Professional Documents
Culture Documents
Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society
Consensus; and Vascular Disease Foundation
Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1494
Preoperative Evaluation . . . . . . . . . . . . . . . . . 1496 Diagnostic Imaging Strategies . . . . . . . . . . . 1507
Correlation of Symptoms and Lesions . . . . 1496 1. Catheter Angiography. . . . . . . . . . . . . . . . . . . . . . 1509
Surgical Procedures. . . . . . . . . . . . . . . . . . . . . 1496 2. Renin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1509
Inflow Procedures: Aortoiliac a. Selective Renal Vein Renin Studies . . . . . . . 1509
Occlusive Disease . . . . . . . . . . . . . . . . . . . . . . 1496 b. Plasma Renin Activity: Captopril Test. . . . . 1509
Outflow Procedures: Infrainguinal Disease . . 1497 D. Treatment of Renovascular Disease: Renal
Follow-Up After Vascular Surgical Artery Stenosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1509
Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1498 1. Medical Treatment . . . . . . . . . . . . . . . . . . . . . . . . 1509
3. Critical Limb Ischemia and Treatment for 2. Indications for Revascularization . . . . . . . . . . . . 1510
Limb Salvage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1498 a. Asymptomatic Stenosis. . . . . . . . . . . . . . . . . . 1510
The reader should note that the text, recommendations, B. Vascular History and Physical Examination
and tables included in this executive summary represent a
RECOMMENDATIONS
succinct summary of the more extensive evidence base,
critical evaluation, tables, and references that are included in Class I
the full-text document. Readers are strongly encouraged to
refer to this source document to gain full access to the 65 1. Individuals at risk for lower extremity PAD (see
tables, more than 1300 references, and supporting text Section 2.1.1 of the full-text guidelines) should un-
assembled by the writing committee. The full-text docu- dergo a vascular review of symptoms to assess walk-
ment can be accessed at http://www.acc.org/clinical/ ing impairment, claudication, ischemic rest pain,
guidelines/pad/index.pdf. and/or the presence of nonhealing wounds. (Level of
A classication of recommendation and level of evi- Evidence: C)
dence have been assigned to each recommendation. 2. Individuals at risk for lower extremity PAD (see
Classications of recommendations and levels of evidence Section 2.1.1 of the full-text guidelines) should un-
are expressed in the American College of Cardiology dergo comprehensive pulse examination and inspec-
(ACC)/American Heart Association (AHA) format as tion of the feet. (Level of Evidence: C)
follows. 3. Individuals over 50 years of age should be asked if
they have a family history of a rst-order relative with
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Pulse intensity should be assessed and should be recorded extremity PAD, denes a signicantly smaller subset of the
numerically as follows: 0, absent; 1, diminished; 2, total population with the disease.
normal; and 3, bounding.
B. Prognosis and Natural History
The shoes and socks should be removed; the feet in-
spected; the color, temperature, and integrity of the skin 1. Coprevalence of Coronary Arterial Disease and Ca-
and intertriginous areas evaluated; and the presence of rotid Disease. The prognosis of patients with lower ex-
ulcerations recorded. tremity PAD is characterized by an increased risk for
Additional ndings suggestive of severe PAD, including cardiovascular ischemic events due to concomitant coronary
distal hair loss, trophic skin changes, and hypertrophic artery disease and cerebrovascular disease (1,4). These car-
nails, should be sought and recorded. diovascular ischemic events are more frequent than ischemic
limb events in any lower extremity PAD cohort, whether
individuals present without symptoms or with atypical leg
II. LOWER EXTREMITY PAD pain, classic claudication, or CLI (Fig. 2) (5).
1. Risk Factors. The major cause of lower extremity PAD Peripheral arterial disease has a diversity of causes beyond
is atherosclerosis. Risk factors for atherosclerosis such as atherosclerosis. Aneurysms may be associated with atheroscle-
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cigarette smoking, diabetes, dyslipidemia, hypertension, and rosis, may be due to underlying hereditary (familial) reasons, or
hyperhomocysteinemia increase the likelihood of develop- may be of acquired (e.g., due to smoking or trauma) origin.
ing lower extremity PAD (Fig. 1). Renal arterial disease may be due to atherosclerosis, bromus-
cular dysplasia, or arteritides. Lower extremity PAD may be
2. Prevalence. Lower extremity PAD is a common syn-
caused by atherosclerotic, thromboembolic, inammatory, or
drome that affects a large proportion of most adult popula-
aneurysmal disease; by trauma, adventitial cysts, or entrapment
tions worldwide (1,2). Peripheral arterial disease can be
syndromes; or by congenital abnormalities. Establishment of
present in subclinical forms that can be detected by use of
an accurate diagnosis is necessary if individual patients are to
sensitive vascular imaging techniques, which may reveal receive ideal pharmacological, endovascular, surgical, or reha-
early manifestations of arterial disease before it is detected bilitative interventions.
by either limb-pressure measurements or clinical symptoms.
When so dened, as, for example, by measurement of the D. Clinical Presentation
intimal-medial thickness (IMT) in the carotid or femoral 1. Asymptomatic.
artery, early forms of PAD are easily detected in populations
at risk (3). Claudication, a symptomatic expression of lower RECOMMENDATIONS
Class I
1. A history of walking impairment, claudication, isch-
emic rest pain, and/or nonhealing wounds is recom-
mended as a required component of a standard review
of systems for adults 50 years and older who have
atherosclerosis risk factors and for adults 70 years and
older. (Level of Evidence: C)
2. Individuals with asymptomatic lower extremity
PAD should be identied by examination and/or
measurement of the ankle-brachial index (ABI) so
that therapeutic interventions known to diminish
their increased risk of myocardial infarction (MI),
stroke, and death may be offered. (Level of Evi-
dence: B)
3. Smoking cessation, lipid lowering, and diabetes and
Figure 1. Risk of developing lower extremity peripheral arterial disease.
The range for each risk factor is estimated from epidemiologic studies hypertension treatment according to current national
(see text). The relative risks take into consideration current smokers vs. treatment guidelines are recommended for individuals
former smokers and nonsmokers; the presence vs. the absence of with asymptomatic lower extremity PAD. (Level of
diabetes and hypertension; and the highest vs. the lowest quartile of
homocysteine and C-reactive protein. The estimate for hypercholester- Evidence: B)
olemia is based on a 10% risk for each 10 mg/dl rise in total cholesterol. 4. Antiplatelet therapy is indicated for individuals with
Adapted from J Vasc Surg, 31, Dormandy JA, Rutherford RB, for the asymptomatic lower extremity PAD to reduce the risk
TransAtlantic Inter-Society Consensus (TASC) Working Group,
Management of peripheral arterial disease (PAD), S1S296, Copyright of adverse cardiovascular ischemic events. (Level of
2000, with permission from Elsevier (16). Evidence: C)
Hirsch et al ACC/AHA Guidelines for the Management of PAD 1479
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Figure 2. The natural history of atherosclerotic lower extremity peripheral arterial disease (PAD). Individuals with atherosclerotic lower extremity PAD
may be: (a) asymptomatic (without identied ischemic leg symptoms, albeit with a functional impairment); (b) present with leg symptoms (classic
claudication or atypical leg symptoms); or (c) present with critical limb ischemia. All individuals with PAD face a risk of progressive limb ischemic
symptoms, as well as a high short-term cardiovascular ischemic event rate and increased mortality. These event rates are most clearly dened for individuals
with claudication or critical limb ischemia (CLI), and less well dened for individuals with asymptomatic PAD. CV cardiovascular; MI myocardial
infarction. Adapted with permission from Weitz JL et al. Circulation 1996;94:3026 49 (5).
Individuals with asymptomatic lower extremity PAD are heart failure, chronic respiratory disease, or orthope-
characterized by a risk factor prole comparable to that of dic limitations) before undergoing an evaluation for
those with symptomatic lower extremity PAD (9,10). The revascularization. (Level of Evidence: C)
high prevalence of diabetes, a history of past or current 4. Individuals with intermittent claudication who are
smoking, hypertension, and/or hypercholesterolemia place offered the option of endovascular or surgical thera-
such individuals at a markedly increased risk of atheroscle- pies should (a) be provided information regarding
rotic ischemic events, including MI and stroke (9,11) and supervised claudication exercise therapy and pharma-
higher degrees of internal carotid artery stenosis (12,13). cotherapy; (b) receive comprehensive risk factor mod-
Given these data, current U.S. national hypertension, lipid, ication and antiplatelet therapy; (c) have a signi-
and antiplatelet treatment guidelines include all patients cant disability, either being unable to perform normal
with lower extremity PAD, regardless of symptom status, as work or having serious impairment of other activities
a high-risk category. All patients with lower extremity important to the patient; and (d) have lower extremity
PAD should achieve risk reduction and specic treatment PAD lesion anatomy such that the revascularization
targets comparable to those of individuals with established procedure would have low risk and a high probability
coronary artery disease (14,15). of initial and long-term success. (Level of Evidence: C)
The responsibility for the detection of lower extremity
PAD should be with the primary care provider. Programs Class III
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Nerve root Radiates down Sharp lancinating Soon, if not Not quickly Relief may be History of back
compression leg, usually pain immediately relieved (also aided by problems
(e.g., posteriorly after onset often present adjusting back
herniated at rest) position
disc)
Spinal stenosis Hip, thigh, Motor weakness After walking or Relieved by Relief by lumbar Frequent history of
buttocks more standing for stopping only spine exion back problems,
(follows prominent variable if position (sitting or provoked by
dermatome) than pain lengths of changed stooping intra-abdominal
time forward) pressure
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Arthritic, Foot, arch Aching pain After variable Not quickly May be relieved Variable, may
inammatory degree of relieved (and by not bearing relate to activity
processes exercise may be weight level
present at
rest)
Hip arthritis Hip, thigh, Aching After variable Not quickly More comfortable Variable, may
buttocks discomfort, degree of relieved (and sitting, weight relate to activity
usually exercise may be taken off legs level, weather
localized to present at changes
hip and gluteal rest)
region
Symptomatic Behind knee, Swelling, With exercise Present at rest None Not intermittent
Bakers cyst down calf soreness,
tenderness
Venous Entire leg, but Tight, bursting After walking Subsides slowly Relief speeded by History of
claudication usually worse pain elevation iliofemoral deep
in thigh and vein thrombosis,
groin signs of venous
congestion,
edema
Chronic Calf muscles Tight, bursting After much Subsides very Relief speeded by Typically occurs in
compartment pain exercise (e.g., slowly elevation heavy muscled
syndrome jogging) athletes
Adapted from J Vasc Surg, 31, Dormandy JA, Rutherford RB, for the TransAtlantic Inter-Society Consensus (TASC) Working Group, Management of peripheral arterial disease
(PAD), S1S296, Copyright 2000, with permission from Elsevier (16).
Most individuals with claudication benet from a com- revascularization may then undergo additional imaging studies
prehensive medical approach that includes risk factor mod- as required to determine whether their arterial anatomy is
ication, antiplatelet therapy, exercise rehabilitation, and suitable for percutaneous or surgical revascularization.
use of claudication medications (see Sections 2.6.1 and
2.6.2). In these individuals, more complex imaging studies 3. Critical Limb Ischemia.
are not required for effective management. Decisions re-
RECOMMENDATIONS
garding revascularization of individuals with claudication
should be based on the severity of symptoms, a signicant Class I
disability as assessed by the patient, failure of medical
therapies, lack of signicant comorbid conditions, vascular 1. Patients with CLI should undergo expedited evalu-
anatomy suitable for the planned revascularization, and a ation and treatment of factors that are known to
favorable risk-benet ratio. These recommendations are increase the risk of amputation (see text). (Level of
summarized in Table 4 (16). Patients selected for possible Evidence: C)
1482 Circulation March 21, 2006
Table 4. Indications for Revascularization in Intermittent Critical limb ischemia is dened by most vascular clini-
Claudication cians in patients who present with lower extremity ischemic
Before offering a patient with intermittent claudication the option of any rest pain, ulceration, or gangrene. In these individuals, the
invasive revascularization therapy, whether endovascular or surgical, the untreated natural history of severe PAD would lead to major
following considerations must be taken into account:
A predicted or observed lack of adequate response to exercise
limb amputation within 6 months. The Rutherford clinical
therapy and claudication pharmacotherapies categories (described earlier) are used to classify the degree
Presence of a severe disability, either being unable to perform of ischemia and salvageability of the limb. Critical limb
normal work or having very serious impairment of other activities ischemia is also a component of the Fontaine clinical
important to the patient
classication system (Table 2).
Absence of other disease that would limit exercise even if the
claudication was improved (e.g., angina or chronic respiratory Patients with CLI usually present with limb pain at rest,
disease) with or without trophic skin changes or tissue loss. The
The individuals anticipated natural history and prognosis discomfort is often worse when the patient is supine (e.g., in
The morphology of the lesion (must be such that the appropriate
bed) and may lessen when the limb is maintained in the
intervention would have low risk and a high probability of initial
and long-term success)
dependent position. Typically, narcotic medications are
required for analgesia. Those factors that are known to
Adapted from J Vasc Surg, 31, Dormandy JA, Rutherford RB, for the TransAtlantic
Inter-Society Consensus (TASC) Working Group, Management of peripheral arterial increase the risk of limb loss in patients with CLI are
disease (PAD), S1S296, Copyright 2000, with permission from Elsevier (16). delineated in Table 5.
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diately and treated by a specialist competent in Severely decreased cardiac output (severe heart failure or shock)
of signs and symptoms of CLI after recent endovascular discrete end points. Table 11 displays the Society for
catheter manipulation, the onset of associated systemic Vascular Surgery/International Society for Cardiovascular
fatigue or muscle discomfort, symmetrical bilateral limb Surgery classication scheme and provides the most useful
symptoms, livido reticularis, or rising creatinine values. clinical method to describe this entity.
Treatment of CLI is dependent on increasing blood ow The hallmark clinical symptoms and physical examination
to the affected extremity to relieve pain, heal ischemic signs of acute limb ischemia include the 5 Ps that suggest
ulcerations, and avoid limb loss. Individuals with minimal or limb jeopardy: pain, paralysis, paresthesias, pulseless, and pal-
no skin breakdown or in whom comorbid conditions pre- lor. Some clinicians would also include a sixth P, polar, to
vent consideration of revascularization can occasionally be indicate a cold extremity. However, arterial embolism can
treated by medical therapies in the absence of revasculariza- occur without symptoms, whereas thrombosis can produce
tion. Medical care strategies have included the use of sudden, severe limb ischemia. The clinical diagnosis of arterial
antiplatelet agents, anticoagulant medications, intravenous embolism is suggested by (a) the sudden onset or sudden
prostanoids, rheologic agents, and maintenance of the limb worsening of symptoms, (b) a known embolic source, (c) the
in a dependent position. However, none of these clinical absence of antecedent claudication or other manifestations of
interventions has been adequately evaluated or proven in obstructive arterial disease, or (d) the presence of normal
prospective clinical trials to offer predictable improve- arterial pulses and Doppler systolic blood pressures in the
ments in limb outcomes. Recent investigation of angio- contralateral limb. Acute limb ischemia is a situation that
genic therapies, via administration of gene or protein, to Table 7. Investigations for Evaluating Patients With Critical
enhance collateral blood ow has offered promise as a Limb Ischemia (CLI)
potential strategy to treat CLI; however, these are not yet To achieve the objectives listed in Table 6, the following investigations
proven interventions and are not available as established should be used in patients with CLI:
therapies. Clinical history and examination, including the coronary and
identify the cause of the ischemia and (b) dene the options Ankle or toe pressure measurement or other objective measures for
1. Patients with acute limb ischemia and a salvageable patients in whom coronary ischemic symptoms would otherwise
merit such an assessment if CLI were not present (such coronary
extremity should undergo an emergent evaluation
assessments should usually not impede associated CLI care)
that denes the anatomic level of occlusion and that
Adapted from J Vasc Surg, 31, Dormandy JA, Rutherford RB, for the TransAtlantic
leads to prompt endovascular or surgical revascular- Inter-Society Consensus (TASC) Working Group, Management of peripheral arterial
ization. (Level of Evidence: B) disease (PAD), S1S296, Copyright 2000, with permission from Elsevier (16).
