Chẩn Đoán Và Điều Trị

Bệnh Lý Động Mạch Ngoại Biên

GS TS BS VÕ THÀNH NHÂN
Đại Học Y Dược – BV Vinmec Central Park – LC Hội Tim Mạch Can Thiệp
TP. Hồ Chí Minh
 Classes of recommendations

Classes of recommendation Defini2on Suggested wording to use

Class I Evidence and/or general agreement Is recommended/ is indicated
that a given treatment or procedure
is beneficial, useful, effective
Class II Conflicting evidence and/or a
divergence of opinion about the
usefulness/efficacy of the given
treatment or procedure
Class IIa Weight of evidence/opinion is in Should be considered
favour of usefulness/efficacy
Class IIb Usefulness/efficacy is less well May be considered
established by evidence/opinion
Class III Evidence or general agreement that Is not recommended
the given treatment or procedure is
not useful/effective, and in some
cases may be harmful
Level of evidence

Data derived from multiple randomized

Level of evidence A
clinical trials or meta-analyses

Data derived from a single randomized clinical

Level of evidence B
trial or large non-randomized studies

Consensus of the experts and/or small

Level of evidence C
studies, retrospective studies, registries
 Management of patients with peripheral arterial diseases

Recommendations Class Level

In healthcare centres, it is recommended to set up a
multi-disciplinary Vascular Team to make decisions for I C
the management of patients with PADs
It is recommended to implement and support
initiatives to improve medical and public awareness of
I C
PADs, especially cerebrovascular and lower extremity
artery diseases
Presentations of Peripheral Arterial Diseases (PADs)

Aorta
disease Territories Presenta8ons
Coronary Artery Cerebrovascular diseases: Stroke, Transient Ischaemic
- Carotid artery disease Attack (TIA), acute
Atherosclerosis

Disease (CAD) monocular blindness

- Vertebral artery disease
Subclavian steal syndrome
Upper-Extremity
pain on exertion, digital
Artery Disease (UEAD) symptoms, acute ischemic

Chronic Mesenteric
Mesenteric artery Ischemia (CMI)
disease Acute Mesenteric
Ischemia (AMI)
Peripheral
Renal Artery Disease Hypertension,
Arterial (RAD) renal failure
Diseases
Typical claudication,
(PADs) Lower-Extremity atypical symptoms,
Artery Disease Chronic Limb-Threatening
(LEAD) Ischemia (CLTI), Acute Limb
Ischemia (ALI)
Main points of medical history for assessment of PADs

Family history of CVD (coronary artery disease, cerebrovascular disease, aor:c aneurysm, LEAD), and
premature CVD (fatal or non-fatal CVD event or/and established diagnosis of CVD in first degree male
rela:ves before 55 years or female rela:ves before 65 years)
Personal history of: 5. Chronic kidney disease
1. Hypertension 6. Sedentary life
2. Diabetes 7. Dietary habits
3. Dyslipidemia 8. History of cancer radiation therapy
4. Smoking (present and/or past), 9. Psycho-social factors
passive smoking exposure 10. Prior CVD

Transient or permanent neurological symptoms

Arm exertion pain, particularly if associated with dizziness or vertigo
Symptoms suggesting angina, dyspnea
Main points of medical history for assessment of PADs
(continued)

Abdominal pain, particularly if related to eating and associated with weight loss

Walking impairment/claudication:
• Type: fatigue, aching, cramping, discomfort, burning,
• Location: buttock, thigh, calf, or foot,
• Timing: triggered by exercise , uphill rather than downhill, quickly relieved with rest; chronic
• distance

Lower limb pain (including foot) at rest, and evolution at upright or recumbent position.
Poorly healing wounds of the extremities
Physical activity assessment:
• Functional capacity and causes of impairment
Erectile dysfunction
Physical examination for assessment of PADs

Auscultation and palpation of cervical and supraclavicular areas.

Careful inspection of upper extremities, including hands (i.e. color, skin integrity)

Palpation of upper extremity pulses.

Blood pressure measurement of both arms and notation of inter-arm difference.
Auscultation at different levels including the flanks, peri-umbilical region, and groin

Abdominal palpation, palpation of femoral, popliteal, dorsalis pedis, and posterior tibial artery
pulses, temperature gradient assessment.
Physical examination for assessment of PAD (continued)

Careful inspection of lower limbs, including feet (i. e. colour, presence of any
cutaneous lesion). Findings suggestive of lower extremity arterial disease,
including calf hair loss and muscle atrophy, should be noted.

