance with EBAC/EACCME guidelines, all authors participating in this programme have disclosed potential conflicts of interest that might
cause a bias in the article. The Organizing Committee is responsible for ensuring that all potential conflicts of interest relevant to the programme are declared to the participants
prior to the CME activities.
CME questions for this article are available at: European Heart Journal http://cme.oxfordjournals.org/cgi/hierarchy/oupcme_node;ehj and European Society of Cardiology http://
www.escardio.org/guidelines.