1484 Circulation March 21, 2006
requires prompt diagnosis and treatment to preserve the limb gram, which may include conducting exercise ABIs
and prevent the systemic illness or death that might result from and other arterial imaging studies at regular intervals
the metabolic abnormalities associated with tissue necrosis. (see duplex ultrasound recommendations, Section 2.5.5
Although the technical ability to recanalize or revascularize of the full-text guidelines). (Level of Evidence: B)
occluded arteries that perfuse ischemic tissues has improved 2. Long-term patency of endovascular sites may be
signicantly, the pathophysiology of the local and systemic evaluated in a surveillance program, which may in-
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clinical sequelae associated with reperfusion of an ischemic clude conducting exercise ABIs and other arterial
limb is only partially understood. Revascularization of an imaging studies at regular intervals (see duplex ultra-
ischemic extremity may be complicated by reperfusion injury to sound recommendations, Section 2.5.5 of the full-
the damaged tissues and precipitate systemic responses, includ- text guidelines). (Level of Evidence: B)
ing cardiac, renal, and pulmonary dysfunction.
Despite increasing short-term success rates for both Postprocedure surveillance after percutaneous or endovascu-
endovascular and surgical revascularization procedures, the lar procedures is less well studied, and standards are less well
possibility of recurrence remains throughout the lifetime of established. Regular visits, with assessment of interval change
the patient. Early revascularization interventions for recur- in symptoms, vascular examination, and ABI measurement, is
rent hemodynamic compromise are preferred, because delay considered the standard of care. Postexercise ABI determina-
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in detection or treatment can lead to higher morbidity and tions may be useful in some individuals. These modalities are
poorer outcome (19 24). Participation in a follow-up sur- clearly useful for patients in whom there is evidence of
veillance program is imperative for patients undergoing both recurrent narrowing at the interventional site. Similarly, distal
percutaneous and surgical revascularization. There are in- or small-caliber endovascular sites (with or without stenting) at
adequate data to permit creation of consensus-based stan- high risk of restenosis may merit more careful noninvasive
dards to dene exact time intervals for surveillance visits evaluation. Whereas the role of surveillance duplex imaging of
after each type of revascularization procedure. In the ab- autogenous and prosthetic grafts has been evaluated (see
full-text guidelines), the utility and role of duplex ultrasound
sence of evidence-based standards, the clinical timeframe
and other noninvasive diagnostic modalities (magnetic reso-
has customarily been based on the judgment of the vascular
nance angiography [MRA] and computed tomographic an-
specialist, by evaluating the specic level and type of
giography [CTA]) for such routine surveillance of endovascu-
revascularization procedure and taking into account specic
lar sites have yet to be determined.
patient characteristics (Tables 12, 13, and 14).
There is no uniformly accepted threshold for repeat angiog-
Recommendations have been made that follow-up of au- raphy and intervention in the patient with evidence of recur-
togenous vein bypass grafts be performed with duplex ultra- rent stenosis. Patients who have recurrent symptoms in asso-
sonography at intervals of 1, 3, 6, 12, 18, and 24 months after ciation with evidence of hemodynamic compromise require
surgery and then yearly thereafter (16). Prompt evaluation with restudy and repeat intervention. Likewise, evidence of rapidly
invasive techniques (angiography) is then indicated when progressive restenosis, even in the absence of symptoms, should
noninvasive methods suggest hemodynamically signicant le- provide a clue that may identify individuals who might benet
sions (e.g., greater than 50% stenosis) (25,26). Some patients from future invasive management. For grafts as well as native
with failing lower extremity grafts due to stenosis documented vessels, a stenosis of less than 50% appears to be associated with
by duplex ultrasound may proceed to have operative repair
without angiography. The benet of surveillance with duplex Table 13. Surveillance Program for Infrainguinal Vein Bypass
Grafts
ultrasound is less well established for prosthetic grafts.
Patients undergoing vein bypass graft placement in the lower extremity
for the treatment of claudication or limb-threatening ischemia should be
Table 12. Surveillance Program for Aortoiliac and Infrainguinal
entered into a surveillance program. This program should consist of:
Transluminal Angioplasty
Interval history (new symptoms)
Patients undergoing aortoiliac and infrainguinal transluminal angioplasty Vascular examination of the leg with palpation of proximal, graft,
for lower extremity revascularization should be entered into a and outow vessel pulses
surveillance program, which consists of: Periodic measurement of resting and, if possible, postexercise ABIs
Interval history (new symptoms) Duplex scanning of the entire length of the graft, with calculation of
Vascular examination of the leg with palpation of proximal and peak systolic velocities and velocity ratios across all identied lesions
outow vessel pulses Surveillance programs should be performed in the immediate
Resting and, if possible, postexercise ABI recording postoperative period and at regular intervals for at least 2 years
Surveillance programs should be performed in the immediate post-PTA Femoral-popliteal and femoral-tibial venous conduit bypass at
period and at intervals for at least 2 years approximately 3, 6, and 12 months and annually
Adapted from J Vasc Surg, 31, Dormandy JA, Rutherford RB, for the TransAtlantic Adapted from J Vasc Surg, 31, Dormandy JA, Rutherford RB, for the TransAtlantic
Inter-Society Consensus (TASC) Working Group, Management of peripheral Inter-Society Consensus (TASC) Working Group, Management of peripheral
arterial disease (PAD), S1S296, Copyright 2000, with permission from Elsevier arterial disease (PAD), S1S296, Copyright 2000, with permission from Elsevier
(16). (16).
ABI ankle-brachial index; PTA percutaneous transluminal angioplasty. ABI ankle-brachial index.
1486 Circulation March 21, 2006
Table 14. Surveillance Program for Infrainguinal Prosthetic whom lower extremity PAD is clinically suspected
Grafts but in whom the ABI test is not reliable due to
Patients undergoing prosthetic femoropopliteal or femorotibial bypass noncompressible vessels (usually patients with
for claudication or limb-threatening ischemia should be entered into a long-standing diabetes or advanced age). (Level of
graft surveillance program that consists of:
Evidence: B)
Interval history (new symptoms)
Table 15. Noninvasive and Invasive Vascular Diagnostic Tools: Benets and Limitations
Diagnostic Tool Benets Limitations
Ankle-brachial A quick and cost-effective way to establish or refute May not be accurate when systolic blood pressure
indices (ABIs) the lower extremity PAD diagnosis (see text) cannot be abolished by ination of an air-lled
blood pressure cuff (noncompressible pedal
arteries), as occurs in a small fraction of diabetic
or very elderly individuals
Toe-brachial A quick and cost-effective way to establish or refute Requires small cuffs and careful technique to
indices the lower extremity PAD diagnosis (see text) preserve accuracy
Can measure digital perfusion when small-vessel
interventions
Pulse volume Useful to establish the diagnosis of PAD in vascular Qualitative, not quantitative, measure of perfusion
recording laboratories or ofce practice May not be accurate in more distal segments
Usefulness maintained in patients with Less accurate than other noninvasive tests in
noncompressible vessels (ABI value greater than providing arterial anatomic localization of PAD
1.3) May be abnormal in patients with low cardiac
revascularization procedures
Continuous-wave Useful to assess lower extremity PAD anatomy, Pulse normalization downstream from stenoses
Doppler severity, and progression can diminish test sensitivity
ultrasound Can provide localizing information in patients with Test specicity greater for patent supercial femoral
postexercise ABIs with increased convenience and low cost individuals with claudication
Treadmill exercise Helps differentiate claudication from Requires use of a motorized treadmill, with or
testing, with and pseudoclaudication in individuals with exertional leg without continuous electrocardiogram monitoring,
without pre- symptoms as well as staff familiar with exercise testing
exercise and Useful to diagnose lower extremity PAD when protocols
postexercise ABIs resting ABI values are normal
Objectively documents the magnitude of symptom
Helpful to provide associated soft tissue diagnostic Venous opacication can obscure arterial lling
information that may be associated with PAD Asymmetrical opacication of the legs may
presentation (e.g., aneurysms, popliteal entrapment, obscure arterial phase in some vessels
and cystic adventitial disease) Accuracy and effectiveness not as well determined
Metal clips, stents, and metallic prostheses do not compared with those of catheter angiography
cause signicant CTA artifacts Requires iodinated contrast and ionizing radiation
Scan times are signicantly faster than for MRA (although radiation exposure is less than with
catheter angiography)
Because CTA requires administration of
eccentric lesions
Tools are listed in order from least to most invasive and from least to most costly.
CLI critical limb ischemia; PAD peripheral arterial disease.
Adapted from Primary Cardiology, 2nd ed., Braunwald E, Goldman L, eds., Recognition
may be considered to select patients with lower
and management of peripheral arterial disease, Hirsch AT, 659 71, Philadelphia, PA: extremity PAD as candidates for surgical bypass and
WB Saunders, Copyright 2003, with permission from Elsevier (30a).
AAA abdominal aortic aneurysm; ABI ankle-brachial index; CTA
to select the sites of surgical anastomosis. (Level of
computed tomographic angiography; MRA magnetic resonance angiography; Evidence: B)
PAD peripheral arterial disease; PVR pulse volume recording.
2. Magnetic resonance angiography of the extremities
may be considered for postrevascularization (endo-
Class IIa vascular and surgical bypass) surveillance in patients
with lower extremity PAD. (Level of Evidence: B)
1. Duplex ultrasound of the extremities can be useful to
select patients as candidates for endovascular inter- 8. Contrast Angiography.
vention. (Level of Evidence: B) RECOMMENDATIONS
2. Duplex ultrasound can be useful to select patients as
Class I
candidates for surgical bypass and to select the sites
of surgical anastomosis. (Level of Evidence: B) 1. Contrast angiography provides detailed information
Class IIb about arterial anatomy and is recommended for
evaluation of patients with lower extremity PAD
1. The use of duplex ultrasound is not well established when revascularization is contemplated. (Level of
to assess long-term patency of percutaneous translu- Evidence: B)
minal angioplasty. (Level of Evidence: B) 2. A history of contrast reaction should be documented
2. Duplex ultrasound may be considered for routine before the performance of contrast angiography and
surveillance after femoral-popliteal bypass with a appropriate pretreatment administered before con-
trast is given. (Level of Evidence: B)
synthetic conduit. (Level of Evidence: B)
3. Decisions regarding the potential utility of invasive
6. Computed Tomographic Angiography. therapeutic interventions (percutaneous or surgical)
in patients with lower extremity PAD should be
RECOMMENDATIONS
made with a complete anatomic assessment of the
Class IIb affected arterial territory, including imaging of the
occlusive lesion, as well as arterial inow and out-
1. Computed tomographic angiography of the ex- ow with angiography or a combination of angiog-
tremities may be considered to diagnose anatomic raphy and noninvasive vascular techniques. (Level of
location and presence of signicant stenosis in Evidence: B)
patients with lower extremity PAD. (Level of Evi- 4. Digital subtraction angiography is recommended for
dence: B) contrast angiographic studies because this tech-
2. Computed tomographic angiography of the extremi- nique allows for enhanced imaging capabilities com-
ties may be considered as a substitute for MRA for pared with conventional unsubtracted contrast an-
giography. (Level of Evidence: A)
those patients with contraindications to MRA. (Level
5. Before performance of contrast angiography, a full
of Evidence: B)
history and complete vascular examination should
7. Magnetic Resonance Angiography. be performed to optimize decisions regarding the
1490 Circulation March 21, 2006
access site, as well as to minimize contrast dose and reasonable for patients with lower extremity PAD at
catheter manipulation. (Level of Evidence: C) very high risk of ischemic events. (Level of Evidence: B)
6. Selective or superselective catheter placement dur- 2. Treatment with a bric acid derivative can be useful
ing lower extremity angiography is indicated be- for patients with PAD and low high-density lipopro-
cause this can enhance imaging, reduce contrast tein (HDL) cholesterol, normal LDL cholesterol,
dose, and improve sensitivity and specicity of the and elevated triglycerides. (Level of Evidence: C)
procedure. (Level of Evidence: C)
It is recommended that patients with PAD and LDL
7. The diagnostic lower extremity arteriogram should
cholesterol of 100 mg per dl or greater be treated with a
image the iliac, femoral, and tibial bifurcations in
statin, but when risk is very high, an LDL cholesterol goal
prole without vessel overlap. (Level of Evidence: B)
of less than 70 mg per dl is a therapeutic option (29,30).
8. When conducting a diagnostic lower extremity ar-
Among the factors that dene very high risk in individuals
teriogram in which the signicance of an obstructive
with established PAD are (a) multiple major risk factors
lesion is ambiguous, transstenotic pressure gradi-
(especially diabetes), (b) severe and poorly controlled risk
ents and supplementary angulated views should be
factors (especially continued cigarette smoking), (c) multiple
obtained. (Level of Evidence: B)
risk factors of the metabolic syndrome (especially high
9. Patients with baseline renal insufciency should
triglycerides; i.e., greater than or equal to 200 mg per dl plus
receive hydration before undergoing contrast an-
non-HDL cholesterol greater than or equal to 130 mg per
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patients with coronary atherosclerosis (33), do not adversely tion interventions, including behavior modication
affect walking capacity (34). Angiotensin-converting en- therapy, nicotine replacement therapy, or bupropion.
zyme inhibitors reduce the risk of death and nonfatal (Level of Evidence: B)
cardiovascular events in patients with coronary artery disease
Physician advice coupled with frequent follow-up
and left ventricular dysfunction (35,36). The Heart Out-
achieves 1-year smoking cessation rates of approximately
comes Prevention Evaluation (HOPE) trial found that in
5% compared with only 0.1% in those attempting to quit
patients with symptomatic PAD, ramipril reduced the risk
smoking without a physicians intervention (42). Phar-
of MI, stroke, or vascular death by approximately 25%, a
macological interventions such as nicotine replacement
level of efcacy comparable to that achieved in the entire
therapy and bupropion achieve 1-year smoking cessation
study population (37). There is currently no evidence base
rates of approximately 16% and 30%, respectively (43).
for the efcacy of ACE inhibitors in patients with asymp-
tomatic PAD, and thus, the use of ACE-inhibitor medica- Tobacco cessation interventions are particularly critical in
tions to lower cardiovascular ischemic event rates in this individuals with thromboangiitis obliterans, because con-
population must be extrapolated from the data on symp- tinued use is associated with a particularly adverse out-
tomatic patients. come (44).
E. HOMOCYSTEINE-LOWERING DRUGS.
C. DIABETES THERAPIES.
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RECOMMENDATIONS RECOMMENDATION
1. Proper foot care, including use of appropriate foot- 1. The effectiveness of the therapeutic use of folic acid
wear, chiropody/podiatric medicine, daily foot in- and B12 vitamin supplements in individuals with
spection, skin cleansing, and use of topical moistur- lower extremity PAD and homocysteine levels greater
izing creams should be encouraged, and skin lesions than 14 micromoles per liter is not well established.
and ulcerations should be addressed urgently in all (Level of Evidence: C)
diabetic patients with lower extremity PAD. (Level of F. ANTIPLATELET AND ANTITHROMBOTIC DRUGS.
Evidence: B)
RECOMMENDATIONS
Class IIa
Class I
1. Treatment of diabetes in individuals with lower
extremity PAD by administration of glucose control 1. Antiplatelet therapy is indicated to reduce the risk of
therapies to reduce the hemoglobin A1C to less than MI, stroke, or vascular death in individuals with
7% can be effective to reduce microvascular compli- atherosclerotic lower extremity PAD. (Level of Evi-
cations and potentially improve cardiovascular out- dence: A)
comes. (Level of Evidence: C) 2. Aspirin, in daily doses of 75 to 325 mg, is recom-
mended as safe and effective antiplatelet therapy to
Aggressive treatment of diabetes is known to decrease the reduce the risk of MI, stroke, or vascular death in
risk for microvascular events such as nephropathy and individuals with atherosclerotic lower extremity
retinopathy (38,39). Patients with lower extremity PAD PAD. (Level of Evidence: A)
and diabetes should be treated to reduce their glycosylated 3. Clopidogrel (75 mg per day) is recommended as an
hemoglobin to less than 7%, per the American Diabetes effective alternative antiplatelet therapy to aspirin to
Association recommendation (40). Frequent foot inspection reduce the risk of MI, stroke, or vascular death in
by patients and physicians will enable early identication of
individuals with atherosclerotic lower extremity
foot lesions and ulcerations and facilitate prompt referral for
PAD. (Level of Evidence: B)
treatment (41).
