New PAD Recommendations Build Support for Endovascular Treatment

In an effort to aid clinical decision-making, the American College of Cardiology and American Heart Association have jointly updated their 2005 guideline on management of peripheral artery disease (PAD). The new version, copublished online September 29, 2011, ahead of print in the Journal of the American College of Cardiology and Circulation, touches on several topics relevant to interventional cardiology.

Barry T. Katzen, MD, of Baptist Cardiac and Vascular Institute (Miami, FL), told TCTMD in an e-mail communication that the recommendations “will go a long way towards establishing standards of practice for PAD, [a field that exhibits] significant diversity in how patients with the disease are treated.” A document like this is particularly helpful, he said, because PAD treatment is multidisciplinary, causing potential difficulty in developing standardized approaches among the various physician specialties.

In a press release, writing committee chair Thom W. Rooke, MD, of the Mayo Clinic (Rochester, MN), expressed a similar hope that the document would unite vascular surgeons, vascular medicine specialists, cardiologists, pulmonologists, interventional radiologists, and primary care physicians in their approach to patient management. “The guideline is especially important for PAD, which is often still treated less aggressively than heart disease, and we know that many patients do not yet receive ideal care,” he said.

Endovascular Therapies Supported

“As in other areas of cardiovascular disease, [PAD] therapy is trending toward increased use of catheter-based therapy, as opposed to open surgery,” Dr. Rooke noted in an e-mail communication with TCTMD.

Especially pertinent to interventional cardiologists are the sections related to critical limb ischemia (CLI), abdominal aortic aneurysm (AAA), and renal disease.

The update stresses that life expectancy should come into play when choosing the appropriate intervention for CLI patients. Angioplasty is now the preferred treatment for those who are expected to live 2 years or less, and in those lacking an autogenous vein conduit. However, bypass surgery is reasonable as the initial treatment when life expectancy is longer than 2 years.

“In practical terms, most patients will benefit from angioplasty, since there are caveats on who should be operated on based on available in situ vein for bypass, which frequently is not available,” Dr. Katzen pointed out.

Endovascular repair of AAA, meanwhile, gained greater acceptance in patients who are good surgical candidates, by shifting from class IIb, level B, to class I, level A category. The change puts the treatment on equal footing with open repair.

However, Dr. Rooke and colleagues also stressed the need for periodic long-term surveillance imaging to “monitor for endoleak, confirm graft position, document shrinkage or stability of the excluded aneurysm sac, and determine the need for further intervention in patients who have undergone endovascular repair of infrarenal aortic and/or iliac aneurysm.” Open repair is preferred if patients cannot comply with such surveillance. In addition, patients at high surgical or anesthetic risk because of coexisting severe cardiac, pulmonary, and/or renal disease receive uncertain benefit from endovascular repair.

One missing piece for AAA in the new document is information regarding proper patient selection, Dr. Katzen noted.

Reservations About Renal Intervention

Although the recommendations for renal disease did not officially change from 2005 to 2011, the writing group made a point of mentioning that evidence from several new studies has begun shifting the tide toward a “more limited role for renal revascularization.”

The ASTRAL (Angioplasty and Stent for Renal Artery Lesions) trial, for example, “concluded that there were substantial risks but no clinical benefit from revascularization [vs. medical therapy alone] in patients with atherosclerotic renovascular disease,” the committee writes, although they note that selection criteria might have excluded patients who could benefit from intervention. However, ongoing research such as the CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial may provide some answers, they say.

Dr. Katzen concurred that more data are needed. “The issue of renal revascularization again focuses on the need for good patient selection to insure value for therapy,” he said, agreeing that CORAL may provide key information.

In summary, Dr. Katzen concluded that although the PAD update is certainly a “great resource” for clinicians, it is important to remember that, as with any such document, these “are guidelines only, and the physician and teams need to tailor treatment for the specific patient involved.”

 

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Source:
Rooke TW, Hirsch AT, Misra S, et al. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline). J Am Coll Cardiol. 2011;Epub ahead of print.

The guidelines were also copublished in Catheterization and Cardiovascular Interventions, the Journal of Vascular Surgery, and Vascular Medicine.

 

 

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