Peripheral neuropathy assessment in case of diabetes or LEAD: sensory loss

(monofilament testing), ability to detect pain and light touch (sharp examination
pin, cotton wool), vibration impairment (128 Hz tuning fork); deep tendon
reflexes examination; sweating.
Laboratory testing in patients with PAD

Routine tests
Fasting plasma glucose
Fasting serum lipid profile:
• total cholesterol
• triglycerides
• high-density lipoprotein cholesterol,
• low-density lipoprotein cholesterol.
Serum creatinine and creatinine clearance
Urine analysis: urinary protein by dipstick test, microalbuminuria.
• Blood count
• Uric acid
Laboratory testing in pts with peripheral arterial diseases
(continued)

Additional tests, based on findings from clinical history, physical examination

and routine tests
Either glycated hemoglobin if fasting plasma glucose >5.6 mmol/L (101 mg/dL)
or impaired glucose tolerance test when there is doubt
Lipoprotein(a) if there is a family history of premature cardio-vascular disease
Quantitative proteinuria if positive dipstick test
The Ankle – Branchial Index
1. Who should have an ABI measurement in clinical practice?
• Patient with clinical suspicion for LEAD:
- lower extremities pulse abolition and/or arterial bruit,
- typical intermittent claudication or symptoms suggestive for LEAD
- non-healing lower extremity wound.
• Patients at risk for LEAD because of the following clinical conditions:
- atherosclerotic diseases: CAD, any PADs
- other conditions: AAA, CKD, heart failure.
• Asymptomatic individuals clinically-free but at-risk for LEAD:
- men and women aged >65years,
- men and women aged <65years classified at high CV risk according
the ESC Guidelines,
- men and women aged >50 years with family history for LEAD
The Ankle – Branchial Index (continued)

2. How to measure the ABI?

Supine position, cuff placed just above the ankle,
avoid wounded zones, After a 5–10 minutes rest,
the SBP is measured by a Doppler probe (5-10 MHz)
on the posterior and the anterior tibial (or dorsal
pedis) arteries of each foot and on the brachial
artery of each arm. Automated BP cuffs are mostly
not valid for ankle pressure and may overestimate
results in case of low ankle pressure. The ABI of
each leg is calculated by dividing the highest ankle
SBP by the highest arm SBP
The Ankle – Branchial Index (continued)
The Ankle – Branchial Index (continued)
3. How to interpret the ABI?
For diagnosis of LEAD interpret each leg separately (one ABI per leg).
For the CV risk stratification: take the lowest ABI between the two legs.
Interpretation:
Pts with peripheral arterial diseases: Best medical therapy

Recommendations Class Level

Smoking cessation is recommended in all patients with PADs. I B
Healthy diet and physical activity are recommended for all
I C
patients with PADs.
Statins are recommended in all patients with PADs I A
In patients with PADs, it is recommended to reduce LDL-C to
<1.8 mmol/L (70 mg/dL) or decrease it by >= 50% if baseline I C
values are 1.8-3.5 mmol/L (70-135 mg/dL).
Pts with peripheral arterial diseases: Best medical therapy
(continued)

Recommendations Class Level

In diabetic patients with PADs, strict glycaemic control is
recommended I C

Antiplatelet therapy is recommended in patients with

symptomatic PADs. I C

In patients with PADs and hypertension, it is recommended

to control blood pressure at < 140/90 mmHg I A

ACEIs or ARBs should be considered as first line therapy in

patients with PADs and hypertension IIa B

www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in
collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Management of antithrombotic treatment in patients with
carotid artery stenosis

Management of antiplatelet therapy in carotid artery stenosis

Asymptomatic Carotid Artery stenting Carotid Surgery

0
DAPT
A+C
SAPT SAPT
Time delay

Class I A
1 mo.
A or C A or C A:
SAPT
A or C Aspirin
Class IIa C Class I A 75-100 mg/day
Class I A
C:
1 year
Clopidogrel
75 mg/day
Long term

www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in collaboration with ESVS
( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
 Antiplatelet therapy in patients with LEAD
Management of antiplatelet therapy in patients with LEAD
not requiring anticoagulation
Asymptomatic Symptomatic Revascularization

Percutaneous Surgery
0 SAPT A:
DAPT
A or C
A+C Class IIb B
Aspirin
No SAPT Class IIa C
75-100 mg/day
SAPT
Time delay