Class III
D. SMOKING CESSATION.
proportional reduction of cardiovascular events with 75 to curred when each exercise session lasted longer than 30
150 mg daily, 26% with 160 to 325 mg daily, and 19% minutes, when sessions took place at least 3 times per
with 500 to 1500 mg daily. There was a signicantly week, when the exercise modality was walking to near-
smaller (13%) reduction in cardiovascular events in pa- maximal pain, and when the program lasted 6 months or
tients being treated with less than 75 mg of aspirin per greater. The key elements of such a therapeutic claudi-
day. In the CAPRIE trial (Clopidogrel Versus Aspirin in cation exercise program for patients with claudication are
Patients at Risk of Ischemic Events), clopidogrel reduced summarized in Table 17.
the risk of MI, stroke, or vascular death by 23.8%
compared with aspirin in patients with PAD (46). To
Table 17. Key Elements of a Therapeutic Claudication Exercise
date, there is no evidence to support the efcacy of
Training Program (Lower Extremity PAD Rehabilitation)
combined aspirin and clopidogrel treatment versus a
Primary Clinician Role
single antiplatelet agent in patients with lower extremity
Establish the PAD diagnosis using the ankle-brachial index
PAD. Information regarding the efcacy of oral antico- measurement or other objective vascular laboratory evaluations
agulants (i.e., coumarin derivatives such as warfarin) in Determine that claudication is the major symptom limiting
oral anticoagulation with coumarin derivatives reduces Provide formal referral to a claudication exercise rehabilitation
Types of Exercise
2. Claudication. Treadmill and track walking are the most effective exercise for
claudication.
A. EXERCISE AND LOWER EXTREMITY PAD REHABILITATION. Resistance training has conferred benet to individuals with other
ommended as an initial treatment modality for moderate severity, which is then followed by a brief period of
standing or sitting rest to permit symptoms to resolve
patients with intermittent claudication. (Level of
Duration
Evidence: A) The exercise-rest-exercise pattern should be repeated throughout the
2. Supervised exercise training should be performed for exercise session
a minimum of 30 to 45 minutes, in sessions per- The initial duration will usually include 35 minutes of intermittent
CILOSTAZOL. RECOMMENDATIONS
PENTOXIFYLLINE. RECOMMENDATIONS
Class I
RECOMMENDATIONS
Class IIb 1. Endovascular procedures are indicated for individu-
als with a vocational or lifestyle-limiting disability
1. Pentoxifylline (400 mg 3 times per day) may be due to intermittent claudication when clinical fea-
considered as second-line alternative therapy to tures suggest a reasonable likelihood of symptomatic
cilostazol to improve walking distance in patients improvement with endovascular intervention and (a)
with intermittent claudication. (Level of Evidence: there has been an inadequate response to exercise or
A) pharmacological therapy and/or (b) there is a very
2. The clinical effectiveness of pentoxifylline as therapy favorable risk-benet ratio (e.g., focal aortoiliac oc-
for claudication is marginal and not well established. clusive disease). (Level of Evidence: A)
(Level of Evidence: C) 2. Endovascular intervention is recommended as the
preferred revascularization technique for Transatlan-
Meta-analyses of randomized, placebo-controlled, tic Inter-Society Consensus type A (see Tables 20
double-blind clinical trials found that pentoxifylline and 21 and Figure 8 of the full-text guidelines) iliac
causes a marginal but statistically signicant improve- and femoropopliteal arterial lesions. (Level of Evi-
ment in pain-free and maximal walking distance (63,64); dence: B)
however, pentoxifylline does not increase the ABI at rest 3. Translesional pressure gradients (with and without
or after exercise (64). Pentoxifylline may be considered to vasodilation) should be obtained to evaluate the
treat patients with intermittent claudication; however, signicance of angiographic iliac arterial stenoses of
the anticipated outcome is likely to be of marginal clinical 50% to 75% diameter before intervention. (Level of
importance. Evidence: C)
1494 Circulation March 21, 2006
4. Provisional stent placement is indicated for use in the of vein bypass graft stenoses has also been reported, with 1-
iliac arteries as salvage therapy for a suboptimal or to 3-year patency rates of the treated site of approximately
failed result from balloon dilation (e.g., persistent 60% (81 83), comparable to surgical repair (81). Percuta-
translesional gradient, residual diameter stenosis neous transluminal angioplasty of multiple vein graft steno-
greater than 50%, or ow-limiting dissection). (Level ses has a much lower 3-year patency rate of only 6% (82).
of Evidence: B) Therefore, patient selection is key in obtaining satisfactory
5. Stenting is effective as primary therapy for common iliac outcomes. For a full discussion of patient and lesion
artery stenosis and occlusions. (Level of Evidence: B) selection, see the full-text guidelines.
6. Stenting is effective as primary therapy in external iliac
D. SURGERY FOR CLAUDICATION.
artery stenoses and occlusions. (Level of Evidence: C)
INDICATIONS.
Class IIa
Table 18. Overview of Primary Patency and Limb Salvage Rates After Endovascular Procedures for Peripheral Arterial Disease of the Lower Extremities
% 30-Day % Major % Technical % Primary Patency (95% CI)*
Severity of No. of Mortality Complication Success
Procedure Lesion Type Disease Reference Limbs (95% CI) (95% CI) (95% CI) 1 yr 2 yrs 3 yrs 4 yrs 5 yrs
Iliac PTA 80% Stenoses, 67% Claudication, (84) 1473 1.0 (02.9) 4.3 (2.06.5) 91 (8696) 74 (7176) 66 (6368) 61 (5964) 58 (5661)
20% occlusion 33% critical
ischemia
Stenoses Claudication ND ND 96 79 72 68 65
Stenoses Critical ischemia ND ND ND 72 61 56 53
Occlusion Claudication ND ND 80 66 60 57 54
Occlusion Critical ischemia ND ND ND 60 51 47 44
Iliac stent 72% Stenoses, 85% Claudication, (84) 901 0.8 (0.70.9) 5.2 (3.56.9) 96 (91100) 86 (8489) 79 (7681) 75 (7278) 74 (6978)
28% occlusion 15% critical
ischemia
Hirsch et al
surgical procedures (inclusive of aortic, femoral, and infra- mittent claudication in very limited settings, such
popliteal segments). This risk is further increased in those as chronic infrarenal aortic occlusion associated
patients with an established history of ischemic heart with symptoms of severe claudication in patients
disease, current angina, or an abnormal electrocardiogram who are not candidates for aortobifemoral bypass.
and may be challenging to assess in those individuals in (Level of Evidence: B)
whom a sedentary lifestyle limits assessment of functional
Class III
capacity. The preoperative cardiovascular risk evaluation is
summarized in more detail in the ACC/AHA Guideline 1. Axillofemoral-femoral bypass should not be used
Update for Perioperative Cardiovascular Evaluation for for the surgical treatment of patients with inter-
Noncardiac Surgery (89). mittent claudication except in very limited settings
(see Class IIb recommendation above). (Level of
CORRELATION OF SYMPTOMS AND LESIONS.
Evidence: B)
SURGICAL PROCEDURES. For individuals with claudication,
There are numerous patterns of aortoiliac occlusive
initial revascularization strategies will usually rely on
disease and procedures to surgically treat them (Table
endovascular techniques, with surgical intervention re-
19). Most commonly, patients demonstrate diffuse dis-
served for individuals in whom arterial anatomy is not
ease of the infrarenal aorta and iliac vessels, with the
favorable for endovascular procedures. As noted in Sec-
lesions of greatest hemodynamic consequence located in
tion 2.6.2.4 of the full-text guidelines, comparable ef-
the iliac arteries. The most effective surgical procedure
cacy can often be achieved, with less risk imposed by
for the treatment for this pattern of atherosclerotic
endovascular intervention when both procedures are fea-
occlusive disease and the resultant buttock and thigh
sible (90 92). Once the decision to proceed with surgical
claudication is aortobifemoral bypass.
intervention has been made and the site and severity of
If the aortoiliac lesions are conned to the area of the
occlusive lesions have been dened through imaging
aortic bifurcation, localized aortoiliac endarterectomy may
studies, the type of revascularization must be chosen. In
be considered. A less invasive approach may be appropriate
patients with combined inow and outow disease,
for patients with adequate aortic ow but stenoses or
inow problems are corrected rst. A signicant im-
occlusions of both iliac vessels. Such patients may not be
provement in inow may diminish the symptoms of
considered acceptable candidates for aortobifemoral bypass
claudication to the extent that supervised exercise therapy
or pharmacotherapies may be effective and, if distal Table 19. Vascular Surgical Procedures for Inow Improvement
revascularization is needed, reduce the likelihood of distal
Operative Expected
graft thrombosis from low ow. Mortality Patency Rates
INFLOW PROCEDURES: AORTOILIAC OCCLUSIVE DISEASE. Inow Procedure (%) (%) References
Aortobifemoral bypass 3.3 87.5 (5 yrs) (93)
Aortoiliac or aortofemoral 12 8590 (5 yrs) (9496)
RECOMMENDATIONS bypass
Iliac endarterectomy 0 7990 (5 yrs) (9799)
Class I Femorofemoral bypass 6 71 (5 yrs) (100)
1. Aortobifemoral bypass is benecial for patients Axillofemoral bypass 6 4980 (3 yrs) (101,102)
Axillofemoral-femoral bypass 4.9 6367.7 (5 yrs) (103,104)
with vocational- or lifestyle-disabling symptoms
Hirsch et al ACC/AHA Guidelines for the Management of PAD 1497
because of comorbid cardiovascular disease. If endovascular claudication in rare instances for certain patients (see
treatment of 1 iliac artery is feasible and can achieve patency text). (Level of Evidence: B)
with this less invasive approach, a subsequent endarterec- 2. Because their use is associated with reduced patency
tomy, unilateral iliofemoral bypass, or a femoral-femoral rates, the effectiveness of the use of synthetic grafts to
bypass can be constructed. In the absence of an inow the popliteal artery above the knee is not well estab-
stenosis within the donor iliac arterial segment, this proce- lished. (Level of Evidence: B)
dure can effectively provide ow to both lower extremities
Class III
and eliminate the symptoms of claudication. Patients with
severe infrarenal aortic atherosclerosis who are at high 1. Femoral-tibial artery bypasses with synthetic graft
cardiovascular or surgical risk for open aortobifemoral by- material should not be used for the treatment of
pass may be treated with axillofemoral-femoral bypass. claudication. (Level of Evidence: C)
Because of lower patency rates, such bypasses are reserved
for those who have no alternatives for revascularization. The most commonly performed infrainguinal bypass
Unilateral iliac stenoses or occlusions that cannot be effec- for the treatment of claudication is the femoral-popliteal
tively treated by angioplasty and stent placement can be artery bypass (Table 20). There are, however, specic
treated by iliac artery endarterectomy, aortoiliac bypass, factors that may modify the result of this procedure. The
2 major factors are the type of conduit and the site of
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Assisted Assisted
First Author Reference Graft Material n 2 5 5 6 6
Johnson (117) SVG 226 81 73
PTFE 265 69 39
Klinkert (118) SVG 75 75.6 79.7
PTFE 76 51.9 57.2
AbuRahma (116) SVG 43 76 83
PTFE 43 68 68
Green (115) PTFE 43 68
Dacron 45 68
n number of patients; PTFE polytetrauoroethylene; SVG saphenous vein graft.
B. ENDOVASCULAR TREATMENTS FOR CLI. (Rutherford category IIb) of more than 14 days
duration. (Level of Evidence: B)
RECOMMENDATIONS
Randomized controlled trials and registry reports in-
Class I
dicate that the use of thrombolytic therapy for acute limb
1. For individuals with combined inow and outow ischemia is effective as initial therapy (139 142). (The
disease with CLI, inow lesions should be addressed terms thrombolysis and thrombolytic are synonymous
rst. (Level of Evidence: C) with the terms brinolysis and brinolytic, as used in
2. For individuals with combined inow and outow other ACC/AHA guidelines.) These randomized trials
disease in whom symptoms of CLI or infection and case series suggest that the use of intra-arterial
persist after inow revascularization, an outow re- thrombolytic therapy for acute limb ischemia is reason-
vascularization procedure should be performed. ably effective and comparable to surgery. The advantage
(Level of Evidence: B) of thrombolytic therapy is that it offers a low-risk
3. If it is unclear whether hemodynamically signicant alternative to open surgery in complex patients with severe
inow disease exists, intra-arterial pressure measure- comorbidities. Other advantages of pursuing immediate
ments across suprainguinal lesions should be mea- angiography in patients with acute limb ischemia include
sured before and after the administration of a vaso- delineation of the limb arterial anatomy with visualization
dilator. (Level of Evidence: C) of both inow and runoff vessels. Finally, thrombolytic
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Table 22. Mechanical Thrombectomy Devices for the Treatment of Peripheral Arterial Occlusions
Device and Primary
First Author Conduit Duration MTD Success,* Adjunctive Patency Complications
(Reference) Year n n (%) n n (%) Procedures (%) (%)
Oasis 1999 51 Native: 44 All acute 6 (11.8) Lysis: 5 1 month: 64 Hemorrhage: 8
Hoptner (143) (86) PTA: 20 6 months: 54 Emboli: 4.8
Grafts: 7 PAT: 15 Acute occlusion: 3
(14) SA: 3 Amputation: 17.7
Mortality: 8
AngioJet
Muller-Hulsbeck 2000 112 Native: 99 All acute 79 (71) Lysis: 20 6 months: 68 Embolization: 9.8
(144) (86) PTA: 68 2 years: 60 Dissection: 8
Grafts: 16 PAT: 11 3 years: 58 Perforation: 3.6
(14) Amputation: 1.8
Mortality: 7
Kasirajan (145) 2001 83 Native: 52 Acute: 62 Complete: 51 Lysis: 50 3 months: 90 Hemorrhage: 10.5
(63) Chronic: 21 (61) PTA: 47 6 months: 78 Emboli: 2.3
Grafts: 31 Partial: 19 Dissection: 3.5
(37) (23) Perforation: 2.3
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Amputation: 11.6
Mortality: 9.3
Silva (146) 1998 22 Native: 13 All acute 21 (95) PTA: 21 NA Hemorrhage: 10
(59) Embolism: 9
Grafts: 9 Dissection: 5
(41) Occlusion: 18
Amputation: 5
Mortality: 14
Wagner (147) 1997 50 Native: 39 All acute 26 (52) Lysis: 15 1 year: 69 Hemorrhage: 6
(78) PTA: 34 Emboli: 6
Grafts: 11 PAT: 9 Dissection: 6
(22) Perforation: 6
Amputation: 8
Mortality: 0
Hydrolyser
Reekers (148) 1996 28 Native: 11 Acute: 23 23 (82) Lysis: 11 1 month: 50 Embolization: 18
(39) Chronic: 5 PTA: 20 Hemorrhage: 0
Grafts: 17 PAT: 2 Acute occlusion: 10
(61) Amputation: 11
Mortality: 0
Henry (149) 1998 41 Native: 28 All acute 34 (83) Lysis: 10 1 month: 73 Acute occlusion: 12
(68) PTA: 29 Emboli: 2.4
Grafts: 8 PAT: 17 Amputation: 0
(20) Mortality: 0
Other: 5 Mortality: 0
Amplatz
Rilinger (150) 1997 40 All native All acute 30 (75) Lysis/PTA/ NA Hemorrhage: 2.5
SA: 9 Device failure: 7.5
Emboli: 0
Amputation: 5
Mortality: 0
Tadavarthy (151) 1994 14 Native: 2 Acute: 9 10 (71) Lysis: 4 6 months: 43 Hemorrhage: 14.3
(14) Chronic: 5 PTA/SA: 11 Emboli: 14
Grafts: 10 Device failure: 7
(71) Amputation: 0
Other: 2 Mortality: 0
Gorich (152) 1998 18 All native All acute 14 (78) Lysis: 12 NA Hemorrhage: 6
PAT: 9 Device failure: 6
Amputation: 6
*Denition of success varies among studies. Reprinted from Haskal ZJ. Mechanical thrombectomy devices for the treatment of peripheral arterial occlusions. Rev Cardiovasc Med
2002;3 Suppl 2:S45S52 (152a).
MTD mechanical thrombectomy device; n number of patients; NA not applicable; PAT percutaneous aspiration thrombectomy; PTA percutaneous transluminal
angioplasty; SA Simpson atherectomy.
