German guideline on the diagnosis and treatment of peripheral artery disease – a comprehensive update 2016

Abstract

Summary:The prevalence of peripheral artery disease (PAD) is increasing worldwide and is strongly age-related, affecting about 20 % of Germans over 70 years of age. Recent advances in endovascular and surgical techniques as well as clinical study results on comparative treatment methods strengthened the need for a comprehensive review of the published evidence for diagnosis, management, and prevention of PAD. The interdisciplinary guideline exclusively covers distal aorta and atherosclerotic lower extremity artery disease. A systematic literature review and formal consensus fi nding process, including delegated members of 22 medical societies and two patient self-support organisations were conducted and supervised by the Association of Scientifi c Medical Societies in Germany, AWMF. Three levels of recommendation were defi ned, A = "is recommended/ indicated", B = "should be considered", C = "may be considered", means agreement of expert opinions due to lack of evidence. Altogether 294 articles, including 34 systematic reviews and 98 RCTs have been analysed. The key diagnostic tools and treatment basics have been defi ned. In patients with intermittent claudication endovascular and/or surgical techniques are treatment options depending on appropriate individual morphology and patient preference. In critical limb ischaemia, revascularisation without delay by means of the most appropriate technique is key. If possible and reasonable, endovascular procedures should be applied fi rst. The TASC classifi cation is no longer recommended as the base of therapeutic decision process due to advances in endovascular techniques and new crural therapeutic options. Limited new data on rehabilitation and follow-up therapies have been integrated. The article summarises major new aspects of PAD treatment from the updated German Guidelines for Diagnosis and Treatment of PAD. Limited scientifi c evidence still calls for randomised clinical trials to close the present gap of evidence.Keywords: Peripheral artery disease, diagnosis, treatment, update, guideline update fi cation [2] has been the basis of the therapeutic decision process for the last decade. Its four types A-B-C-D classify peripheral atherosclerotic vascular lesions of increasing length and complexity. According to TASC, type A and B lesions were recommended to be treated endovascular-fi rst, type C and D lesions were typically fi rst addressed for surgical repair. With increasing experience of intervention and advanced stent technologies, such as drug eluted and covered stent grafts of increasing lengths, bifurcational stents, and covered angioplasty catheters, the endovascular procedures recently have become increasingly successful. Patients request non-surgical procedures as an alternative approach without risk of narcosis and lower invasive character. A renunciation from the TASC guided approach has become the consequence of the scientifi c literature evaluation.

Sulodexide improves pain-free walking distance in patients with lower extremity peripheral arterial disease: A systematic review and meta-analysis

“…In the studies that we included in our final review, concomitant treatments were homogeneous in the sulodexide group and in the control group, with no specific activity programmes in place, as suggested by guidelines; 51,72 in one study, a progressive walking programme was strongly recommended. 40 The number of patients who improved their medical condition after treatment with sulodexide suggests that this drug can be useful in the management of IC.…”

Die periphere arterielle Verschlusskrankheit

“…Ziel ist es, einen frei durchgängigen Blutstrom bis zum Fuß wiederherzustellen. Wegen der geringen Invasivität und der vergleichbar guten Ergebnisse im Hinblick auf den Extremitätenerhalt sind interventionelle Verfahren gegenüber offen chirurgischen zu bevorzugen [7]. Diese Patienten haben aufgrund kardiovaskulärer, pulmonaler, renaler und anderer Begleiterkrankungen oft ein erhöhtes Operationsrisiko und eine eingeschränkte Lebenserwartung.…”

Multiple stent delivery system Multi-LOC, a new technology for spot-stenting of the femoropopliteal artery – proof of concept study in a preclinical large animal model

“…In femoropopliteal lesions of peripheral artery disease, current guidelines recommend an endovascular therapy as the fi rst-line revascularization method for all femoropopliteal TASC A-C lesions with high evidence, and percutaneous intervention can also be considered in TASC D lesions [1][2][3]. Advancing techniques and devices have led to very high procedural success rates at low risk.…”