1 mo. A or C
SAPT C:
Class I A A or C VKA Clopidogrel
Class III A O 75 mg/day
Class IIa C Class IIb B

O:
1 year
Oral
Long term anticoagulation

www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Antithrombotic therapy in pts with LEAD requiring oral
anticoagulation
LEAD in patients requiring long-term oral anticoagulation

(A)symptomatic Surgery Percutaneous intervention

Bleeding risk low Bleeding risk high

0 DAT A:
OAC OA or C OAC Aspirin
Class IIa 75-100 mg/day
Time delay

1 mo. Monotherapy Monotherapy

DAT
O OA+ C O C:
Class IIb O Clopidogrel
Class I OAC Class IIa 75 mg/day
Monotherapy
Class IIb
O:
1 year
Oral
Long term anticoagulation

www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in collaboration with ESVS
( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Antithrombotic therapy in patients with PADs (continued)

Recommendations Class Level

Carotid artery disease
In patients with symptomatic carotid stenosis, long-term SAPT is
I A
recommended.
DAPT with Aspirin and Clopidogrel is recommended for at least one
I B
month after CAS
In patients with asymptomatic > 50% CAS, long-term anti-platelet
therapy (common low dose aspirin) should be considered when the IIa C
bleeding risk is low
Lower extremity artery disease
Long-term SAPT is recommended in symptomatic patients I A
Long-term SAPT is recommended in all patients who have undergone
I C
revascularization

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Antithrombotic therapy in patients with PADs (continued)

Recommendations Class Level

Lower extremity artery disease (continued)
SAPT is recommended after infra-inguinal bypass surgery
I A

In patients requiring antiplatelet therapy, clopidogrel may be

IIb B
preferred over aspirin
Vitamin K antagonists may be considered after autologous vein infra
IIb B
inguinal bypass
DAPT with aspirin and clopidogrel for at least one month should be
IIa C
considered after infra-inguinal stent implantation
DAPT with aspirin and clopidogrel may be considered in below-knee
IIb B
bypass with prosthetic graft

www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in
collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Antithrombotic therapy in patients with PADs (continued)

Recommendations Class Level

Lower extremity artery disease (continued)
Because of a lack of proved benefit, antiplatelet therapy
is not routinely indicated in patients with isolated III A
asymptomatic LEAD
Antithrombotic therapy for PADs patients requiring oral anticoagulant
In patients with PADs and AF, oral anticoagulation:
• Is recommended when CHA2DS2-VASc score ≥ 2, I A
• Should be considered in all other patients IIa B
In patients with PADs who have an indication for OAC
(e.g. AF or mechanical prosthetic valve), oral IIa B
anticoagulants alone should be considered
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Antithrombotic therapy in patients with PADs (continued)

Recommendations Class Level

Antithrombotic therapy for PADs patients requiring oral anticoagulant (continued)
After endovascular revascularization, aspirin or clopidogrel
should be considered in addition to OAC for at least 1 month if
the bleeding risk is low compared to the risk of stent/graft IIa C
occlusion
After endovascular revascularization, OAC alone should be
considered if the bleeding risk is high compared to the risk of IIa C
stent/graft occlusion
OAC and SAPT may be considered beyond one month in high
ischaemic risk patients or when there is another firm indication IIb C
for long-term SAPT

www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in
collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Angiographic carotid stenosis according to different methods

𝑨"𝑩 𝑪"𝑩
NASCET 𝑨
ECST 𝑪

NASCET ECST
30 65
40 70
50 75
60 80
70 85
80 91
90 97
Approximate equivalent degrees of internal carotid
artery stenosis used in NASCET and ESCT according to
recent comparisons
www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in
collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Imaging of extracranial carotid arteries

Recommendations Class Level

DUS (as first-line), CTA and/or MRA are recommended
for evaluating the extent and severity of extracranial I B
carotid stenoses
When CAS is being considered, it is recommended that
any DUS study be followed either by MRA or CTA to
I B
evaluate the aortic arch, as well as the extra- and
intracranial circulation
When CEA is considered, it is recommended that the
DUS stenosis estimation be corroborated either by
I B
MRA or CTA (or by a repeat DUS study performed in an
expert vascular laboratory)
www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in
collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Management of asymptomatic carotid artery disease