Hirsch et al ACC/AHA Guidelines for the Management of PAD 1501
Class III Nearly all studies that have compared vein to prosthetic
conduit for arterial reconstruction of the lower extremity
1. Surgical and endovascular intervention is not indi- have demonstrated the superior patency of vein (115118).
cated in patients with severe decrements in limb In its absence, polytetrauoroethylene or Dacron (polyester
perfusion (e.g., ABI less than 0.4) in the absence of ber) may be used with an expected lower but acceptable
clinical symptoms of CLI. (Level of Evidence: C) patency rate for above-knee bypasses. Patency of prosthetic
grafts is signicantly lower once the knee joint is crossed
The goal of surgical intervention in patients with CLI is
(85). When vein length is inadequate, a composite sequen-
the elimination of clinical manifestations of severe lower
tial graft that consists of a prosthetic graft to the above-knee
extremity PAD, whether rest pain, ischemic ulcers, or distal
popliteal artery and a jump graft of autogenous vein to the
ischemic gangrene. A signicant improvement in inow
distal vessel may be used. If no other option exists, the use
may diminish the symptoms of rest pain, but pulsatile ow of a prosthetic with an adjunctive procedure, such as
to the foot is generally necessary for the treatment of arteriovenous stula or vein interposition or cuff, may
ischemic ulcers or ischemic gangrene. Therefore, if infec- improve patency, although this has not been proven. The
tion, ischemic ulcers, or gangrenous lesions persist and the least-diseased tibial or pedal artery with continuous ow to
ABI is less than 0.8 after correction of inow, an outow the foot should be used as the outow vessel for the
procedure should be performed that bypasses all major distal construction of a distal bypass, because equivalent results
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stenoses and occlusions (138). Surgery for the treatment of can be achieved with all tibial and even pedal arteries
severe lower extremity ischemia (as for endovascular treat- (153,154).
ment) must be based on specic goals, such as the relief of
rest pain or healing of ulcers, prior revascularization at- OUTFLOW PROCEDURES: INFRAINGUINAL DISEASE.
tempts, the type of procedure required to accomplish the
goals, and the patients overall ability to successfully recover RECOMMENDATIONS
from the effort. In patients with combined inow and
outow disease, inow problems must be corrected rst. Class I
INFLOW PROCEDURES: AORTOILIAC OCCLUSIVE DISEASE. 1. Bypasses to the above-knee popliteal artery should be
constructed with autogenous saphenous vein when
possible. (Level of Evidence: A)
RECOMMENDATIONS 2. Bypasses to the below-knee popliteal artery should be
Class I constructed with autogenous vein when possible.
(Level of Evidence: A)
1. When surgery is to be undertaken, aortobifemoral 3. The most distal artery with continuous ow from
bypass is recommended for patients with symptom- above and without a stenosis greater than 20% should
atic, hemodynamically signicant, aorto-bi-iliac dis- be used as the point of origin for a distal bypass.
ease requiring intervention. (Level of Evidence: A) (Level of Evidence: B)
2. Iliac endarterectomy, patch angioplasty, or aortoiliac 4. The tibial or pedal artery that is capable of providing
or iliofemoral bypass in the setting of acceptable continuous and uncompromised outow to the foot
aortic inow should be used for the treatment of should be used as the site of distal anastomosis.
unilateral disease or in conjunction with femoral- (Level of Evidence: B)
femoral bypass for the treatment of a patient with 5. Femoral-tibial artery bypasses should be constructed
bilateral iliac artery occlusive disease if the patient is with autogenous vein, including the ipsilateral
not a suitable candidate for aortobifemoral bypass greater saphenous vein, or if unavailable, other
grafting. (Level of Evidence: B) sources of vein from the leg or arm. (Level of Evi-
3. Axillofemoral-femoral bypass is indicated for the dence: B)
treatment of patients with CLI who have extensive 6. Composite sequential femoropopliteal-tibial bypass
aortoiliac disease and are not candidates for other and bypass to an isolated popliteal arterial segment
that has collateral outow to the foot are both
types of intervention. (Level of Evidence: B)
acceptable methods of revascularization and should
The creation of an in situ or reversed greater saphenous be considered when no other form of bypass with
vein bypass to a tibial vessel is the most commonly per- adequate autogenous conduit is possible. (Level of
formed limb salvage procedure. This type of bypass can be Evidence: B)
performed under general or regional (or, more rarely, local) 7. If no autogenous vein is available, a prosthetic
anesthesia and is generally well tolerated. There are, how- femoral-tibial bypass, and possibly an adjunctive
ever, specic factors that may modify the result of this procedure, such as arteriovenous stula or vein in-
procedure, most notably, the type of conduit and the terposition or cuff, should be used when amputation
outow tract beyond the distal anastomosis. is imminent. (Level of Evidence: B)
1502 Circulation March 21, 2006
Class IIa aortic arch and great vessels to the origin of the donor vessel
should be obtained.
1. Prosthetic material can be used effectively for by- Axillofemoral and axillobifemoral grafts are signicantly
passes to the below-knee popliteal artery when no inferior to aortobifemoral bypass grafts or aortoiliac endar-
autogenous vein from ipsilateral or contralateral leg terectomy for the treatment of severe diffuse aortoiliac
or arms is available. (Level of Evidence: B) disease. The 5-year patency rate for axillofemoral grafts
ranges from 19% to 50% (160,161). The results of axillobi-
There are numerous patterns of aortoiliac occlusive dis-
femoral bypass are somewhat better, with 5-year patency
ease and procedures to surgically treat them. Most com-
rates that range from 50% to 76% (162).
monly, patients demonstrate diffuse disease of the infrarenal
aorta and iliac vessels, with the lesions of greatest hemody- POSTSURGICAL CARE.
namic consequence located in the iliac arteries. The most
effective surgical procedure for the treatment for this pattern RECOMMENDATIONS
of atherosclerotic occlusive disease is aortobifemoral bypass.
Aortobifemoral grafting is associated with an operative Class I
mortality of 3.3% and a morbidity of 8.3% (93). Major
morbidity is most commonly due to MI (0.8% to 5.2%) or 1. Unless contraindicated, all patients undergoing re-
vascularization for CLI should be placed on anti-
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may prolong graft patency; most case series include small high prevalence of RAS in these atherosclerotic subgroups, it
numbers of patients, and thus the overall database is inconclu- remains controversial as to which lesions are associated with
sive as yet (163,164). One retrospective analysis of patients who important clinical sequelae.
had undergone infrainguinal bypass suggested that the use of
an ACE inhibitor might decrease mortality (165). To maintain B. Clinical Clues to the Diagnosis of RAS
optimal outcomes, patients should undergo periodic graft
RECOMMENDATIONS
surveillance for at least 2 years after placement. For vein grafts,
duplex imaging of the donor and recipient arteries, proximal Class I
and distal anastomoses, and the entire graft length is of benet
for the detection of grafts with reduced ow secondary to 1. The performance of diagnostic studies to identify
intraluminal lesions. Duplex imaging is of limited benet for clinically signicant RAS is indicated in patients with
the detection of lesions within synthetic grafts. Therefore, the the onset of hypertension before the age of 30 years.
periodic recording of ABIs is sufcient. (Level of Evidence: B)
G. Algorithms 2. The performance of diagnostic studies to identify
clinically signicant RAS is indicated in patients with
1. Diagnostic and Treatment Pathways. The diagnosis of the onset of severe hypertension [as dened in the
lower extremity PAD should be considered in individuals who Seventh Report of the Joint National Committee on
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are either at risk for lower extremity PAD and in those who Prevention, Detection, Evaluation, and Treatment of
present with lower extremity ischemic symptoms (Fig. 3). High Blood Pressure: the JNC 7 report (187)] after
Specic clinical information should be used to identify these the age of 55 years. (Level of Evidence: B)
at-risk individuals who merit pursuit of an objective lower 3. The performance of diagnostic studies to identify
extremity PAD diagnosis by measurement of an ABI exami- clinically signicant RAS is indicated in patients
nation or by use of alternative PAD testing strategies (Figs. 3 with the following characteristics: (a) accelerated
to 5). Clinical data that should guide this assessment include hypertension (sudden and persistent worsening of
the presence of atherosclerosis risk factors (especially age, previously controlled hypertension); (b) resistant
smoking, and diabetes), clinical history (a history of athero- hypertension (dened as the failure to achieve
sclerotic coronary artery, carotid artery, or renal artery disease goal blood pressure in patients who are adhering
and lower extremity symptoms), and an abnormal lower to full doses of an appropriate 3-drug regimen
extremity pulse examination. Subsequent diagnostic testing that includes a diuretic); or (c) malignant hyper-
and therapeutic interventions are dependent on the severity tension (hypertension with coexistent evidence of
and acuity of the presenting limb symptoms (Figs. 4 to 8). Use acute end-organ damage; i.e., acute renal failure,
of lower extremity symptoms and ABI data should then be acutely decompensated congestive heart failure,
used to initiate therapeutic interventions to decrease cardiovas- new visual or neurological disturbance, and/or
cular ischemic risk; diminish claudication symptoms; and advanced [grade III to IV] retinopathy). (Level of
promptly identify individuals with CLI or those who are at risk Evidence: C)
for amputation. Algorithms for the diagnosis and treatment of 4. The performance of diagnostic studies to identify
PAD are presented for individuals with PAD who are asymp- clinically signicant RAS is indicated in patients
tomatic or who present with atypical symptoms (Fig. 4), with new azotemia or worsening renal function
claudication (Figs. 5 and 6), CLI (Fig. 7), and acute limb after the administration of an ACE inhibitor or an
ischemia (Figs. 8 and 9). angiotensin receptor blocking agent. (Level of Ev-
idence: B)
III. RENAL ARTERIAL DISEASE 5. The performance of diagnostic studies to identify
A. Prevalence and Natural History clinically signicant RAS is indicated in patients with
an unexplained atrophic kidney or a discrepancy in
Renal artery stenosis (RAS) is both a common and progressive size between the 2 kidneys of greater than 1.5 cm.
disease in patients with atherosclerosis and a relatively uncom-
(Level of Evidence: B)
mon cause of hypertension (166,167). From a limited epide-
6. The performance of diagnostic studies to identify
miological database, it is estimated that atherosclerotic RAS
clinically signicant RAS is indicated in patients with
may affect as many as 6.8% of people aged 65 years and older
sudden, unexplained pulmonary edema (especially in
(168). However, atherosclerotic RAS is common in cohorts
azotemic patients). (Level of Evidence: B)
that have clinically evident atherosclerosis in other arterial
circulations. For example, 22% to 59% of patients with PAD Class IIa
have hemodynamically signicant RAS (as dened by a ste-
nosis greater than 50%) (169 179). In individuals with histo- 1. The performance of diagnostic studies to identify
ries of proven MI, 12% of postmortem examinations demon- clinically signicant RAS is reasonable in patients
strate the presence of an RAS of 75% or greater. Despite the with unexplained renal failure, including individuals
1504 Circulation March 21, 2006
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Figure 3. Steps toward the diagnosis of peripheral arterial disease (PAD). *Atypical leg pain is dened by lower extremity discomfort that is
exertional, but that does not consistently resolve with rest, consistently limit exercise at a reproducible distance, or meet all Rose questionnaire
criteria. The ve Ps are dened by the clinical symptoms and signs that suggest potential limb jeopardy: pain, pulselessness, pallor, paresthesias,
and paralysis (with polar being a sixth P).
starting renal replacement therapy (dialysis or renal clinical clues (Fig. 10) or PAD at the time of
transplantation). (Level of Evidence: B) arteriography. (Level of Evidence: B)
2. The performance of diagnostic studies to identify
Class IIb
clinically signicant RAS may be reasonable in pa-
1. The performance of arteriography to identify signif- tients with unexplained congestive heart failure or
icant RAS may be reasonable in patients with mul- refractory angina (see Section 3.5.2.4 of the full-text
tivessel coronary artery disease and none of the guidelines). (Level of Evidence: C)
Hirsch et al ACC/AHA Guidelines for the Management of PAD 1505
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Figure 4. Diagnosis and treatment of asymptomatic peripheral arterial disease (PAD) and atypical leg pain. *Duplex ultrasonography should generally be
reserved for use in symptomatic patients in whom anatomic diagnostic data is required for care. Other causes of leg pain may include: lumbar disk disease,
sciatica, radiculopathy; muscle strain; neuropathy; compartment syndrome. It is not yet proven that treatment of diabetes mellitus will signicantly reduce
PAD-specic (limb ischemic) endpoints. Primary treatment of diabetes mellitus should be continued according to established guidelines. #The benet of
angiotensin-converting enzyme (ACE) inhibition in individuals without claudication has not been specically documented in prospective clinical trials, but
has been extrapolated from other at risk populations. Adapted with permission from Hiatt WR. Medical treatment of peripheral arterial disease and
claudication. N Engl J Med 2001;344:1608 21 (179a). Copyright 2001 Massachusetts Medical Society. All rights reserved. ABI ankle-brachial index;
HgbA1c hemoglobin A; JNC-7 Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure; LOE level of evidence; NCEP ATP III National Cholesterol Education Program Adult Treatment Panel III.
Several clinical features raise the suspicion of RAS and C. Diagnostic Methods
provide relative indications for application of more specic RECOMMENDATIONS
diagnostic testing strategies. Such diagnostic testing strate-
Class I
gies should be performed when establishment of the RAS
diagnosis is likely to offer information that can benecially 1. Duplex ultrasonography is recommended as a screen-
be linked to an effective patient-specic treatment strategy. ing test to establish the diagnosis of RAS. (Level of
See Figure 10 for a summary. Evidence: B)
1506 Circulation March 21, 2006
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Figure 5. Diagnosis of claudication and systemic risk treatment. *It is not yet proven that treatment of diabetes mellitus will signicantly reduce peripheral
arterial disease (PAD)-specic (limb ischemic) endpoints. Primary treatment of diabetes mellitus should be continued according to established guidelines.
The benet of angiotensin-converting enzyme (ACE) inhibition in individuals without claudication has not been specically documented in prospective
clinical trials, but has been extrapolated from other at risk populations. ABI ankle-brachial index; HgbA1c hemoglobin A; JNC-7 Seventh Report
of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; LOE level of evidence; NCEP ATP
III National Cholesterol Education Program Adult Treatment Panel III.
Figure 6. Treatment of claudication. *Inow disease should be suspected in individuals with gluteal or thigh claudication and femoral pulse diminution or
bruit and should be conrmed by noninvasive vascular laboratory diagnostic evidence of aortoiliac stenoses Outow disease represents femoropopliteal and
infrapopliteal stenoses (the presence of occlusive lesions in the lower extremity arterial tree below the inguinal ligament from the common femoral artery
to the pedal vessels). PAD peripheral arterial disease.
4. The captopril test (measurement of plasma renin SUMMARY OF NONINVASIVE RENAL ARTERY DIAGNOSTIC IMAGING
activity after captopril administration) is not recom- STRATEGIES. There are relative advantages and disadvan-
mended as a useful screening test to establish the tages to each of the aforementioned imaging modalities.
diagnosis of RAS. (Level of Evidence: B) Captopril renography has been validated in a large
number of patients but is limited in value to a subset of
Renal artery stenosis is best diagnosed with an imaging all potential renovascular patients and is of limited value
modality. The ideal tool should evaluate both the main in patients with signicant azotemia, bilateral RAS, or
and accessory renal arteries, assess the hemodynamic RAS to a single functioning kidney. Duplex renal sonog-
signicance of the demonstrated lesions, identify the site raphy, because of the critical role of the sonographer, is
and severity of the stenosis, and identify associated accurate in experienced laboratories and is thus ideally
perirenal pathology, including the presence of an abdom- performed in high-volume accredited laboratories. The
inal aortic aneurysm or renal or adrenal masses. Direct diagnostic accuracy of these ultrasound-based examina-
imaging modalities such as duplex ultrasound, CTA, and tions is further limited in patients with large body habitus
MRA are best suited to serve as effective diagnostic or intestinal gas obscuring visualization of the entirety of
screening methods. The choice of imaging procedure will the renal artery. Computed tomographic angiography
depend on the availability of the diagnostic tool, the currently provides higher spatial resolution than MRA
experience and local accuracy of the chosen modality, and and may be more readily available; however, the require-
patient characteristics (e.g., body size, renal function, ment to use iodinated contrast makes it an unattractive
contrast allergy, and presence of prior stents or metallic modality in patients with impaired renal function.
objects that may serve as contraindications to MRA or Gadolinium-enhanced MRA provides excellent and less-
CTA techniques). nephrotoxic characterization of the renal arteries, sur-
1508 Circulation March 21, 2006
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Figure 7. Diagnosis and treatment of critical limb ischemia (CLI). *Based on patient comorbidities. Based on anatomy or lack of conduit. Risk factor
normalization: immediate smoking cessation, treat hypertension per the Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure guidelines; treat lipids per National Cholesterol Education Program Adult Treatment Panel III
guidelines; treat diabetes mellitus (HgbA1c [hemoglobin A] less than 7%; Class IIa). It is not yet proven that treatment of diabetes mellitus will signicantly
reduce peripheral arterial disease (PAD)-specic (limb ischemic) end points. Primary treatment of diabetes mellitus should be continued according to
established guidelines. ABI ankle-brachial index; CTA computed tomographic angiography; ECG electrocardiogram; MRA magnetic resonance
angiography; PVR pulse volume recording; TBI toe-brachial index; TEE transesophageal echocardiography; US ultrasound.
