Follow-up of patients after revascularisation for peripheral arterial diseases: a consensus document from the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases and the European Society for Vascular Surgery.

Peripheral arterial diseases comprise different clinical presentations, from cerebrovascular disease down to lower extremity artery disease, from subclinical to disabling symptoms and events. According to clinical presentation, the patient's general condition, anatomical location and extension of lesions, revascularisation may be needed in addition to best medical treatment. The 2017 European Society of Cardiology guidelines in collaboration with the European Society for Vascular Surgery have addressed the indications for revascularisation. While most cases are amenable to either endovascular or surgical revascularisation, maintaining long-term patency is often challenging. Early and late procedural complications, but also local and remote recurrences frequently lead to revascularisation failure. The rationale for surveillance is to propose the accurate implementation of preventive strategies to avoid other cardiovascular events and disease progression and avoid recurrence of symptoms and the need for redo revascularisation. Combined with vascular history and physical examination, duplex ultrasound scanning is the pivotal imaging technique for identifying revascularisation failures. Other non-invasive examinations (ankle and toe brachial index, computed tomography scan, magnetic resonance imaging) at regular intervals can optimise surveillance in specific settings. Currently, optimal revascularisation surveillance programmes are not well defined and systematic reviews addressing long-term results after revascularisation are lacking. We have systematically reviewed the literature addressing follow-up after revascularisation and we propose this consensus document as a complement to the recent guidelines for optimal surveillance of revascularised patients beyond the perioperative period.

Editor's Choice - Follow-up of Patients After Revascularisation for Peripheral Arterial Diseases: A Consensus Document From the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases and the European Society for Vascular Surgery.

Peripheral arterial diseases comprise different clinical presentations, from cerebrovascular disease down to lower extremity artery disease, from subclinical to disabling symptoms and events. According to clinical presentation, the patient's general condition, anatomical location and extension of lesions, revascularisation may be needed in addition to best medical treatment. The 2017 European Society of Cardiology guidelines in collaboration with the European Society for Vascular Surgery have addressed the indications for revascularisation. While most cases are amenable to either endovascular or surgical revascularisation, maintaining long-term patency is often challenging. Early and late procedural complications, but also local and remote recurrences frequently lead to revascularisation failure. The rationale for surveillance is to propose the accurate implementation of preventive strategies to avoid other cardiovascular events and disease progression and avoid recurrence of symptoms and the need for redo revascularisation. Combined with vascular history and physical examination, duplex ultrasound scanning is the pivotal imaging technique for identifying revascularisation failures. Other non-invasive examinations (ankle and toe brachial index, computed tomography scan, magnetic resonance imaging) at regular intervals can optimise surveillance in specific settings. Currently, optimal revascularisation surveillance programmes are not well defined and systematic reviews addressing long-term results after revascularisation are lacking. We have systematically reviewed the literature addressing follow-up after revascularisation and we propose this consensus document as a complement to the recent guidelines for optimal surveillance of revascularised patients beyond the perioperative period.

EURObservational Research Programme: the Chronic Ischaemic Cardiovascular Disease Registry: Pilot phase (CICD-PILOT).

AIMS: Chronic ischaemic cardiovascular disease (CICD) is a major cause of mortality and morbidity worldwide. The primary objective of the CICD-Pilot registry was to describe the clinical characteristics and management modalities across Europe in a broad spectrum of patients with CICD. METHODS AND RESULTS: The CICD-Pilot registry is an international prospective observational longitudinal registry, conducted in 100 centres from 10 countries selected to reflect the diversity of health systems and care attitudes across Europe. From April 2013 to December 2014, 2420 consecutive CICD patients with non-ST-elevation acute coronary syndrome (n = 755) and chronic stable coronary artery disease (n = 1464), of whom 933 (63.7%) were planned for elective coronary intervention, or with peripheral artery disease (PAD) (n = 201), were enrolled (30.5% female patients). Mean age was 66.6 ± 10.9 years. The following risk factors were reported: smoking 54.6%, diabetes mellitus 29.2%, hypertension 82.6%, and hypercholesterolaemia 74.1%. Assessment of cardiac function was made in 69.5% and an exercise stress test in 21.2% during/within 1 year preceding admission. New stress imaging modalities were applied in a minority of patients. A marked increase was observed at discharge in the rate of prescription of angiotensin-converting enzyme-inhibitors/angiotensin receptor blockers (82.8%), beta-blockers (80.2%), statins (92.7%), aspirin (90.3%), and clopidogrel (66.8%). Marked differences in clinical profile and treatment modalities were observed across the four cohorts. CONCLUSION: The CICD-Pilot registry suggests that implementation of guideline-recommended therapies has improved since the previous surveys but that important heterogeneity exists in the clinical profile and treatment modalities in the different cohorts of patients enrolled with a broad spectrum of CICDs.

