Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication
Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication
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DOI：
10.1016/j.jvs.2014.12.009
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发表时间：
2015-03-01
影响因子：
4.3
通讯作者：
Sidawy, Anton N.
中科院分区：
文献类型：
--
作者：
Conte, Michael S.;Pomposelli, Frank B.;Sidawy, Anton N.
外周动脉疾病（PAD）在全球流行率持续增长，并消耗了美国医疗保健系统越来越多的资源。近年来，PAD的总体干预率一直在稳步上升。人口结构的变化、技术的发展和结果研究数据库的扩大是影响PAD临床决策的主要力量。PAD的管理是多学科的，包括初级保健医生和在诊断和治疗方式方面具有不同专业知识的血管专家。PAD代表了从无症状到严重肢体缺血的广泛疾病。血管外科学会下肢实践指南委员会审查了支持临床护理治疗无症状PAD和间歇性跛行（IC）的证据。委员会使用GRADE（建议评估、发展和评估等级）系统提出具体的实践建议。对于该领域的许多关键问题，可获得的一级数据有限，这表明迫切需要对PAD进行比较有效性研究。重点放在危险因素的修改，医学治疗和更广泛地使用锻炼计划，以改善心血管健康和功能表现。目前，PAD筛查似乎没有得到证实的益处。经过仔细的风险-收益分析后，IC血运重建术是一种适合于有致残症状的患者的治疗方法。治疗应根据合并症、功能损害程度和解剖因素进行个体化。侵入性治疗应提供可预测的功能改善和合理的持久性。建议将至少2年持续有效可能性的最低阈值定为bb50 - 50%作为基准。解剖上的通畅（无再狭窄）被认为是IC血管重建术持续有效的先决条件。血管内入路对大多数髂主动脉疾病候选人和部分股腘动脉疾病患者是有利的，这些患者的解剖持久性有望达到这一最低阈值。相反，在耐久性有限的解剖环境（广泛钙化，小口径动脉，弥漫性腹股沟下疾病，径流差）中使用IC干预措施时需要谨慎。手术旁路可能是具有这些疾病模式的高危患者或先前有血管内衰竭的患者的首选策略。股动脉疾病应手术治疗，隐静脉是腹股沟下旁路移植术的首选导管。接受有创治疗的IC患者应定期监测，以记录主观改善，评估危险因素，优化心脏保护药物的依从性，并监测血流动力学和通畅状态。
Peripheral arterial disease (PAD) continues to grow in global prevalence and consumes an increasing amount of resources in the United States health care system. Overall rates of intervention for PAD have been rising steadily in recent years. Changing demographics, evolution of technologies, and an expanding database of outcomes studies are primary forces influencing clinical decision making in PAD. The management of PAD is multidisciplinary, involving primary care physicians and vascular specialists with varying expertise in diagnostic and treatment modalities. PAD represents a broad spectrum of disease from asymptomatic through severe limb ischemia. The Society for Vascular Surgery Lower Extremity Practice Guidelines committee reviewed the evidence supporting clinical care in the treatment of asymptomatic PAD and intermittent claudication (IC). The committee made specific practice recommendations using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system. There are limited Level I data available for many of the critical questions in the field, demonstrating the urgent need for comparative effectiveness research in PAD. Emphasis is placed on risk factor modification, medical therapies, and broader use of exercise programs to improve cardiovascular health and functional performance. Screening for PAD appears of unproven benefit at present. Revascularization for IC is an appropriate therapy for selected patients with disabling symptoms, after a careful risk-benefit analysis. Treatment should be individualized based on comorbid conditions, degree of functional impairment, and anatomic factors. Invasive treatments for IC should provide predictable functional improvements with reasonable durability. A minimum threshold of a >50% likelihood of sustained efficacy for at least 2 years is suggested as a benchmark. Anatomic patency (freedom from restenosis) is considered a prerequisite for sustained efficacy of revascularization in IC. Endovascular approaches are favored for most candidates with aortoiliac disease and for selected patients with femoropopliteal disease in whom anatomic durability is expected to meet this minimum threshold. Conversely, caution is warranted in the use of interventions for IC in anatomic settings where durability is limited (extensive calcification, small-caliber arteries, diffuse infrainguinal disease, poor runoff). Surgical bypass may be a preferred strategy in good-risk patients with these disease patterns or in those with prior endovascular failures. Common femoral artery disease should be treated surgically, and saphenous vein is the preferred conduit for infrainguinal bypass grafting. Patients who undergo invasive treatments for IC should be monitored regularly in a surveillance program to record subjective improvements, assess risk factors, optimize compliance with cardioprotective medications, and monitor hemodynamic and patency status.