Hirsch et al ACC/AHA Guidelines for the Management of PAD 1509
Figure 9. Treatment of acute limb ischemia. Adapted from J Vasc Surg 26, Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports
dealing with lower extremity ischemia: revised version, 51738, Copyright 1997, with permission from Elsevier (180a). PAD peripheral arterial disease;
PVR pulse volume recording; US ultrasound.
2. Angiotensin receptor blockers are effective medica- pressure in individuals with RAS, their effects need to be tested
tions for treatment of hypertension associated with further in large randomized trials. There are currently few
unilateral RAS. (Level of Evidence: B) objective clinical clues that permit selection of specic patient
3. Calcium-channel blockers are effective medications cohorts that would best be treated by medical therapy versus
for treatment of hypertension associated with unilat- renal arterial revascularization, which remains an area of active
eral RAS. (Level of Evidence: A) clinical investigation. Individuals with atherosclerotic disease
4. Beta-blockers are effective medications for treatment and hypertension should be treated according to the goals of
of hypertension associated with RAS. (Level of Evi- the Seventh Report of the Joint National Committee on
dence: A) Prevention, Detection, Evaluation, and Treatment of High
Multiple studies have now shown that ACE inhibitors and Blood Pressure (187).
calcium-channel blockers are effective in the treatment of 2. Indications for Revascularization.
hypertension in the presence of RAS (182186). These results
A. ASYMPTOMATIC STENOSIS.
address primarily the treatment of hypertension, but diminu-
tion in the progression of renal disease has also been demon-
RECOMMENDATIONS
strated. There is also evidence that alternative therapies, based
largely on chlorothiazide, hydralazine, and beta-blockers, also Class IIb
appear effective to achieve target blood pressures in individuals
with RAS. Although the angiotensin II receptor blockers also 1. Percutaneous revascularization may be considered for
have an evidence base of efcacy for normalization of blood treatment of an asymptomatic bilateral or solitary
Hirsch et al ACC/AHA Guidelines for the Management of PAD 1511
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Figure 10. Clinical clues to the diagnosis of renal artery stenosis. *For denition of hypertension, please see Chobanian AV, Bakris GL, Black HR, et al.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.
JAMA 2003;289:2560 72 (187). For example, atrophic kidney due to chronic pyelonephritis is not an indication for RAS evaluation. ACE
angiotensin-converting enzyme; ARB angiotensin receptor blocking agent; CT computed tomography; LOE level of evidence; MRA magnetic
resonance angiography; RAS renal artery stenosis.
viable kidney with a hemodynamically signicant tomatic RAS improves any renal or systemic outcome,
RAS. (Level of Evidence: C) including renal preservation, blood pressure, or cardio-
2. The usefulness of percutaneous revascularization of vascular morbidity or mortality. Therefore, these recom-
an asymptomatic unilateral hemodynamically signif- mendations must be individualized for the patient by
icant RAS in a viable kidney is not well established each treating physician.
and is presently clinically unproven. (Level of Evi- B. HYPERTENSION.
dence: C)
RECOMMENDATIONS
There are no well-controlled prospective randomized
investigations to measure the relative risk and benet of
endovascular interventions (or associated medical thera- Class IIa
pies) in individuals with asymptomatic renal artery dis- 1. Percutaneous revascularization is reasonable for pa-
ease, and thus, the role of such interventions remains tients with hemodynamically signicant RAS and
controversial. Recommendations regarding the role of accelerated hypertension, resistant hypertension, ma-
percutaneous revascularization of asymptomatic renal lignant hypertension, hypertension with an unex-
disease are made largely on the basis of expert opinion plained unilateral small kidney, and hypertension
and are not based on evidence that treatment of asymp- with intolerance to medication. (Level of Evidence: B)
1512 Circulation March 21, 2006
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Figure 11. Indications for renal revascularization. *Viable means kidney linear length greater than 7 cm. It is recognized that renal artery surgery has proven
efcacy in alleviating renal arterial stenosis (RAS) due to atherosclerosis and bromuscular dysplasia. Currently, however, its role is often reserved for
individuals in whom less invasive percutaneous RAS interventions are not feasible. CHF congestive heart failure; CRI chronic renal insufciency; LOE
level of evidence; PTA percutaneous transluminal angioplasty.
The current evidence base suggests that patients with Revascularization is effective in stabilizing or improving
severe atherosclerotic RAS and accelerated, resistant, and renal function in patients with symptomatic atheroscle-
malignant hypertension may expect to receive some clinical rotic RAS (188 193). Several factors may argue against
benet, including improved blood pressure control, the need renal revascularization or predict poorer outcomes, in-
for fewer medications, or both. However, cure of hyper- cluding the presence of proteinuria greater than 1 g every
tension is rare, improvement in blood pressure control is 24 hours, renal atrophy, severe renal parenchymal disease,
common, and a moderate fraction of individuals do not and severe diffuse intrarenal arteriolar disease. Moreover,
achieve measurable benet (see Table 36 of the full-text the adverse consequences of renal atheroembolization at
guidelines). the time of surgical revascularization have been docu-
mented (194). Similarly, potentially severe atheroembo-
C. PRESERVATION OF RENAL FUNCTION.
lization may be provoked by renal percutaneous revascu-
RECOMMENDATIONS larization methods (195).
Class IIa D. IMPACT OF RAS ON CONGESTIVE HEART FAILURE AND
UNSTABLE ANGINA.
1. Percutaneous revascularization is reasonable for pa-
tients with RAS and progressive chronic kidney RECOMMENDATIONS
disease with bilateral RAS or a RAS to a solitary Class I
functioning kidney. (Level of Evidence: B)
Class IIb 1. Percutaneous revascularization is indicated for pa-
tients with hemodynamically signicant RAS and
1. Percutaneous revascularization may be considered for recurrent, unexplained congestive heart failure or
patients with RAS and chronic renal insufciency sudden, unexplained pulmonary edema (see text).
with unilateral RAS. (Level of Evidence: C) (Level of Evidence: B)
Hirsch et al ACC/AHA Guidelines for the Management of PAD 1513
sonography of the abdomen is not an appropriate C. NATURAL HISTORY. All series of acute intestinal isch-
diagnostic tool for suspected acute intestinal isch- emia patients include some who had a history of chronic
emia. (Level of Evidence: C) abdominal pain and weight loss. The frequency with which
chronic intestinal ischemia caused by arterial obstruction
CLINICAL PRESENTATION. Approximately two thirds of pa-
becomes acute intestinal ischemia (presumably by thrombo-
tients with acute intestinal ischemia are women, with a
sis) is unknown.
median age of 70 years. Most patients have a history of
pre-existing cardiovascular disease (217219,222). Abdom- D. SURGICAL TREATMENT.
inal pain is always present; its nature, location, and duration
RECOMMENDATION
are variable, but most commonly, the pain is anterior,
periumbilical, and sufciently severe that medical attention Class I
is sought immediately. Initially, signs of peritoneal irritation
are absent, which is classically referred to as pain out of 1. Surgical treatment of acute obstructive intestinal
proportion to physical ndings. ischemia includes revascularization, resection of ne-
crotic bowel, and, when appropriate, a second look
LABORATORY FINDINGS. Laboratory evaluation most fre- operation 24 to 48 hours after the revascularization.
quently shows leukocytosis and lactic acidosis, and amylase (Level of Evidence: B)
is elevated in approximately 50% of patients; approximately
25% of patients have occult blood in the stool. Abdominal Surgical treatment consists of laparotomy, revasculariza-
radiographs most frequently show some dilated loops of tion of the ischemic intestine either by embolectomy or by
intestine. There are no specic laboratory or plain radio- bypass grafting, assessment of the viability of the intestine
graph ndings for acute intestinal ischemia. after revascularization, resection of nonviable intestine, and
intensive care. Scheduled second look operations, 24 to 48
ULTRASOUND. Although duplex ultrasound scanning is capa- hours after the initial procedure, are the best way to avoid
ble of identifying occlusive lesions of the intestinal arteries, both excessive resection of potentially viable bowel and
in practice, it is not very helpful. The abdominal distention failure to resect nonviable intestine.
and uid frequently present with acute ischemia preclude
successful scanning in most patients. Because of the need for E. ENDOVASCULAR TREATMENT.
2. Acute Nonocclusive Intestinal Ischemia. and allow direct intra-arterial instillation of vasodilator
medications (227,229,232).
A. ETIOLOGY.
C. TREATMENT.
RECOMMENDATIONS
RECOMMENDATIONS
Class I
Class I
1. Nonocclusive intestinal ischemia should be suspected
in patients with low ow states or shock, especially 1. Treatment of the underlying shock state is the most
cardiogenic shock, who develop abdominal pain. important initial step in treatment of nonocclusive
(Level of Evidence: B) intestinal ischemia. (Level of Evidence: C)
2. Nonocclusive intestinal ischemia should be suspected 2. Laparotomy and resection of nonviable bowel is
in patients receiving vasoconstrictor substances and indicated in patients with nonocclusive intestinal
medications (e.g., cocaine, ergot, vasopressin, or nor- ischemia who have persistent symptoms despite
epinephrine) who develop abdominal pain. (Level of treatment. (Level of Evidence: B)
Evidence: B) Class IIa
3. Nonocclusive intestinal ischemia should be suspected
in patients who develop abdominal pain after coarc- 1. Transcatheter administration of vasodilator medica-
tation repair or after surgical revascularization for tions into the area of vasospasm is indicated in
intestinal ischemia caused by arterial obstruction. patients with nonocclusive intestinal ischemia who
(Level of Evidence: B) do not respond to systemic supportive treatment and
Acute intestinal ischemia sufcient to produce infarction in patients with intestinal ischemia due to cocaine or
also occurs in the absence of xed arterial obstruction. The ergot poisoning. (Level of Evidence: B)
most frequent setting is severe systemic illness with systemic Initial treatment of nonocclusive intestinal ischemia should
shock, usually as a result of reduced cardiac output be directed at treatment of the underlying shock state. The
(217,226 230). In this situation, the intestinal ischemia has most intensive hemodynamic monitoring possible, including
been shown to be the result of severe and prolonged appropriate uid/pharmacological therapy to improve cardiac
intestinal arterial vasospasm. Intestinal vasospasm sufcient output/peripheral perfusion, is the most reliable way to relieve
to produce ischemia/infarction also occurs as a result of the inappropriate vasospasm. Administration of vasodilators by
cocaine ingestion and ergot poisoning (231,232). Therapeu- percutaneously placed catheters at the site of inappropriate
tic drugs may produce intestinal ischemia from vasospasm, vasospasm has been associated with relief of vasospasm/
especially when vasopressors are used in high doses to treat ischemic symptoms in multiple patients (226). Transcatheter
circulatory shock. administration of vasodilators is especially appropriate in non-
Intestinal ischemia can also occur as a result of mesenteric occlusive mesenteric ischemia caused by drugs such as ergot or
arterial spasm after repair of aortic coarctation (233) and cocaine, in which systemic shock may not coexist (234).
occasionally occurs after revascularization procedures for Abdominal symptoms/ndings that persist after relief of intes-
chronic mesenteric ischemia (228). The mechanism of this tinal arterial vasospasm are an indication for laparotomy/
apparently paradoxical spasm is unknown. resection of necrotic intestine.
1516 Circulation March 21, 2006
B. Chronic Intestinal Ischemia of subjects in the elective setting. The test has an overall
accuracy of approximately 90% for detection of greater
1. Etiology. Although atherosclerotic disease of the celiac
than 70% diameter stenoses or occlusions of the celiac
and mesenteric vessels is common, the clinical presentation
and superior mesenteric arteries when performed in
of chronic intestinal ischemia is rare. It is nearly uniformly
highly experienced laboratories (240 242). Both
caused by atherosclerosis (235). Classic clinical approaches
contrast-enhanced CTA and gadolinium-enhanced
to the diagnosis of intestinal ischemia have often suggested
MRA are well suited for visualizing the typical athero-
that this syndrome requires occlusion or stenosis of at least
sclerotic lesions at the origins of the intestinal arteries,
2 of the 3 intestinal arteries; however, this is not entirely
although they are less suited for visualizing the more
true (236,237). Well-documented cases of intestinal isch-
distal intestinal arteries and for diagnosis of some of the
emia occur as a result of single-vessel disease, virtually
more unusual causes of intestinal ischemia. Arteriograms
always of the superior mesenteric artery. Patients in whom
provide denitive diagnosis of intestinal arterial lesions,
some of the normal collateral intestinal arterial connections
although not chronic intestinal ischemia. Lateral aortog-
have been interrupted by previous surgery are especially
raphy is best suited for display of the typical origin
vulnerable to single-vessel occlusions.
lesions, which may not be apparent on frontal projec-
Patients with chronic intestinal ischemia are most often
tions. The presence of an enlarged Arc of Riolan (an
female (70%) and classically complain of severe abdominal
enlarged collateral vessel connecting the left colic branch of the
pain induced by eating. The pattern of pain is quite variable,
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plasty and stents undergo careful follow-up. As with open V. ANEURYSMS OF THE ABDOMINAL AORTA, ITS
surgery, recurrent symptoms have nearly always indicated BRANCH VESSELS, AND THE LOWER EXTREMITIES
recurrent arterial obstruction.
Although their etiology may be substantially different in
5. Surgical Treatment. some cases, arterial aneurysms share many of the same
RECOMMENDATIONS atherosclerotic risk factors and pose similar threats to life,
limb, and vital organ function as occlusive arterial disease.
Class I Like occlusive disease, the presence of most common
1. Surgical treatment of chronic intestinal ischemia is aneurysms can be suspected on the basis of an attentive
indicated in patients with chronic intestinal ischemia. physical examination and subsequently conrmed by non-
(Level of Evidence: B) invasive, widely available imaging studies. Just as important,
there are now a variety of therapeutic options that include
Class IIb both traditional open surgery and endovascular techniques,
1. Revascularization of asymptomatic intestinal arterial such that relatively few large aneurysms should merely be
obstructions may be considered for patients undergo- observed until morbid events occur.
ing aortic/renal artery surgery for other indications.