Effectiveness of screening for abdominal aortic aneurysm during echocardiography.

Screening patients with abdominal aortic aneurysm (AAA) is associated with reduced AAA-related mortality, but population screening is poorly implemented. Opportunistic screening during imaging for other indications might be efficient. Single-center series reported AAA rates of 0.8% to 6.5% in patients undergoing transthoracic echocardiography (TTE), with disparities due to selection bias. In this first multicenter study, we aimed to assess the feasibility and criteria for screening AAA during TTE in real-life practice. During a week of May 2011, 79 centers participated in a nationwide survey. All patients aged ≥65 years requiring TTE for any indication were eligible, except for those with operated abdominal aorta. We defined AAA by an anteroposterior diameter of the infrarenal aorta≥30 mm. Of 1,382 consecutive patients, abdominal aorta imaging was feasible in 96.7%, with a median delay of 1.7 minutes (>3 minutes in 3.6% of cases). We found AAA in 50 patients (3.7%). Unknown AAA (2.7%) was more frequent in men than women (3.7% vs 1.3%, respectively, p=0.007) and increased by age at 2.2%, 2.5%, and 5.8% in age bands of 65 to 74, 75 to 84, and 85+ years, respectively. None of the female participants aged <75 years had AAA. Smoking status and family history of AAA were significantly more frequent among patients with AAA. The ascending aorta was larger in those with AAA (36.2±4.7 vs 34.0±5.2 mm, p=0.006), and bicuspid aortic valve and/or major aortic regurgitation were also more frequent (8% vs 2.6%, p=0.017). In conclusion, rapid AAA screening during TTE is feasible and should be limited to men ≥65 years and women≥75 years.

The PANDORA study: peripheral arterial disease in patients with non-high cardiovascular risk.

Few studies are available with sufficient sample size to accurately describe the prevalence of low ankle-brachial index (ABI) in patients at 'non-high' cardiovascular (CV) risk. The aim of this study was to evaluate the prevalence of asymptomatic peripheral arterial disease (PAD), as determined by using ABI, in this patient population. A non-interventional, cross-sectional, pan-European study was conducted in patients with ≥1 CV risk factor in addition to age, evaluating the prevalence of asymptomatic PAD (ABI ≤ 0.90). Secondary objectives included assessing the prevalence and treatment of CV risk factors. Patients were consecutively recruited during scheduled visits to the physician's office, or were randomly selected by the physician from a list of eligible patients. Patients with diabetes were excluded as this condition was deemed to be a secondary prevention risk. 10,287 patients were enrolled (9,816 evaluable: mean age 64.3 years; 53.5% male). Prevalence of asymptomatic PAD was 17.8% (99% CI 16.84-18.83). Factors significantly associated with asymptomatic PAD included hypertension, age, alcohol intake, family history of coronary heart disease, low levels of high-density lipoprotein-cholesterol, and smoking (p < 0.0001). Patients treated with statins were significantly less likely to have asymptomatic PAD than those who were not (odds ratio 0.62; 95% CI 0.50-0.76; p < 0.0001). Asymptomatic PAD was highly prevalent in patients with non-high CV risk, the majority of whom would not typically be candidates for ABI assessment. These patients should be carefully screened, and ABI measured, so that therapeutic interventions known to diminish their increased CV risk may be offered.

Screening abdominal aorta aneurysm during echocardiography: literature review and proposal for a French nationwide study.