Recommendations Class Level

In “average surgical risk” patients with an asymptomatic 60-
99% stenosis, CEA should be considered in the presence of
clinical and/or more imaging characteristics that may be
associated with an increased risk of late ipsilateral stroke, IIa B
provided documented perioperative stroke/death rates are <
3% and the patient’s life expectancy is > 5 years.
In asymptomatic patients who have been deemed “high-risk for
CEA” and who have an asymptomatic 60-99% stenosis in the
presence of clinical and/or imaging characteristics that may be
associated with an increased risk of late ipsilateral stroke, CAS IIa B
should be considered, provided documented perioperative
stroke/death rates are < 3% and the patient’s life expectancy is
> 5 years
www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in
collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Management of asymptomatic carotid artery disease
(continued)

Recommendations Class Level

In “average surgical risk” patients with an asymptomatic
60-99% stenosis in the presence of clinical and/or imaging
characteristicsd that may be associated with an increased
IIb B
risk of late ipsilateral stroke, CAS may be an alternative to
CEA provided documented perioperative stroke/death
rates are < 3% and the patient’s life expectancy is > 5 years

www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in
collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Features associated with increased risk of stroke in patients
with asymptomatic carotid stenosis treated medically

Clinical • Contralateral TIA/stroke

Celebral imaging • Ipsilateral silent infarction
Ultrasound imaging • Stenosis progression ( >20%)
• Spontaneous embolization on transcranial Doppler
(HITS)
• Impaired cerebral vascular reserve
• Large plaques
• Echolucent plaques
• Increased juxta-luminal black (hypoechogenic) area
MRA • Intraplaque haemorrhage
• Lipid-rich necrotic core
www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in
collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Management of extracranial carotid artery disease
Recent (< 6 months) symptoms of stroke/TIA
No Yes
Imaging of carotid artery disease by Duplex Imaging of carotid artery disease by Duplex
ultrasound, CTA and/or MRA ultrasound, CTA and/or MRA

Carotid Carotid Occlusion or Carotid Carotid Carotid

stenosis stenosis near stenosis stenosis stenosis
60-99% < 60% occlusion < 50% 50 - 69% 70 - 99%
Yes Yes

CEA + BMT CEA + BMT

Life expectancy > 5 yrs should be
Favourable anatomy No BMT considered is recommended
≥ 1 feature suggesting Class I A Class IIa B Class I A
higher stroke risk on BMT
CAS + BMT CAS + BMT
Yes may be should be
considered considered if
CEA + BMT Class IIb B high risk for CEA
should be considered Class IIa B
Class IIa B “otherwise
CAS + BMT maybe
considered”
may be considered Class IIb B
Class IIb B

www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Management of extracranial carotid artery disease

Recent (< 6 months) symptoms of stroke/TIA

No Yes

Imaging of carotid artery disease by Imaging of carotid artery disease by

Duplex ultrasound, CTA and/or MRA Duplex ultrasound, CTA and/or MRA

Carotid Carotid Occlusio Carotid Carotid Carotid

stenosis stenosis n or near stenosis stenosis stenosis
60-99% < 60% occlusion < 50% 50 - 69% 70 - 99%
Yes Yes

(continued)
www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in collaboration with ESVS ( European Heart Journal
2017; doi:10.1093/eurheartj/ehx095
Management of extracranial carotid artery disease
(continued)
Asymptomatic Symptomatic

Carotid Carotid Occlusion Carotid Carotid Carotid

stenosis stenosis or near stenosis stenosis stenosis
60-99% < 60% occlusion < 50% 50 - 69% 70 - 99%
Yes Yes
Life expectancy > 5 yrs CEA + BMT CEA + BMT
Favourable anatomy BMT should be is recommended
No considered
≥ 1 feature suggesting Class I A Class I A
higher stroke risk on Class IIa B
BMT
CAS + BMT CAS + BMT
Yes may be should be
CEA + BMT considered considered if
should be considered Class IIb B high risk for CEA
Class IIa B
Class IIa B “otherwise
CAS + BMT maybe
may be considered considered”
Class IIb B
Class IIb B

www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Revascularization in patients with symptomatic carotid
disease
Recommendations Class Level
CEA is recommended in symptomatic patients with 70-99%
carotid stenoses, provided the documented procedural I A
death/stroke rate is < 6%
CEA should be considered in symptomatic patients with 50-
69% carotid stenoses, provided the documented procedural IIa A
death/stroke rate is < 6%
In recently symptomatic patients with a 50-99% stenosis
who present with adverse anatomical features or medical
comorbidities that are considered to make them “high risk IIa B
for CEA”, CAS should be considered, provided the
documented procedural death/stroke rate is < 6%
www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Revascularization in patients with symptomatic carotid
disease (continued)