(Level of Evidence: B) A. Denition
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A. GENERALIZED ARTERIOMEGALY. Generalized arterio- relatively unlikely to have generalized arteriomegaly (268),
megaly reects a systemic alteration of the elastic compo- but the familial pattern of generalized arteriomegaly is
nent of the arterial wall that results in dilation and elonga- similar. In one series, there was a family history of aneu-
tion of many arteries. Patients with localized AAAs are rysms in 10% (4/40) of patients with peripheral aneurysms,
Hirsch et al ACC/AHA Guidelines for the Management of PAD 1519
in 22% (19/86) of patients with AAAs, and in 36% (5/14) eurysms (275). The overall mean annual expansion rate was
of patients with generalized arteriomegaly (269). 2.7 mm per year irrespective of chronic obstructive pulmo-
2. Etiology. Most aortic and peripheral aneurysms repre- nary disease but was 4.7 mm per year among patients treated
sent a manifestation of aortic medial degeneration, which with corticosteroid agents compared with 2.6 mm per year
has complex biological mechanisms. Data (see full-text among those who were not treated (p less than 0.05).
guidelines) suggest that many aneurysms form in response
to altered tissue metalloproteinases that diminish the integ- D. INFLAMMATORY ANEURYSMS. Inammatory AAAs rep-
rity of the arterial wall. resent a unique clinical entity, typically consisting of an
AAA that is associated with an unusually thickened aneu-
A. HEREDITARY RISK FACTORS. A family history of AAAs is rysm wall, shiny white perianeurysmal brosis, and intense
particularly relevant for male siblings of male probands, in adherence of adjacent intra-abdominal structures. Abnor-
whom the relative risk for AAA is as high as 18% (270), mal accumulation of macrophages and cytokines in aneu-
which suggests a single dominant gene effect. (See Table 45 rysmal aortic tissue supports an association with inamma-
of the full-text guidelines.) First-degree male relatives of tion (276,277). In a case-control study, there were no
patients with AAA have 2 to 4 times the normal risk for distinctions between patients with inammatory aneurysms
AAA. Female rst-degree relatives appear to be at similar and those with noninammatory aneurysms with respect to
risk, but the data are less certain. risk factors, treatment requirements, or prognosis, but
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B. ATHEROSCLEROTIC RISK FACTORS. patients with inammatory aneurysms were more often
symptomatic and had a higher erythrocyte sedimentation
RECOMMENDATIONS rate, larger aneurysm diameter, and more retroperitoneal
Class I inammatory reaction (278).
The triad of chronic abdominal pain, weight loss, and
1. In patients with AAAs, blood pressure and fasting elevated erythrocyte sedimentation rate in a patient with
serum lipid values should be monitored and con- AAA is highly suggestive of an inammatory aneurysm.
trolled as recommended for patients with atheroscle- Inammatory aortic or iliac aneurysms were present in
rotic disease. (Level of Evidence: C) 4.5% of the 2816 patients who underwent elective AAA
2. Patients with aneurysms or a family history of aneu- repair at the Mayo Clinic from 1955 to 1985 (279). More
rysms should be advised to stop smoking and be than 90% of the patients with inammatory aneurysms
offered smoking cessation interventions, including were smokers, and clinical evidence of peripheral arterial
behavior modication, nicotine replacement, or bu- occlusive disease and coronary artery disease was found in
propion. (Level of Evidence: B) 27% and 39%, respectively. Compared with patients with
noninammatory atherosclerotic aneurysms, those with
Patients with AAAs have a signicantly higher preva-
lence of hypertension, smoking, MI, heart failure, and inammatory aneurysms were more likely to have symp-
carotid artery disease or lower extremity PAD than do age- toms (66% vs. 20%, p less than 0.0001), weight loss
and gender-matched controls. The lipoprotein(a) serum (20.5% vs. 10%, p less than 0.05), a higher erythrocyte
level, an indicator of atherosclerosis, is also elevated in sedimentation rate (73% vs. 33%, p less than 0.0001), and
patients with AAA, independent of other cardiovascular a higher operative mortality rate (7.9% vs. 2.4%, p less
risk factors and the extent of atherosclerosis (271). than 0.002).
3. Natural History. The natural history of arterial aneu-
C. COLLAGENASE, ELASTASE, AND METALLOPROTEASES. The rysms is distinguished by gradual and/or sporadic expan-
striking histological feature of aortic aneurysms is destruc- sion in their diameter and by the accumulation of mural
tion of the media and elastic tissue. Excessive proteolytic thrombus caused by turbulent blood ow at their periph-
enzyme activity in the aortic wall may promote deterioration ery. These features contribute to the 3 most common
of structural matrix proteins, such as elastin and collagen complications of aneurysms, that is, rupture, thrombo-
(272). Smooth muscle cells derived from patients with embolic ischemic events, and the compression or erosion
AAAs display increased migration, perhaps related to over- of adjacent structures, which often are quite specic to
production of the matrix metalloproteinase MMP-2, which their location.
may lead to extracellular matrix remodeling and medial
disruption (273). Abnormal biochemical elastolytic and A. AORTIC ANEURYSM RUPTURE.
active proteolytic activity has also been identied in aneu- RECOMMENDATIONS
rysmal aortas (274).
The association between AAAs and chronic obstructive Class I
pulmonary disease has been attributed to elastin degradation
caused by tobacco smoking. Among 4404 men 65 to 73 1. Patients with infrarenal or juxtarenal AAAs measur-
years of age with a 4.2% prevalence of AAA, 7.7% of those ing 5.5 cm or larger should undergo repair to elimi-
with chronic obstructive pulmonary disease had aortic an- nate the risk of rupture. (Level of Evidence: B)
1520 Circulation March 21, 2006
Table 25. Rupture and Survival Rates for Patients With Abdominal Aortic Aneurysms, Since 1990
No. of Baseline Aneurysm Follow-Up Aneurysm Survival
First Author Reference Year Patients Diameter Interval Rupture Rate Rate
Case series
Bengtsson (282) 1993 155 Median, 4 cm Median, 3.4 yrs 14% 30%
Perko (283) 1993 63 Smaller than 6 cm Less than 5% NA
Larger than or 10% to 15% NA
equal to 6 cm
Galland (284) 1998 267 Smaller than 4 cm 5 yrs 4% NA
4 to 5.5 cm 5 yrs 21% NA
Jones (285) 1998 25 5 to 5.9 cm 3 yrs 28% NA
32 6 cm or larger 3 yrs 41% NA
Scott (286) 1998 218 3 to 4.4 cm 7 yrs 2.1% per year and/or NA
operation
4.5 to 5.9 cm 7 yrs 10% per year and/or NA
operation
Conway (281) 2001 23 5.5 to 5.9 cm 10 yrs 22% 39%
62 6 to 7 cm 10 yrs 34% 32%
21 Larger than 7 cm 10 yrs 52% 5%
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2. Patients with infrarenal or juxtarenal AAAs measur- Aneurysm size remains the single most important pre-
ing 4.0 to 5.4 cm in diameter should be monitored by dictor not only for aneurysm rupture but also for unrelated
ultrasound or CT scans every 6 to 12 months to death from other cardiopulmonary events (280,281). Data
detect expansion. (Level of Evidence: A) suggest that the eventual risk for rupture is approximately
Class IIa 20% for aneurysms larger than 5.0 cm in diameter, 40% for
those at least 6.0 cm in diameter, and greater than 50% for
1. Repair can be benecial in patients with infrarenal or aneurysms that exceed 7.0 cm in diameter (Table 25).
juxtarenal AAAs 5.0 to 5.4 cm in diameter. (Level of Conversely, the rupture rate for truly small aneurysms
Evidence: B) that are less than 4.0 cm in diameter is quite low, perhaps
2. Repair is probably indicated in patients with supra- because aged patients with such small aneurysms ordinarily
renal or type IV thoracoabdominal aortic aneurysms do not survive long enough for this complication to occur.
larger than 5.5 to 6.0 cm. (Level of Evidence: B) Bengtsson et al. have recommended only 1 annual follow-up
3. In patients with AAAs smaller than 4.0 cm in diam- scan for aneurysms less than 3.5 cm in diameter, because the
eter, monitoring by ultrasound examination every 2 unrelated mortality rate in such patients is so high that
to 3 years is reasonable. (Level of Evidence: B) relatively few live long enough to incur sufcient aneurysm
Class III growth to warrant elective surgical treatment (292). Pro-
spective nonrandomized studies have indicated that small
1. Intervention is not recommended for asymptomatic aneurysms may be safely monitored by annual or semiannual
infrarenal or juxtarenal AAAs if they measure less imaging scans with a low risk for rupture, provided elective
than 5.0 cm in diameter in men or less than 4.5 cm in repair is advised once a diameter of at least 5.0 cm has been
diameter in women. (Level of Evidence: A) documented (286, 293).
Hirsch et al ACC/AHA Guidelines for the Management of PAD 1521
RANDOMIZED TRIALS. Prospective randomized trials compar- Table 26. Outcomes of Early Elective Repair Versus
ing early intervention versus expectant observation for in- Nonoperative Surveillance of Asymptomatic Abdominal
Aortic Aneurysms*
frarenal abdominal aortic aneurysms measuring 4.0 to 5.4
cm in diameter have been conducted in the United King- UK Trial (2002) VA Trial (2002)
dom (UK) and by the U.S. Department of Veterans Affairs Total patients 1090 1136
(VA) during the past decade (291,294 296). By protocol, Early elective repair 563 569
elective surgical treatment was not offered to patients who Open 536 567
Endovascular 27 2
were allocated to the nonoperative cohort in each trial until Nonoperative 527 567
their aneurysms exceeded 5.4 cm on serial imaging studies. surveillance
Selected data from both investigations are summarized in Men 902 1127
Table 26, using updated information from the UK trial at a Women 188 9
Age 69 plus or minus 68 plus or minus
mean follow-up interval of 8 years (296) compared with 4.6
4 years 6 years
years when its ndings rst were disclosed in 1998. Not Operative mortality rate 5.4% (30 days) 2.1% (30 days);
surprisingly, the principal demographic difference between (surgical cohorts) 2.7% (in-
the 2 trials is the fact that whereas women accounted for hospital)
17% of the patients in the UK study, they represented only Follow-up period Range 6 to 10 Range 3.5 to 8.0
years; mean years; mean
0.8% of the VA population. Thirty-day operative mortality
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noninvasive imaging. Contrast-enhanced CT scans or mag- abdominal palpation comes from 15 studies of patients who
netic resonance imaging studies appear to be better suited were not previously known to have AAAs but were screened
for this purpose than ultrasonography because many com- with both an abdominal examination and ultrasound scans
mon iliac aneurysms are situated deep in the pelvis. (304). The pooled sensitivity of abdominal palpation in-
creased signicantly with aortic diameter (p less than 0.001),
4. Diagnosis.
ranging from 29% for AAAs of 3.0 to 3.9 cm to 50% for
A. SYMPTOMATIC AORTIC OR ILIAC ANEURYSMS. AAAs of 4.0 to 4.9 cm and 76% for AAAs measuring 5.0
cm or more by ultrasonography. In a 3-year retrospective
RECOMMENDATIONS
study of 198 patients with AAAs that was conducted by
Class I Alcorn et al. (305) in a general hospital setting, 48% of the
aneurysms had been discovered clinically, 37% represented
1. In patients with the clinical triad of abdominal
incidental ndings during the radiographic investigation of
and/or back pain, a pulsatile abdominal mass, and
another condition, and 15% were encountered during un-
hypotension, immediate surgical evaluation is indi-
related abdominal operations. Not surprisingly, the average
cated. (Level of Evidence: B)
size of palpable AAAs was larger than that of nonpalpable
2. In patients with symptomatic aortic aneurysms, re-
AAAs (6.4 plus or minus 1.2 cm vs. 4.9 plus or minus 1.4
pair is indicated regardless of diameter. (Level of
cm, p less than 0.001).
Evidence: C)
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1 cm per year, or if symptoms occurred. More than 27 000 beta-adrenergic blockade has slowed the rate of thoracic
(80%) of the 33 839 men in the invited group agreed to aortic dilation and decreased the incidence of aortic com-
screening, and 1333 aneurysms were detected. There were plications in patients with Marfan syndrome. Retrospective
65 aneurysm-related deaths (absolute risk 0.19%) in the studies have suggested that beta-adrenergic antagonist
invited group and 113 (0.33%) in the control group (risk agents might reduce the risk of AAA expansion and
reduction 42%, 95% CI 22% to 58%, p equals 0.0002), rupture. One prospective randomized trial found that the
including a 53% reduction of risk (95% CI 30% to 64%) expansion rate of AAAs was not attenuated by beta-
among those who actually underwent screening. During the adrenergic blockers.
4 years in which this trial was conducted, there were 47 B. FOLLOW-UP SURVEILLANCE. A number of prospective
fewer deaths related to AAAs in the screening group than in nonrandomized studies that were reported before the dis-
the control group, but the additional costs incurred were 2.2 closures from the UK Small Aneurysm Trial and the VA
million British pounds (approximately $3.5 million U.S. Aneurysm Detection and Management (ADAM) Trial
dollars). The hazard ratio for AAA was 0.58 (95% CI 0.42 were made suggested annual ultrasound surveillance for
to 0.78). Over 4 years, the mean incremental cost- aneurysms measuring less than 4.0 cm in diameter and
effectiveness ratio for screening was 28 400/$45 000 per ultrasound scans every 6 months for those 4.0 to 4.9 cm in
life-year that was gained, a gure that is equivalent to about diameter, with a recommendation for elective aneurysm
36 000/$57 000 per quality-adjusted life-year. After 10 repair in appropriate surgical candidates whenever an AAA
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years, this gure was estimated to decline to approximately reached a size of at least 5.0 cm. One such study of 99
8000/$12 500 per life-year gained (309).
patients documented a mean expansion rate of 2.2 mm in
Selected screening of populations with a high prevalence
the rst year of observation, 2.8 mm in the second year, and
of AAA (e.g., males 60 years or older who have a family
1.8 mm in the third year for aneurysms that initially were
history of AAA, in whom the prevalence is approximately
smaller than 4.0 cm. The corresponding growth rates for
18%) and the use of a limited ultrasound scan are more
aneurysms measuring 4.0 to 4.9 cm were 2.7, 4.2, and 2.2
cost-effective than conventional abdominal imaging of un-
mm (312). Given the usual slow rate of expansion for truly
selected populations. The United States Preventive Services
small aneurysms, however, some studies have recommended
Task Force meta-analysis supports the concept that screen-
that those measuring less than 4.0 cm in diameter can safely
ing for AAA and surgical repair of large AAAs (5.5 cm or
be followed up with ultrasound scans every 2 to 3 years.
more) in men aged 65 to 75 years who have ever smoked
(inclusive of both current and former smokers) leads to 6. Open Aortic Aneurysm Repair. The management of
decreased AAA-specic mortality when abdominal ultra- patients who have AAAs that are sufciently large to
sonography is performed in a setting with adequate quality represent a predictable risk for fatal rupture is guided by
assurance (i.e., in an accredited facility with credentialed several considerations. First, the survival rate of this patient
technologists). The data do not support the application of population generally is acknowledged to be signicantly
AAA screening for men who have never smoked or for lower than that of a normal population of the same age
women. (313316). Second, it has long been recognized that coro-
nary artery disease and its consequences represent the
5. Observational Management. leading causes of late death in these patients, superseding
A. BLOOD PRESSURE CONTROL AND BETA-BLOCKADE. even the mortality rate that can be attributed directly to
unoperated aneurysms (317,318). Therefore, in addition to
RECOMMENDATIONS their importance regarding early surgical risk, these obser-
Class I vations have long-term implications with respect to the
identication and treatment of underlying coronary disease
1. Perioperative administration of beta-adrenergic before the elective repair of aortic aneurysms. Finally, the
blocking agents, in the absence of contraindications, emergence of new technology for transfemoral endovascular
is indicated to reduce the risk of adverse cardiac repair of AAAs with a variety of commercially available U.S.
events and mortality in patients with coronary artery Food and Drug Administrationapproved stent grafts now
disease undergoing surgical repair of atherosclerotic provides an alternative to open surgical treatment in patients
aortic aneurysms. (Level of Evidence: A) with aneurysms that warrant repair on the basis of their size
Class IIb or expansion rate. Thus, management of aortic aneurysms
must be tailored to the individual patient.