Several international guidelines, including those in France, recommend the screening of abdominal aorta aneurysm (AAA) by ultrasound in high-risk populations. However, this preventive screening strategy is poorly implemented. Many patients who undergo transthoracic echocardiography (TTE) are at risk of AAA as defined by the guidelines, and the cardiac ultrasound machines and probes fit perfectly for AAA screening. In this literature review, we collected data from more than 20,000 patients who underwent screening for AAA during TTE, from 10 single-centre series. While the studies differed regarding patient selection and AAA definition, the feasibility of AAA screening during TTE was excellent (mostly >90%), with the need for an average of 2-7 minutes to be added to the cardiac imaging time. The prevalence of AAA >30 mm ranged from 0.8% to 6.5%, and up to 19% in men aged >70 years. The risk factors for the presence of AAA among attendees of echocardiography laboratories were similar to those reported in the general population: age, male gender, smoking, hypertension, family history of AAA and prevalent atherosclerotic diseases. Some echocardiography-specific factors, such as left ventricular hypertrophy or dilation and poor left ventricular ejection fraction were also reported. To better assess the benefit of and indications for AAA screening during TTE in clinical practice, we propose a multicentre, nationwide, screening study in echocardiography laboratories in our country.

Prevalence of unknown peripheral arterial disease in patients with coronary artery disease: data in primary care from the IPSILON study.

BACKGROUND: Peripheral arterial disease (PAD) is a marker of increased risk of cardiovascular events and of poor prognosis in patients with coronary artery disease (CAD). The prevalence of unknown PAD among patients with CAD varies between studies according to the mode of diagnosis. AIMS: To evaluate the prevalence of unknown PAD, diagnosed using the ankle-brachial index (ABI), in patients from the IPSILON study with a CAD diagnosis; to assess the profile of these patients; and to determine predictors of PAD. METHODS: IPSILON was an observational, cross-sectional study. General practitioners measured ABI in 5679 consecutive adults aged 55 years or over with signs or symptoms suggestive of PAD (21.3%), a history of an atherothrombotic event (42.1%) or two or more cardiovascular risk factors (36.6%). This analysis focuses on the subgroup of patients with CAD and no other known overt atherothrombotic disease. RESULTS: A total of 1340 patients presented with isolated CAD. PAD (ABI<0.90) was diagnosed in 26.6% of these patients; 16.2% were asymptomatic. Older age, symptoms suggestive of PAD and cardiovascular risk factors were found to be independent predictors of PAD in multivariable analysis. CONCLUSION: Over 26% of patients with CAD present with unknown PAD, as diagnosed using ABI measurement. More than half of these patients are asymptomatic. Screening for PAD in patients with CAD will allow detection of a subpopulation at particularly high cardiovascular risk. An aggressive medical treatment strategy could help to improve their outcome.

[Is it valuable to screen for peripheral arterial disease in patients with coronary artery diseases?]. / Dépistage de l'artériopathie oblitérante des membres inférieurs chez le patient ayant une maladie coronaire : quel intérêt ?

Peripheral arterial disease (PAD), symptomatic or not, is a marker of poor prognosis which is considered as an equivalent of secondary prevention. In patients with coronary artery disease, PAD is often ignored, despite it could be a marker of worsened outcome. It seems interesting to screen for PAD in patients with coronary artery disease in order to detect a particularly high risk sub group of patients who will benefit of an adapted adjustment of the therapeutic strategy.

Benefits of cerebral protection during carotid stenting with the PercuSurge GuardWire system: midterm results.

PURPOSE: To examine the possible beneficial effect of a new cerebral protection device based on balloon occlusion of the distal internal carotid artery (ICA) and debris aspiration for patients undergoing carotid artery stenting (CAS). METHODS: One hundred and eighty-four CAS procedures were attempted under cerebral protection using the PercuSurge GuardWire system in 167 patients (129 men; mean age 70.5 +/- 9.2 years, range 40-91)). The lesions were mainly atherosclerotic, and half (n = 93) were asymptomatic. Eighteen restenotic and 7 post-radiation stenoses were also treated. RESULTS: Technical success was 99.5%. All lesions were stented except 3 postangioplasty restenoses. Prophylactic occlusion during balloon dilation and stenting was well tolerated in 176 (95.7%) patients. Microscopic analysis of the aspirated blood showed different types of particles numbering between 7 and 145 per procedure with a mean diameter of 250 microm (56-2652 microm). The 30-day stroke and death rate was 2.7%: 3 periprocedural complications at <48 hours (1 major stroke and 2 transient ischemic attacks), 1 intracerebral hemorrhage at 3 days, and 1 death of cardiac failure at 3 weeks. CONCLUSIONS: This study yielded a favorably low rate of periprocedural embolic events comparable with standard CAS series. Protection devices may play an important role in future carotid interventions and expand the applicability of the procedure. Randomized studies (surgery versus CAS with and without cerebral protection) are awaited.