Recommendations Class Level

When revascularization is indicated in “average surgical risk”
patients with symptomatic carotid disease, CAS may be
IIb B
considered as an alternative to surgery, provided the
documented procedural death/stroke rate is < 6%
When decided, it is recommended to perform
revascularization of symptomatic 50-99% carotid stenoses as
I A
soon as possible, preferably within 14 days of symptom
onset
Revascularization is not recommended in patients with a
III A
< 50% carotid stenosis
www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in
collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Use of embolic protection device during carotid stenting

Recommendations Class Level

The use of embolic protection devices
should be considered in patients undergoing IIa C
carotid artery stenting

www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in
collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
 Các bước tiến hành chụp và can thiệp ĐM cảnh
• Quy trình trước can thiệp
1. Không nhất thiết phải Siêu âm Doppler, chụp động mạch cảnh
bằng MRI hoặc CT. Tuy nhiên các phương pháp này có thể được sử
dụng trong giai đoạn đầu để lên kế hoạch trước can thiệp, đặc biệt cho
những ca phức tạp.
2. Đánh giá lâm sàng thần kinh độc lập.
• Tiền mê
- Liệu pháp kháng tiểu cầu kép với aspirin và clopidogrel nên
đươc thực hiện 5 ngày trước thủ thuật (lí tưởng), và tiếp tục sử dụng ít
nhất 30 ngày sau đó. Sau đó có thể ngưng clopidogrel.
 Chuẩn bị dung cụ

1. Ống thông các loại.

2. Ống bao (hay ống luồn: sheath)
3. Kim chọc mạch
4. Dây dẫn
5. Đầu nối / Ống nối dài 100 cm.
6. Lưỡi dao mỗ (thường là số 11)
7. Găng tay phẫu thuật các cỡ
8. Ống tiêm dùng một lần
9. Thuốc tê tại chỗ (Lidocaine 1-2%)
10. Heparin
11. Thuốc cản quang
12. Dịch truyền ( Nước muối, đường…)
13. Băng keo (ví dụ Elastoplast)
 Chuẩn bị bệnh nhân

1. Không ăn uống 4-6 giờ trước thủ thuật.

2. Đưa BN trên giường đẩy
3. Mặc áo choàng bệnh viện
4. Vệ sinh vùng bẹn 2 bên (Cạo lông)
5. Chuẩn bị hồ sơ đầy đủ (tất cả xét nghiệm cần thiết)
6. BN cần được bù nước tốt.
7. Đi tiểu trước khi làm thủ thuật (thông tiểu, bao cao su có dây nối)
8. Các mạch ngoại vi được đánh dấu (nếu cần).
9. Đặt đường truyền tĩnh mạch.
10. Ký cam kết thủ thuật
 Quy trình chung
1. Có dung cụ để đỡ đầu và không sử dụng an thần.
2. Theo dõi các thông số sinh tồn và các chỉ số đánh giá thần
kinh trong quá trình can thiệp thủ thuật bằng các phương
thức giao tiếp đơn giản và cử động của BN.
3. Bù đủ dịch và duy trì dịch truyền muối.
4. Heparin tĩnh mạch hoặc động mạch 70U/Kg (ACT 200 - 300
giây; với mục tiêu 250 – 300 giây nếu có bít đoạn gần để
phòng thuyên tắc mạch).
 Thuốc điều trị tăng huyết áp
1. Không dùng thuốc điều trị tăng huyết áp trong ngày làm
thủ thuật và một số ngày đầu hậu phẫu.
2. Dùng lại khi huyết áp hết thấp để đảm bảo không có
phản ứng dội của huyết áp (rebound hypertension).
 Kỹ thuật – tiếp cận mạch máu
Tiếp cận qua ĐM đùi được khuyến cáo mạnh mẽ, tuy nhiên, trong trường
hợp động mạch chậu bị tắc hoặc quá ngoằn ngoèo, có thể tiếp cận qua
ĐM cánh tay/quay.
ĐÁNH GIÁ CƠ BẢN BẰNG CHỤP MẠCH
1. Chụp cản quang cung động mạch chủ được thực hiện ống thông đuôi
heo (góc 30 – 45o chếch trái trước, LAO) để xác định hình dạng cung
ĐMC và nguy cơ thuyên tắc mạch, hình ảnh xuất phát của các động
mạch bắt nguồn từ cung động mạch chủ.
2. Chụp mạch ngoài sọ hai bên có chọn lọc.
3. Phải chụp cản quang các mạch nội sọ.
4. Chỉ chụp cản quang động mạch cảnh và động mạch đốt sống khi ca
bệnh phức tạp và có khuyến cáo bắt buộc. ( để đánh giá tuần hoàn
bảng hệ có đủ và chức năng của vòng Willis).
 Giải phẫu học quai ĐMC
Type I (A), Type II (B) TypeIII (C) arches
 Những giải phẫu đầy thách thức của các mạch bên trên ĐMC
(A) accentuated tortuosity of the RCCA; (C) proximal kinking followed by distal tortuosity of the LCCA,
(B) tortuosity of both common carotid arteries; (D) Kinking of the brachiocephalic trunk followed by
angulated common carotid arteries in a bovine aortic arch.
 Những giải phẫu đầy thách thức của các mạch bên trên ĐMC