1. Beta-adrenergic blocking agents may be considered
to reduce the rate of aneurysm expansion in patients A. INFRARENAL AAAS.
with aortic aneurysms. (Level of Evidence: B) PREOPERATIVE CARDIAC EVALUATION. A number of studies
Perioperative administration of beta-adrenergic blockers have demonstrated that the perioperative and long-term
reduces the risk of adverse cardiac events and death in mortality rates in conjunction with open aortic aneurysm
patients who undergo AAA surgery (310,311). Long-term repair are highest among patients who have symptomatic
1524 Circulation March 21, 2006
coronary disease (i.e., Class III to IV angina pectoris or heim et al. (338) and Dimick et al. (347) have estimated that
congestive heart failure), intermediate in those who have the operative mortality rate for elective aneurysm repair is
chronic stable angina and/or a history of remote MI, and reduced by approximately 50% in high-volume hospitals in
lowest among those who have no indication of coronary the U.S., and Wen et al. (335) have calculated that there is
disease whatsoever (319 323). Several large clinical series a 6% reduction in the relative odds for death with every 10
have reported that the mortality rate for open aortic aneu- additional elective cases that are added to the annual
rysm repair can be reduced to less than 2% in a setting in hospital volume in Ontario. Pearce et al. (340) discovered
which approximately 5% to 15% of patients undergo pre- that a doubling of the annual surgeon volume was associated
liminary coronary artery intervention (324 327). However, with an 11% reduction in the relative risk for death after
the role of revascularization in the context of contemporary aortic aneurysm repair in Florida, and Dardik et al. (339)
medical management appears to be less than has been have determined that hospital charges are signicantly lower
assumed traditionally. Intensive medical therapy and coro- in conjunction with the repair of either intact or ruptured
nary revascularization (including percutaneous coronary in- aortic aneurysms by high-volume surgeons in Maryland.
tervention and coronary artery bypass grafting), when of-
B. JUXTARENAL, PARARENAL, AND SUPRARENAL AORTIC AN-
fered to individuals anticipated to undergo AAA repair or
EURYSMS. Aneurysms involving the upper abdominal aorta
lower extremity revascularization surgery, had equal post-
generally are classied according to their relationship to the
operative rates of cardiovascular ischemic events in a recent
renal arteries. Juxtarenal aneurysms arise distal to the renal
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Table 27. Operative Mortality Rates for Open Repair of Intact Abdominal Aortic Aneurysms, Since 1995
Year Mortality
First Author Reference (Study Period) No. of Patients Rate (%)
Case series
Sicard (330) 1995 145 1.4
Lloyd (331) 1996 (19801995) 1000 2.4
Starr (318) 1996 (19831989) Men: 490 5.1
Women: 92 4.3
Total: 582 5.0
Aune (315) 2001 (19851999) Age less than 66 yrs: 118 1.7
Age 66 yrs and older: 333 6.0
Total: 451 4.9
Hertzer (327) 2002 (19891998) 1135 1.2
Menard (332) 2003 (19902000) Low risk: 444 0.0
High risk: 128 4.7
Total: 572 1.0
Randomized trials
UK Small Aneurysm Trial (290) 1998 563 5.8
(surgical cohort)
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particular contraindications to conventional surgical treat- facilitate graft deployment, the majority of modern en-
ment. This has resulted in a distinct shift in the paradigm dografts also are modular in construction. The absence of an
for management of infrarenal aortic aneurysms in some adequate length of relatively normal aorta below the renal
geographic areas during a relatively short period of time. arteries historically has excluded patients from consideration
According to statewide data from New York, for example, for endovascular repair because of the high risk for proximal
53% of patients who underwent AAA repair received attachment failure, graft migration, and endoleak.
endografts in 2002 compared with 40% in 2001 (363). In an attempt to overcome the risk of distal migration and
Most contemporary stent grafts are supported by a proximal attachment failure, a growing number of new
metallic skeleton that is secured to the fabric of the graft devices now incorporate barbed hooks that are sufciently
during the manufacturing process to maintain linear stabil- long to secure the metallic frame of the stent graft to the
ity once the device has been implanted and to avoid kinking visceral segment of the aorta above the renal arteries. In
that can result in graft limb occlusion with unsupported aggregate, modular externally supported bifurcation en-
grafts. To better accommodate the aortoiliac anatomy and dografts are more widely applicable, less prone to migrate
1526 Circulation March 21, 2006
Table 28. Volume/Outcome Relationships for Open Abdominal Aortic Aneurysm Repair in the United States Since 1990
Overall Annual Volume
Year No. of Mortality
First Author Reference (Study Period) Patients Rate (%) Hospital Surgeon
Intact aneurysms
Hannan (New (350) 1992 (19821987) 6042 7.6 Low: 12%; medium: 6.8%; Low: 11%; medium: 7.3%;
York statewide) high: 5.6% high: 5.6%
Katz (Michigan (351) 1994 (19801990) 8185 7.5 Low: 8.9%; high: 6.2% NA
statewide) (p less than 0.001)
Kazmers (Veterans (334) 1996 (19911993) 3419 4.9 Low: 6.7%; high: 4.2% NA
Affairs) (p less than 0.05)
Dardik (Maryland (339) 1999 (19901995) 2335 3.5 Low: 4.3%; medium: Very low: 9.9%; low: 4.9%;
statewide) 4.2%; high: 2.5% medium: 2.8%; high: 2.9%
(p equals 0.08)
Ruptured aneurysms
Katz (Michigan (351) 1994 (19801990) 1829 50 Low: 54%; high: 46% NA
statewide) (p equals 0.0026)
Dardik (Maryland (339) 1998 (19901995) 527 47 Low: 46%; medium: 49%; Low: 51%; medium: 47%;
statewide) high: 47% (p equals NS) high: 36% (p equals 0.05)
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from their sites of attachment, and more likely to remain ANATOMIC LIMITATIONS. Because of the inexibility of exter-
patent than was the case with the rst generation of nally supported grafts, this segment of the aorta must not be
unsupported endografts only a few years ago. Some aspects severely angulated. This requirement may impose a gender
of endovascular aneurysm repair remain problematic, how- bias in patient selection because, in addition to the fact that
ever, and will require further renements in the future. In their small external iliac arteries often present problems with
addition to the vexing problem of metal fatigue (364,365), respect to vascular access, women also appear to have a
these include anatomic limitations and intrasac endoleaks. higher prevalence of short, angulated aneurysm necks than
Table 29. Operative Mortality and Postoperative Complication Rates for Open Repair of Pararenal, Suprarenal, and/or Type IV
Thoracoabdominal Aortic Aneurysms, Since 1990
Postoperative Complication Rate (%)
Year No. of Mortality Rate
First Author Reference (Study Period) Patients (%) Renal Paraplegia Other
Pararenal or
suprarenal
Nypaver (353) 1993 (19851992) 53 3.8 Transient: 23; NA NA
dialysis: 5.7
Faggioli (354) 1998 50 12 NA NA NA
Jean-Claude (355) 1999 (19771997) 257 5.8 Transient: 30; 0.4 31
sustained: 9.3;
dialysis: 7.0
Anagnostopoulos (356) 2001 (19861999) 65 0 Total: 42; 0 NA
dialysis: 9.2;
permanent: 1.5
Type IV
thoracoabdominal
Cox (357) 1992 (19661991) 42 Total: 31; NA Total: 11; NA
elective: 12; elective: 4.3;
urgent: 55 urgent: 20
Svensson (358) 1993 (19601991) 346 5.8 Total: 22 4.3 NA
Coselli (359) 1995 (19841993) 35 14 (Reoperations) None permanent 2.9 NA
Schwartz (360) 1996 (19771994) 58 5.3 Transient: 31; 1.8 42
sustained: 28;
dialysis: 8.8;
permanent: 1.9
Dunning (361) 1999 (19951998) 26 12 Dialysis: 3.8 3.8 42
Martin (362) 2000 (19891998) 165 Total: 11; Transient: 19; 3.6 56
elective: 7.2; dialysis: 14;
urgent: 22 permanent: 3.0
NA not available.
Hirsch et al ACC/AHA Guidelines for the Management of PAD 1527
men (366,367). Considering all of these criteria, Carpenter may be dictated by patient selection, because severe cardiac
et al. reported that a disproportionate number of women disease already will have been documented in many patients
were excluded from endograft repair because of anatomic who are treated at centers where endografting is restricted to
limitations (60% of women vs. 30% of men; p equals high-risk cases. Perhaps for this reason, relatively little
0.0009) (368). Becker et al. (369) also found that signi- published information is available on this topic. On the
cantly fewer women qualied for endovascular aneurysm basis of admittedly incomplete data, elective endovascular
repair (26% of women vs. 41% of men), and Mathison et al. aortic aneurysm repair in unselected patients probably
(370) were forced to abandon more attempted endograft should be considered as an intermediate or low surgical risk
procedures in women (17%) than in men (2.1%, p less than procedure according to the previous ACC/AHA Guideline
0.01). Wolf et al. described comparable eligibility rates for Update for Perioperative Cardiovascular Evaluation for
endograft repair in women (49%) and men (57%), but the Noncardiac Surgery (89).
women in this series had a higher incidence of intraopera-
tive complications than men (31% vs. 13%, p less than 0.05) C. EARLY MORTALITY AND COMPLICATION RATES. Table
and required more adjunctive arterial reconstructions (42% 30 contains representative data regarding the procedural
vs. 21%, p less than 0.05) to correct those complications mortality rate for endovascular aneurysm repair, the inci-
(371). dence of early endoleaks, and the risk for immediate
conversion to an open operation. This information has been
INTRASAC ENDOLEAKS. Type I endoleaks are caused by in-
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Table 30. Representative Early Results for Endovascular Repair of Infrarenal Abdominal Aortic Aneurysms Since 2000
Endoleaks (%) Procedural
First Author Year Immediate Open Mortality Rate
(Study/Sponsor) Reference (Study Period) No. of Patients Conversion (%) Total Persistent (%)
Case series
Becquemin (378) 2000 (19951999) Endo: 73; None 23 9.6 2.7
Open: 195
Chuter (379) 2000 (19961999) High risk: 116 None NA 10 1.7
Zarins (380) 2000 (19962000) 149 1.30 36 18 1.3
Blum (381) 2001 (19942001) 19941996; 111 3.6 (19941996) 14 (19941996) NA Total: 8.1
19961997: 159 0.6 (19961997) 3.1 (19961997)
19982001: 28 None (19982001) 11 (19982001)
Becker (369) 2001 (19942001) 305 1.30 23 17 2.6
Fairman (382) 2001 (19981999) 75 None 44 20 0
Holzenbein (383) 2001 173 1.2 4.6 (Type I) NA 2.8
Howell (384) 2001 215 None 42 11 0
Mathison (370) 2001 (19942000) 305 1.3 23 NA 2.6
May (385) 2001 (19951998) Endo: 148; 0.7 6.8 5.4 2.7 (Endo);
Open: 135 5.9 (Open)
Sicard (386) 2001 (19972000) Endo: 260; 0.8 13 3 1.9 (Endo);
Open: 210 2.9 (Open)
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Immediate conversion to an open operation presently is is added to the base cost ($6000 to $12 000 U.S. dollars) of
necessary in only 1% of patients, and approximately half of most endografts. Despite the shorter length of stay and
all early endoleaks appear to resolve spontaneously within a earlier return to normal activity associated with aortic
period of 30 days. Several reports have indicated that endografting, this procedure does not appear to be associ-
endovascular procedures have fewer early complications ated with superior late functional outcome or longer quality-
than open operations, require less intensive care, and are adjusted life expectancy compared with open surgical treat-
associated with correspondingly shorter lengths of stay in ment (408,409).
the hospital (402 404). Nevertheless, these and other stud- TECHNICAL SUCCESS RATES. The technical success rate is a
ies (405 407) also have suggested that the total costs of useful way to express endograft results because it condenses
endovascular repair probably exceed those for open repair, a number of events into a single outcome value that
especially when the expense of subsequent follow-up imag- ordinarily is calculated with the life-table method. Table 31
ing, further intervention, and secondary hospital admissions summarizes the early and intermediate-term technical suc-
Hirsch et al ACC/AHA Guidelines for the Management of PAD 1529
Table 31. Technical Success Rates For Endograft Repair of Infrarenal Abdominal Aortic Aneurysms, Since 2000
Technical Success Rate
First Author Year Criteria for Technical
(Device/Vendor) Reference (Study Period) No. of Patients Success Early Late
Case series
Becquemin (378) 2000 (19951999) Endo: 73; No endoleaks; no 74% (p equals 0.001);
Open: 107 reintervention 94% (1 yr)
Chuter (379) 2000 (19961999) High risk: 116 Successful deployment; 86% (2 weeks)
no endoleaks
Howell (411) 2000 56 NA 83% Primary;
85% secondary
(6 months)
Blum (381) 2001 (19942001) 111 (1994 1996); Successful deployment; 82% (1994 1996);
159 (1996 1997); no endoleaks 96% (1996 1997);
28 (1998 2001) 89% (1998 2001)
Ohki (412) 2001 (19922000) 239 Successful deployment; 89%
no endoleaks
Device trials
Zarins (380) 2000 (19971998) 398 Survival free of 88% (18 months)
(AneuRx/Medtronic) aneurysm rupture,
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open conversion, or
reintervention for
endoleaks or graft
thrombosis
Beebe (392) 2001 (19971998) 240 Successful deployment; 89% (30 days)
(Vanguard/Boston no endoleaks; graft
Scientic) patent; no deaths
Criado (413) 2001 (19972001) High risk: 127; Successful deployment; High risk: 86%
(Talent/Medtronic Low risk: 151 no endoleaks (96% at 30 days);
WorldMedical) low risk: 88%
(97% at 30 days)
EUROSTAR
Buth (396) 2000 (19941999) 1554 Successful deployment; 72% (30 days)
no endoleaks; no
deaths
Laheij (414) 2000 (19961999) 1023 Freedom from any 1 yr; 89%; 3 yrs;
secondary 67%; 4 yrs; 62%
intervention
Endo endovascular repair; EUROSTAR European collaborators registry on stent-graft techniques for abdominal aortic aneurysm repair; NA not available.
cess rates from 10 recent reports. These data suggest that aneurysms. The next step is to establish, on the basis of
longer follow-up will be necessary to determine the relative ultrasonography or CT/magnetic resonance scanning,
merit of endovascular repair compared with open operations whether a particular aortic aneurysm already is large
for AAAs. In comparison, the technical success rate for enough to warrant intervention or instead should be
endograft repair of isolated iliac aneurysms appears to be placed under periodic surveillance to determine its rate of
quite favorable according to the scant follow-up information expansion. Ultimately, once an infrarenal aortic aneurysm
that is available. Scheinert et al. (410) described a series of reaches an appropriate size for graft replacement, a choice
53 such aneurysms in 48 patients with successful endograft must be made between a traditional open operation or
deployment in 98%, no persistent or secondary endoleaks, endovascular repair. Like all other aspects of aneurysm
and patency rates of 95% and 88% at 3 and 4 years of management, this decision requires a balanced judgment
follow-up, respectively. of relative risks.
8. Prevention of Aortic Aneurysm Rupture. Aside from
A. MANAGEMENT OVERVIEW.
their infrequent other complications (e.g., peripheral or
visceral embolism, aortocaval or primary aortoenteric RECOMMENDATIONS
stula), the single most compelling reason to repair
Class I
AAAs is to prevent fatal rupture. The rst step in this
process is to identify the presence of these aneurysms, 1. Open repair of infrarenal AAAs and/or common iliac
beginning with a thorough physical examination or their aneurysms is indicated in patients who are good or
recognition as an incidental nding on unrelated abdom- average surgical candidates. (Level of Evidence: B)
inal imaging studies. This is especially important in 2. Periodic long-term surveillance imaging should be
certain high-prevalence populations, such as those with performed to monitor for an endoleak, to document
known popliteal aneurysms or a family history of aortic shrinkage or stability of the excluded aneurysm sac,
1530 Circulation March 21, 2006
and to determine the need for further intervention in pregnant and in patients of either gender undergoing
patients who have undergone endovascular repair of liver transplantation. (Level of Evidence: B)
infrarenal aortic and/or iliac aneurysms. (Level of
Class IIa
Evidence: B)
Class IIa 1. Open repair or catheter-based intervention is proba-
1. Endovascular repair of infrarenal aortic and/or com- bly indicated for visceral aneurysms 2.0 cm in diam-
mon iliac aneurysms is reasonable in patients at high eter or larger in women beyond childbearing age and
risk of complications from open operations because in men. (Level of Evidence: B)
of cardiopulmonary or other associated diseases. Visceral aneurysms are insidious because they usually
(Level of Evidence: B) cannot be detected by physical examination, are easily
Class IIb overlooked on plain roentgenograms unless mural calcica-
tion is present, and occur so infrequently that they may not
1. Endovascular repair of infrarenal aortic and/or com- be fully appreciated during incidental CT/magnetic reso-
mon iliac aneurysms may be considered in patients at nance imaging scanning. Not surprisingly, therefore, several
low or average surgical risk. (Level of Evidence: B) studies have indicated that approximately half of all visceral
An overview of the management of AAAs is depicted in artery aneurysms present with rupture (Table 32). In com-
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Figure 12. This algorithm incorporates the results of the parison, spontaneous rupture appears to be an unusual event
randomized UK and VA trials and takes into account the for renal artery aneurysms, possibly because exceptionally
still relatively limited information that is available regarding large renal artery aneurysms may be discovered on the basis
the long-term outcome of endograft repair for infrarenal of nonacute symptoms, such as hypertension or hematuria.
aneurysms. It must be conceded from the outset that there Although rare under any circumstances, both visceral and
could be honest scientic disagreement regarding a few of renal artery aneurysms most commonly occur in multiparous
the recommended pathways that are illustrated in this women (416,417). Furthermore, some studies have sug-
algorithm. Some clinicians may think that infrarenal aneu- gested that the incidence of splenic artery aneurysms is
rysms should continue to be repaired at a size of only 5.0 particularly high among patients who have portal hyperten-
cm, whereas others could believe that the conclusions of the sion or a history of previous liver transplantation (418
UK and VA trials are not directly applicable to aortic 420). The mortality rate for surgical repair of ruptured
aneurysms that involve the renal arteries and that these visceral aneurysms is sufciently ominous (25% or higher)
aneurysms should be even larger than 5.5 cm in diameter that patients who have these risk factors probably should be
before elective surgical treatment is advised, to warrant its investigated for visceral artery aneurysms in the presence of
additional risks. In addition, there undoubtedly are many unexplained abdominal symptoms.
who consider the present technology of endovascular repair 1. Management Options. An array of open surgical and
to be at a state of development that justies its general use
laparoscopic approaches has been reported for visceral artery
in low-risk and average-risk patients and in those who
aneurysms, with varying mortality rates depending on the
appear to be at high risk for conventional open operations.
clinical setting. Percutaneous catheter-based therapy with
There is nothing unfavorable about its early safety to
coil embolization leading to thrombosis of visceral aneu-
discourage this opinion. As an example from northern
rysms has been described for elective patients and for those
California and Nevada, proctored endovascular aneurysm
repair was undertaken at 22 community hospitals in a series who present with acute rupture. The technical success rate
of 257 patients, only 29% of whom had medical contrain- for these nonsurgical options ranges from 67% to 100%,
dications to conventional operations, with 2 immediate with few fatalities or complications (250,426,427). One
open conversions and a 30-day mortality rate of 1.2% (415). concern that should be recognized related to the catheter-
However, this report shares the current liability of many based management of visceral artery aneurysms is the
studies concerning aortic stent grafts; the mean follow-up limited ability to assess the end organ after aneurysm
period for these patients is only 9.6 months, during which treatment. This is in contrast to open surgical visceral artery
another 8% of them have required reintervention. aneurysm repair, in which the end organ may be visualized
and assessed.
C. Visceral Artery Aneurysms
D. Lower Extremity Aneurysms
RECOMMENDATIONS
1. Etiology. As illustrated in Figures 20 and 21 of the
Class I full-text guideline, the diameters of peripheral arteries
1. Open repair or catheter-based intervention is indicated increase approximately 20% to 25% between the ages of 20
for visceral aneurysms measuring 2.0 cm in diameter or and 70 years (260,428). Coexistent AAAs have been re-
larger in women of childbearing age who are not ported in 85% of patients with femoral aneurysms (429) and
Hirsch et al ACC/AHA Guidelines for the Management of PAD 1531
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Figure 12. Management of abdominal aortic aneurysms. CT computed tomography; MR magnetic resonance.
in 62% of those with popliteal aneurysms (430), whereas 2. Natural History. Unlike AAAs, the natural history of
femoral or popliteal aneurysms are present in 3% to 7% of extremity-artery aneurysms is not one of expansion and
patients who have AAAs. rupture but one of thromboembolism or thrombosis.
1532 Circulation March 21, 2006
Table 32. Presentation and Mortality Rates for Visceral Artery Aneurysms
Symptomatic and/ Complications
Patients and/or or Ruptured on Initial With Observation Mortality
First Author Reference Year Aneurysms, n Presentation Treatment Alone Rate
All visceral
Carmeci (421) 2000 31 74% Open: 25; NA 3%
(20 Women) endo: 9
Carr (422) 2001 26/34 Ruptured: 42% Open: 19 14% Ruptured Total: 12%;
ruptured: 25%
Splenic
Trastek (416) 1982 100 17%; 3% ruptured Open: 81 None at 7.4 yrs 1%
(87 Women)
Lee (420) 1999 34 Ruptured: 44% Open: 34 NA Elective: 0%;
(21 Women) ruptured: 40%
Superior
mesenteric
Stone (423) 2002 21 52%; 38% ruptured Open: 13; None Elective: 0%;
(7 Women) (50% of men) endo: 3 (mean, 1.8 cm) ruptured: 38%
Renal
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RECOMMENDATION RECOMMENDATIONS
Class I Class I
1. In patients with femoral or popliteal aneurysms, 1. Patients with a palpable popliteal mass should un-
ultrasound (or CT or magnetic resonance) imaging is dergo an ultrasound examination to exclude popliteal
recommended to exclude contralateral femoral or aneurysm. (Level of Evidence: B)
popliteal aneurysms and AAA. (Level of Evidence: B) 2. Patients with popliteal aneurysms 2.0 cm in diameter
or larger should undergo repair to reduce the risk of
A. POPLITEAL ARTERY ANEURYSMS. Popliteal aneurysms ac- thromboembolic complications and limb loss. (Level
count for 70% of all aneurysms in the lower extremities and of Evidence: B)
have an estimated incidence of 0.1% to 2.8% (431,432). 3. Patients with anastomotic pseudoaneurysms or symp-
Approximately 5% of small aortic aneurysms are discovered tomatic femoral artery aneurysms should undergo re-
because of lower extremity ischemia caused by distal embo- pair. (Level of Evidence: A)
lization of mural thrombus (433). However, thromboem-
bolic complications are much more common with popliteal Class IIa
aneurysms, which often are bilateral and also may be
1. Surveillance by annual ultrasound imaging is sug-
associated with aneurysms involving the aorta and the
gested for patients with asymptomatic femoral artery
femoral and supercial femoral arteries (Table 33).
true aneurysms smaller than 3.0 cm in diameter.
The unfavorable consequences of popliteal aneurysms
(Level of Evidence: C)
suggest that even when asymptomatic with good distal
2. In patients with acute ischemia and popliteal artery
runoff, they should be repaired electively, although there is
aneurysms and absent runoff, catheter-directed
a lack of prospective studies to support an unqualied
thrombolysis or mechanical thrombectomy (or both)
recommendation in this regard, especially for aneurysms
is suggested to restore distal runoff and resolve
measuring less than 2.0 cm in diameter. In fact, there is a
emboli. (Level of Evidence: B)
published consensus that small popliteal aneurysms rarely
3. In patients with asymptomatic enlargement of the
become symptomatic and that elective surgical intervention
popliteal arteries twice the normal diameter for age
should be considered only for those measuring at least 2.0
and gender, annual ultrasound monitoring is reason-
cm in diameter (431,440,441).
able. (Level of Evidence: C)
B. FEMORAL ARTERY ANEURYSMS. Femoral artery aneu- 4. In patients with femoral or popliteal artery aneu-
rysms may be discovered incidentally as a pulsatile mass in rysms, administration of antiplatelet medication may
the thigh, or they may present with distal ischemia, and be benecial. (Level of Evidence: C)
even more rarely, with rupture and bleeding.
A. POPLITEAL ANEURYSMS. A popliteal mass should be
3. Management. studied by duplex ultrasonography to distinguish an
Hirsch et al ACC/AHA Guidelines for the Management of PAD 1533
Table 33. Presentation and Complication Rates for Popliteal Aneurysms, Since 1990
Bilateral Complications
Popliteal or Initial With Related
First Patients and/or Other Symptoms Before Surgical Observation Amputation
Author Reference Year Aneurysms, n Aneurysms Presentation Treatment Alone Rate
Case series
Dawson (434) 1991 50/71 42% Bilateral; NA 65% 54% NA
32% other
Carpenter (435) 1994 33/54 62% Bilateral; 61%; 39% Ischemic 83% NA 11%
61% other
Dawson (436) 1994 42/42 NA All asymptomatic None 60% 7%
Lowell (437) 1994 106/161 52% Bilateral 42% 31% 22% 7%
(103 Men)
Schroder (438) 1996 217/349 61% Bilateral 45% 63% 47% NA
Duffy (431) 1998 24/40 66% Bilateral 58% 75% None None
(23 Men) (smaller than 2 cm)
Collective
reviews
Dawson (439) 1997 1673/2445 50% Bilateral; 67% NA 36% NA
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aneurysm from other soft-tissue lesions, especially if the The algorithm presented in Figure 13 summarizes the
patient has a history of other arterial aneurysms involving management options for either symptomatic or asymp-
the contralateral lower extremity or the abdominal aorta. tomatic popliteal aneurysms. In the presence of mural
Nonoperative observation with periodic noninvasive sur- thrombus, the diameter of a popliteal aneurysm will
veillance may be appropriate if the aneurysm measures appear to be smaller on an arteriogram than its true
less than 2.0 cm in diameter or contains no thrombus or diameter on duplex ultrasound or CT imaging, but the
if the patient is at high surgical risk or has limited value of an arteriogram is to determine the adequacy of
longevity because of medical comorbidities. If symptoms tibioperoneal outow and whether the use of catheter-
develop or the aneurysm enlarges on follow-up duplex directed thrombolytic therapy should be considered to
scans, the risk of thromboembolic complications and restore runoff. The decision to proceed with elective
limb loss then must be weighed against whatever factors surgical treatment in the absence of limb-threatening
originally may have inuenced the decision to postpone ischemia is not predicated on aneurysm size alone. It
surgical treatment. must also take into account the overall clinical situation,
In the setting of acute ischemia related to popliteal the severity of symptoms in the leg, and the surgical or
artery aneurysm thrombosis or thromboembolism, endovascular facilities that are available.
catheter-directed thrombolytic therapy is useful to re-
establish patency of the popliteal and tibial trunks, which B. FEMORAL ANEURYSMS. The cause of femoral artery
allows for more effective denitive aneurysm treatment aneurysms may be arterial degeneration (i.e., true aneu-
and limb salvage. Largely because of previous and often rysms) or false aneurysms related to previous vascular
unrecognized emboli, one of the obstacles to a successful reconstructions or arterial injury. Femoral artery pseudo-
surgical outcome is the absence of adequate arterial aneurysm represents a pulsatile mass that is contained by
outow in the calf and foot. Because limb salvage rates incomplete elements of the arterial wall and surrounding
can be correlated directly with the number of available subcutaneous/brous tissue and may result from disrup-
runoff vessels, as much thrombus as possible must be tion of a previous femoral suture line, femoral artery
cleared from the tibioperoneal and plantar arteries in access for a catheter-based procedure, or injury resulting
conjunction with bypass grafting to exclude the popliteal from puncture due to self-administered drug abuse.
aneurysm from the circulation. In the past, this has been Regardless of the cause, a pulsatile groin mass should
done strictly with thromboembolectomy balloon cathe- be evaluated by duplex ultrasound and/or contrast-
ters in the operating room, often after preoperative enhanced CT scan. The clinical presentation of true
arteriograms or MRA scans have failed to determine femoral artery aneurysms is summarized in Table 34
whether a target vessel for revascularization even is (443). Most reports encourage a policy of elective surgi-
present. Some series now have been reported, however, in cal treatment for symptomatic patients if their opera-
which preoperative intra-arterial thrombolytic therapy tive risk is low and the patient has a reasonable life
has been a valuable adjunct for restoring runoff in the expectancy. In 2 series, however, nonoperative observa-
presence of recent thromboembolic events (270,436, tion has been used twice as often as elective interven-
437,442). tion for asymptomatic femoral aneurysms and appears
1534 Circulation March 21, 2006
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Figure 13. Diagnostic and treatment algorithm for popliteal mass. CT computed tomography.
to be associated with a relatively low risk for complica- normal dimensions makes it difcult to determine an
tions during follow-up periods of 28 to 52 months arbitrary size at which true femoral aneurysms should be
(393,444). Therefore, the stable femoral artery aneurysm repaired. By convention, femoral aneurysms measuring
presents a therapeutic dilemma, because its complication 3.0 cm or larger appear most likely to cause compressive
rate appears to be substantially lower than that for symptoms and therefore also are most likely to be treated
popliteal aneurysms of similar size. A wide range of surgically. Although the presence of mural thrombus
RECOMMENDATIONS
Class I
1. Patients with suspected femoral pseudoaneurysms
should be evaluated by duplex ultrasonography.
(Level of Evidence: B)
2. Initial treatment with ultrasound-guided compres-
sion or thrombin injection is recommended in pa-
tients with large and/or symptomatic femoral artery
pseudoaneurysms. (Level of Evidence: B)
eurysm.
pression or thrombin injection. (Level of Evidence: B)
2. Re-evaluation by ultrasound 1 month after the orig-
conceivably could represent a risk for distal emboli unless inal injury can be useful in patients with asymptom-
elective repair is performed, the actual magnitude of this atic femoral artery pseudoaneurysms smaller than 2.0
risk is unknown. cm in diameter. (Level of Evidence: B)
Anastomotic pseudoaneurysms occur with an incidence
Although a pulsatile mass is an obvious indication that a
of 2% to 5%, are encountered most commonly as a late
pseudoaneurysm may be present, a diagnostic duplex scan
complication of synthetic aortofemoral bypass grafting, should be obtained whenever the diagnosis is even suspected.
inevitably continue to enlarge if left untreated, and may In the absence of antithrombotic therapy, several studies have
require arteriography before repair. Infected femoral indicated that catheter-related pseudoaneurysms that are less
pseudoaneurysms may occur as the result of arterial than 2.0 cm in diameter tend to heal spontaneously and usually
puncture during drug abuse and must be treated by require no treatment. Figure 14 illustrates the spontaneous
extensive operative debridement, often in conjunction closure rate of selected pseudoaneurysms that were not imme-
with either autogenous in situ reconstruction or extra- diately repaired, 90% of which resolved within 2 months.
anatomic bypass grafts to avoid CLI. Skin erosion or Accordingly, small asymptomatic pseudoaneurysms probably
expanding rupture into adjacent soft tissue obviously is an can be managed conservatively unless they are still present on
unstable situation for which urgent surgical repair is a follow-up duplex scan 2 months later.
necessary irrespective of the etiology of the femoral artery At the opposite extreme, large pseudoaneurysms can rupture
aneurysm or pseudoaneurysm. into the retroperitoneal space or the upper thigh or cause
venous thrombosis or painful neuropathy by compressing the compression therapy include pain at the site of compression,
adjacent femoral vein or the femoral nerve. Urgent surgical long compression times, and incomplete closure, each of which
repair clearly is necessary if any of these serious complications is more problematic with large pseudoaneurysms. Table 35
occur, and until recently, it was the mainstay of treatment for contains information from 17 series of patients who underwent
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most catheter-related femoral artery injuries. Many reports ultrasound-guided compression therapy with a primary success
now have demonstrated, however, that the majority of uncom- rate of 86% and surgical treatment in only 4.9%. Recurrences
plicated pseudoaneurysms can be managed nonoperatively usually responded to further compression and most frequently
with either ultrasound-guided compression therapy or the were associated with pseudoaneurysms that exceeded 4.0 cm in
injection of miniscule amounts of thrombin directly into the size in patients who had required larger-diameter delivery
pseudoaneurysm cavity. Problems with ultrasound-guided sheaths or periprocedural anticoagulation.
Figure 15. Diagnostic and treatment algorithm for femoral pseudoaneurysm. AV arteriovenous; US ultrasound.
Hirsch et al ACC/AHA Guidelines for the Management of PAD 1537
Pseudoaneurysms ranging in size from 1.5 to more than 7.5 Treatment of High Blood Pressure. NIH Pub. No. 98-4080.
Bethesda, MD: NIH, 1997.
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ance. Table 36 contains data from seven institutional series in Adults. Third Report of the National Cholesterol Education Pro-
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ACC/AHA 2005 Practice Guidelines for the Management of Patients With Peripheral
Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): Executive
Summary: A Collaborative Report From the American Association for Vascular
Surgery/Society for Vascular Surgery,* Society for Cardiovascular Angiography and
Interventions, Society for Vascular Medicine and Biology, Society of Interventional
Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to
Develop Guidelines for the Management of Patients With Peripheral Arterial Disease):
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Circulation. 2006;113:1474-1547
doi: 10.1161/CIRCULATIONAHA.106.173994
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