L. Norgren, W. R. Hiatt, J. A. Dormandy, M. R. Nehler, K. A. Harris, F

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Presentation transcript:

Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) L. Norgren, W.R. Hiatt, J.A. Dormandy, M.R. Nehler, K.A. Harris, F.G.R. Fowkes Journal of Vascular Surgery Volume 45, Issue 1, Pages S5-S67 (January 2007) DOI: 10.1016/j.jvs.2006.12.037 Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. A1 Weighted mean prevalence of intermittent claudication (symptomatic PAD) in large population-based studies. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. A2 Approximate range of odds ratios for risk factors for symptomatic peripheral arterial disease. Treatment of risk factors and the effect on the outcomes of PAD are described in Chapter B. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. A3 Fate of the claudicant over 5 years (adapted from ACC/AHA guidelines5). PAD – peripheral arterial disease; CLI – critical limb ischemia; CV – cardiovascular; MI – myocardial infarction. Adapted with permission from Hirsch AT et al. J Am Coll Cardiol 2006;47:1239–1312. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. A4 Approximate magnitude of the effect of risk factors on the development of critical limb ischemia in patients with peripheral arterial disease. CLI – critical limb ischemia. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. A5 Fate of the patients presenting with chronic critical leg ischemia. CLI – critical limb ischemia. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. A6 Fate of the patient with below-knee amputation. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. A7 Typical overlap in vascular disease affecting different territories.26 Based on REACH data. PAD – peripheral arterial disease. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. A8 Survival of patients with peripheral arterial disease. IC – intermittent claudication; CLI – critical limb ischemia. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. A9 Adjusted odds of a cardiovascular event by ankle-brachial index.29 Data from the placebo arm of the Appropriate Blood Pressure Control in Diabetes study29 show an inverse correlation between ABI and odds of a major cardiovascular event. ABI – ankle-brachial index; CV – cardiovascular; MI – myocardial infarction. Reproduced with permission from Mehler PS et al. Circulation 2003;107:753–756. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. B1 Algorithm for use of the ABI in the assessment of systemic risk in the population. Primary prevention: No antiplatelet therapy; LDL (low density lipoprotein) <3.37mmol/L (<130mg/dL) except in patients with diabetes where the LDL goal is <2.59mmol/L (<100mg/dL) even in the absence of CVD (cardiovascular disease); appropriate blood pressure (<140/90mmHg and <130/80mmHg in diabetes/renal insufficiency). Secondary prevention: Prescribe antiplatelet therapy; LDL <2.59mmol/L (<100mg/dL) (<1.81mmol/L [<70mg/dL] in high risk); appropriate blood pressure (<140/90mmHg and <130/80mmHg in diabetes/renal insufficiency). See section B1.2 and surrounding text for references. In patients with diabetes, HbA1c <7.0%. See text for references. ABI – ankle-brachial index; PAD – peripheral arterial disease; CLI – critical limb ischemia. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. B2 All cause mortality as a function of baseline ABI. Excess mortality was observed at ABI values <1.00 and >1.40.34 ABI – ankle-brachial index. Reproduced with permission from Resnick HE et al. Circulation 2004;109(6):733–739. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. B3 Percent abstinence for bupropion SR, nicotine replacement, or both, versus placebo.38 Reproduced with permission from Jorenby DE et al. N Engl J Med 1999;340(9):685–691. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. C1 Measurement of the ABI. ABI – ankle-brachial index. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. C2 Algorithm for diagnosis of peripheral arterial disease. TBI – toe brachial index; VWF – velocity wave form; PVR – pulse volume recording. Reproduced with permission from Hiatt WR. N Engl J Med 2001;344:1608–1621. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. C3 Overall treatment strategy for peripheral arterial disease. BP – blood pressure; HbA1c – hemoglobin A1c; LDL – low density lipoprotein; MRA – magnetic resonance angiography; CTA – computed tomographic angiography. Reproduced with permission from Hiatt WR. N Engl J Med 2001;344:1608–1621. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. D1 Approximate frequencies of various ulcer etiologies. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. D2 Distribution of diabetic foot ulcers.125 Copyright © 1999 American Diabetes Association from Diabetes Care, Vol. 22, 1999; 157–162. Modified with permission from The American Diabetes Association. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. D3 Relative prevalence of different diabetic ulcer etiologies.127 Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. D4 Algorithm for treatment of the patient with critical limb ischemia. Contraindications are: patients not fit for revascularization; revascularization not technically possible; benefit cannot be expected (i.e. widespread ulceration-gangrene – see also section D7.5). CLI – critical limb ischemia; MRA – magnetic resonance angiography; CTA – computed tomographic angiography. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. E1 Etiology of acute limb ischemia. (Summarizes Berridge et al. 2002 and Campbell et al. 1998172,173). Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. E2 Time to presentation in relation to etiology. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. E3 Categories of acute limb ischemia on presentation. *Some of these patients are moribund. In some series this group is up to 15%. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. E4 Algorithm for management of acute limb ischemia. Category I – Viable Category IIA – Marginally Threatened Category IIB – Immediately Threatened; α Confirming either absent or severely diminished ankle pressure/signals; *In some centers imaging would be performed. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. F1 TASC classification of aorto-iliac lesions. CIA – common iliac artery; EIA – external iliac artery; CFA – common femoral artery; AAA – abdominal aortic aneurysm. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. F2 TASC classification of femoral popliteal lesions. CFA – common femoral artery; SFA – superficial femoral artery. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. F3 Bilateral bypass from infra renal abdominal aorta to both femoral arteries. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. F4 Axillo (bi) femoral bypass. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. F5 Cross-over femoral bypass. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. F6 Above-knee femoral popliteal bypass. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. F7 Femoral tibial bypass. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig. F8 Results summary: Average results for surgical treatment. Ao-bi-fem – Aortobifemoral bypass; Fem-pop – femoropopliteal; BK – below knee; Ax-bi-fem – Axillobifemoral; PTA – Percutaneous Transluminal Angioplasty; Ax-uni-fem – Axillounifemoral bypass; pros – prosthetic. Journal of Vascular Surgery 2007 45, S5-S67DOI: (10.1016/j.jvs.2006.12.037) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions