Eur J Vasc Endovasc Surg 33, 1e2 (2007)
doi:10.1016/j.ejvs.2006.11.008, available online at http://www.sciencedirect.com on
EDITORIAL
TASC II Document on the Management of Peripheral Arterial Disease
The original TransAtlantic InterSociety Consensus
(TASC) on the Management of Peripheral Arterial
Disease (PAD) published in 2000 was the first interna-
tional consensus on the diagnosis and treatment of
PAD.1 The document was undoubtedly comprehen-
sive and authoritative and was welcomed by vascular
surgeons and interventionalists alike because it
guided them in their practice, helped them to improve
their research, and facilitated their understanding of
the available literature. However, TASC I was not
aimed at, or embraced by, the non-specialists in pri-
mary and secondary care who, in reality, make the ini-
tial diagnosis and provide day-to-day medical care to
the majority of the millions affected by PAD across the
world. As such, the impact of TASC I on communities
and populations, as opposed to individual patients,
was probably limited. Furthermore, at the time TASC I
was written and published, the management of PAD
lagged some way behind that of coronary artery dis-
ease in terms of the availability of ‘‘level one’’ evidence
from randomised controlled trials (RCTs).2 Although
there is still much work to be done, to a significant
extent that evidence gap has been closed and more
recent guidelines from both sides of the ‘‘pond’’ have
set out the increasing evidence for the ‘best medical
treatment’ (BMT) of patients with PAD.3e6
Recognising that much has changed in the last
5 years, the TASC II Document represents a major ad-
vance on its predecessor and takes a more ‘holistic’
approach to the overall management of PAD.7 The
authorship of the document has also been extended
geographically beyond North America and Europe;
the Working Group now includes representatives
from societies based in Japan, Australasia and South
Africa. Some things have not changed; the TASC clas-
sification of the anatomical extent of disease that has
proved invaluable to specialists for both practice
and research and has, quite rightly, been retained.
To reflect the growing availability of data from multi-
centre RCTs, recommendations are now graded
according to guidance issued by the US Agency for
Healthcare Research and Quality. In particular, the
role of endovascular treatment in comparison to
1078–5884/000001 + 02 $32.00/0 Ó 2006 Published by Elsevier Ltd.
open surgical intervention in the management of
more extensive arterial disease has been expanded
to reflect new data and the resulting changes in clini-
cal practice.8 Appropriately, given the world-wide
burden of disease there is more emphasis on the
role of diabetes and the problem of neuro-ischaemic
diabetic foot lesions.9 There is less technical detail in
TASC II and only key references have been included.
Some purists may find either or both of these changes
unpalatable. However, others will feel it is a price
worth paying if it aids greater dissemination, reader-
ship and thus impact.
Unfortunately, despite advances in technology and
our understanding of the underlying pathophysiol-
ogy, the prognosis of patients with presenting with es-
tablished, symptomatic PAD remains poor in terms of
functional status, limb salvage, life expectancy and
health-related quality of life. Most patients with inter-
mittent claudication are not candidates for interven-
tional treatment10 and, in truth, even in so-called
developed countries, most patients with severe limb
ischaemia are treated conservatively.8 Thus, the keys
to improving population-based outcomes from PAD
are to: tackle the important public health and life-style
issues responsible; make the diagnosis early; institute
BMT at the first possible opportunity; and refer appro-
priately to vascular specialists the minority of patients
who will benefit from intervention. Only by appealing
to and educating a wider audience, namely policy-
makers and primary care physicians, can we as vascu-
lar specialists hope to have a significant and sustained
impact on the lives of those with, or at risk of devel-
oping, life and limb-threatening PAD. It is important
and appropriate, therefore, that TASCII has been writ-
ten to reflect that reality and laudable aspiration.
References
1 DORMANDY JA, RUTHERFORD RB, on behalf of the TASC Working
Group. Management of peripheral arterial disease (PAD). Trans-
Atlantic Inter-Society Consensus (TASC). Eur J Vasc Endovasc
Surg 2000;19(Suppl A):SieSxxviii, S1eS250.
2 D. J. Adam and A. W. Bradbury
2 BRADBURY AW, RUCKLEY CV. Angioplasty for lower-limb ischae-
mia: time for randomised controlled trials. Lancet 1996;
347(8997):277e278.
3 Joint British Societies 2. Guidelines on prevention of cardiovas-
cular disease in clinical practice. Heart 2005;91(Suppl. 5):v1ev52.
4 HIRSCH AT, HASKAL ZJ, HERTZER NR, BAKAL CW, CREAGER MA,
HALPERIN JL et al. ACC/AHA 2005 guidelines for the manage-
ment of patients with peripheral arterial disease (lower extrem-
ity, renal, mesenteric, and abdominal aortic). J Am Coll Cardiol
2006;47(6):1239e1312.
5 HIRSCH AT, HASKAL ZJ, HERTZER NR, BAKAL CW, CREAGER MA,
HALPERIN JL et al. ACC/AHA 2005 Practice Guidelines for the
management of patients with peripheral arterial disease (lower
extremity, renal, mesenteric, and abdominal aortic). Circulation
2006;113(11):e463ee654.
6 BURNS P, GOUGH S, BRADBURY AW. Management of peri-
pheral arterial disease in primary care. BMJ 2003;326(7389):
584e588.
7 NORGREN L, on behalf of the TASC Working Group. The Trans-
Atlantic Inter-Society Consensus (TASC II) Document on
Eur J Vasc Endovasc Surg Vol 33, January 2007
Management of Peripheral Arterial Disease. Eur J Vasc Endovasc
Surg 2007;33(Suppl. 1):S1eS75.
8 ADAM DJ, BEARD JD, CLEVELAND T, BELL J, BRADBURY AW, FORBES JF
et al. Bypass versus angioplasty in severe ischaemia of the leg
(BASIL): multicentre, randomised controlled trial. Lancet 2005;
366:1925e1934.
9 CAVANAGH PR, LIPSKY BA, BRADBURY AW, BOTEK G. Treatment for
diabetic foot ulcers. Lancet 2005;366(9498):1725e1735.
10 HOBBS SD, BRADBURY AW. The EXercise versus Angioplasty in
Claudication Trial (EXACT): reasons for recruitment failure
and the implications for research into and treatment of intermit-
tent claudication. J Vasc Surg 2006;44(2):432e433.
D.J. Adam, MD, FRCSEd
A.W. Bradbury, Bsc, MBA, MD, FRCSEd
University Department of Vascular Surgery,
Heart of England NHS Foundation Trust,
Birmingham, UK