Quai động mạch chủ có hình dạng của quai ĐMC bò là khi ĐMCCT xuất phát từ thân tay đầu
(A) Angiographic aspect of an ulcerated ultrasonographic appearance of a “soft”
carotid plaque (circle); plaque
B) ulcerated portion in detail;
Intracranial ICA and ipsilateral/contralateral cerebral circulation
A. Right AP Intracranual angiogram C. A severe lesion (red dotted circle) at the ostium of the MCA
B. Right lateral intracranial angiogram requires treatment before approaching the carotid bifurcation.
 Cài ống thông vào động mạch cảnh chung (ĐMCC)

- Cài ống thông vào ĐMCC một cách an toàn và ổn định là một trong
những điểm quan trọng nhất.
- Đây là sự khác biệt nổi bật giữa can thiệp ĐMC và can thiệp ĐM vành vì
các ĐM trên động mạch chủ thường nằm sâu hơn và khó tiếp cận hơn,
đòi hỏi phải có nhiều kinh nghiệm hơn.
- Chỉ cần dùng ống thông JR4.
- Đối với cung động mạch chủ týp III hoặc gập góc hoặc ĐMCC trái xuất
phát từ thân tay đầu ( dạng cung ĐM chủ của bò: Bovine arch) thì ống
thông JB2 thường được sử dụng nhất.
- Trong một số trường hợp cung động mạch chủ týp III phức tạp hoặc
dạng cung ĐM chủ của bò thì có thể phải sử dụng ống thông Simmons
 Hướng dẫn cài ống thông can thiệp (guiding)
- Đặt ống bao (sheath) 6 - 8Fr vào ĐM đùi.
- Ống thông can thiệp dài 90 - 100cm, kiểu ống thông tùy theo hình
dáng của cung động mạch chủ.
- Đối với các giải phẫu phức tạp, loại ống thông có góc như ống thông
Hockey được sử dụng để cài vào đầu gần CCA.
- Với các giải phẫu đơn giản, ống thông đầu mềm có góc 40o được
đưa lên giữa ĐMCC trên một dây dẫn ái nước tiêu chuẩn 0.035” vào
ngay bên dưới chỗ chia (bifurcation).
- Có thể dùng 2 tới 3, dây dẫn 0.035” để đẩy ống thông đi trong các
trường hợp giải phẫu phức tạp, ống thông không ổn định (buddy
wire).
 Quản lý thiết bị phòng thuyên tắc (EPD)
- Lưới lọc ở đầu xa được đặt cách thương tổn khoảng 30 –
40mm (để tránh mắc kẹt vào stent).
- Các lưới lọc phải áp sát thành mạch, xác nhận bằng chụp
mạch cản quang ở 2 góc chiếu (projections).
- Khi sử dụng kỹ thuật phòng ngừa thuyên tắc với lưới lọc đặt
ở đầu xa, lúc nào cũng phải thấy vị trí của đầu ống thông
can thiệp.
 Nong bóng trước khi thả stent
1. Nong bóng trước khi thả stent được thực hiện khi:
– Tổn thương hẹp nặng
– Vôi hóa nặng
– Tổn thương xơ hoá dài.
2. Dùng bóng nong mạch vành tiết diện nhỏ
– Đường kính 2.5 – 3.5 mm
– Dài 20 – 30 mm, bơm với áp lực định danh (nominal pressure) 9 atm
– Bóng cắt, dùng trong trường hợp vôi hóa nặng, thường có đường kính
3.5 – 4.0 mm và bơm với áp lực vừa phải ( 8 atm ).
3. Cần tiêm tĩnh mạch trước Atropin 0.5 – 1.0 mg ở giai đoạn này
và/hoặc giai đoạn nong bóng sau đặt stent.
4. Nguyên tắc cơ bản của nong bóng trong đặt stent ĐM cảnh
(CAS) là dung áp lực định danh để nong trong một thời gian rất
ngắn (khoảng 5 giây)
 Thả stent
- Sử dụng stent có kích thước 1-2 mm lớn hơn vùng lớn nhất
của mạch được stent.
- Kích thước stent được sử dụng phổ biến nhất khi tham
chiếu ở đầu gần nơi ĐMCC (CCA) là 8 – 10 mm.
- Trong trường hợp dùng stent thuôn dần thì tham chiếu
được sử dụng phổ biến của đầu xa stent nơi ĐMCT (ICA) là 6
– 8 mm.
 Nong bóng sau khi thả stent
- Chọn kích thước bóng tuỳ vào đường kính ĐMCT nơi đầu xa của stent để
không gây bóc tách hoặc không ép vật liệu mãng xơ vữa qua lưới stent,
đường kính bóng nong không lớn hơn 5.5 mm.
- Phổ biến nhất là bóng có đường kính 5.0 mm và 5.5 mm với chiều dài 20 mm.
- Chấp nhận độ hẹp tồn lưu 10 – 30%.
- Đoạn stent trong ĐMCC không cần phải nong lại.
- Nếu mảng xơ vữa đi xuyên qua mắt cáo của stent (hiệu ứng nạo phô mai:
cheese-grater), không nên nong bóng thêm mà nên đặt thêm stent thứ hai,
ưu tiên loại có thiết kế lỗ mắt cáo đóng (close cell).
 Chụp mạch đánh giá khi kết thúc

- Phải cùng góc chiếu với đánh giá ban đầu.

- Nếu sử dụng lưới lọc ở đầu xa thì cần kiểm tra vùng thả stent cẩn
thận.
- Chụp kiểm tra động mạch nội sọ cùng bên đặt stent thường qui.
 Các biến chứng
1. Nhịp tim chậm và huyết áp thấp
2. Co thắt động mạch cảnh
3. Tắc mạch đầu xa
4. Băng huyết nội sọ
5. Hội chứng tăng tưới máu
6. Sự rối loạn tuần hoàn não
7. Bóc tách động mạch cảnh.
8. Thủng động mạch cảnh.
9. Tắc nghẽn động mạch cảnh.
10.Huyết khối stent cấp tính.
11.Tái hẹp.
Management of vertebral artery stenosis

Recommendations Class Level

In patient with symptomatic extracranial vertebral
artery stenosis, revascularization may be considered
for lesions ≥ 50% in patients with recurrent ischaemic IIb B
events, despite optimal medical management
Revascularization of asymptomatic vertebral artery
stenosis is not indicated, irrespective of the degree of III C
severity

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Differential diagnosis in upper limbs artery disease
2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095

Causes Subclavian Axillary Brachial Forearm Hand

Atherosclerosis X
Thoracic outlet syndrome X
Giant cell arteritis X
Takayasu arteritis X X
Radiation artery fibrosis X X
Embolic X x x X
Fibromuscular dysplasia X X
Buerger’s disease X X
Ergotism X X
Connective tissue disease x X
Cytotoxic drugs x
Arterial drug injection X
Diabetes mellitus X
Myeloproliferative disorders X
Hypercoagulative status X
Cryoglobulins X
Repetitive trauma X
Vinyl chloride exposure X
Latrogenic lesions x x x x x
Differential diagnosis in upper limbs artery disease
Causes Subclavian Axillary Brachial Forearm Hand
Atherosclerosis X
Thoracic outlet syndrome X
Giant cell arteritis X
Takayasu arteritis X X
Radiation artery fibrosis X X
Embolic X x x X
Fibromuscular dysplasia X X
Buerger’s disease X X
Ergotism X X
Connective tissue disease x X

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collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Differential diagnosis in upper limbs artery disease
Causes Subclavian Axillary Brachial Forearm Hand
Cytotoxic drugs x
Arterial drug injection X
Diabetes mellitus X
Myeloproliferative X
disorders
Hypercoagulative status X
Cryoglobulins X
Repetitive trauma X
Vinyl chloride exposure X
Latrogenic lesions x x x x x
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Management of subclavian artery stenosis

Recommendations Class Level

In symptomatic patients with subclavian artery stenosis/

occlusion revascularization should be considered IIa C

In symptomatic patients with a stenotic/occlused

subclavian artery, both revascularization options
(stenting or surgery) should be considered and discussed IIa C
case by case according to the lesion characteristics and
patient’s risk.

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collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Management of subclavian artery stenosis (continued)

Recommendations Class Level

In asymptomatic subclavian artery stenosis, revascularization:
• Should be considered in the case of proximal stenosis in
patients undergoing CABG using the ipsilateral internal IIa C
mammary artery
• Should be considered in the case of proximal stenosis in
patients who already have the ipsilateral internal
IIa C
mammary artery grafted to coronary arteries with
evidence of myocardial ischaemia
• Should be considered in case of subclavian artery
IIa C
stenosis and ipsilateral arteriovenous fistula for dialysis
• May be considered in the case of bilateral stenosis, in
IIb C
order to be able to monitor blood pressure accurately

www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in
collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Management of acute mesenteric ischaemia
Recommendations Class Level
Diagnosis
In patients with suspected acute mesenteric ischaemia, urgent
CTA is recommended I C

In patients with suspicion of acute mesenteric ischaemia, the

measurement of D-dimer should be considered to rule out the IIa B
diagnosis
Treatment
In patients of acute thrombotic occlusion of the superior
mesenteric artery, endovascular therapy shouldbe considered as IIa B
first line therapy for revascularization
In patients with acute embolic occlusion of the superior
mesenteric artery, both endovascular and open surgery therapy IIa
shoulbe considered
Management of acute mesenteric ischaemia

Recommendations Class Level

Diagnosis
In patients with suspected CMI, DUS is recommended as the
first line examination I C

In patients with suspected CMI, occlusive disease of a single

mesenteric artery makes the diagnosis unlikely, and a careful IIa C
search for alternative causes should be considered
Treatment
In patients with symptomatic multivessel CMI,
I C
revascularization is recommended
In patients with symptomatic multivessel CMI, it is not
recommended to delay revascularization in order to improve III C
the nutritional status
Clinical situations raising suspicion for renal artery disease
• Onset of HTN < 30 years • Hypertensive crisis (acute HF, acute renal
• Onset of severe HTN > 55 years, when failure, hypertensive encephalopathy, or
associated with CKD or HF grade 3-4 retinopathy)

• HTN and abdominal bruit • New azotaemia or worsening of renal

function after treatment with RAAS
• Rapid and persistent worsening of blockers
previously controlled HTN
• Unexplained atrophic kidney or
• Resistant HTN ( other secondary form
discrepancy in kidney size, or unexplained
unlikely and target not achieved despite
renal failure.
4 drugs classes including a diuretic and a
mineralocorticoid-receptor antagonist in • Flash pulmonary oedema
appropriate doses)

www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arteriral Diseases, in
collaboration with ESVS ( European Heart Journal 2017; doi:10.1093/eurheartj/ehx095
Diagnostic strategies for renal artery disease

Recommendations Class Level

DUS ( as first-line), CTA and MRA are recommended
imaging modalities to establish a diagnosis of RAD I B

DSA may be considered to confirm a diagnosis of RAD

when clinical suspicion is high and the results of non-
invasive examinations are inconclusive IIb C

Renal scintigraphy, plasma renin measurements before

and after ACEI provocation, and vein renin measurements
are not recommended for screening of atherosclerotic III C
RAD

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Treatment strategies for renal artery disease

Recommendations Class Level

Medical Therapy
ACEIs/ARBs are recommended for treatment of hypertension I B
associated with unilateral RAS

Calcium channel blockers, beta-blockers and diuretics are I C

recommended for treatment of hypertension associated with
renal artery disease

ACEIs/ARBs may be considered in bilateral severe RAS and in the IIb B

case of stenosis in a single functioning kidney, if well tolerated
and under close monitoring

(European Heart Journal 2417; doi:10.1093/eurheartj/ehx095)

Treatment strategies for renal artery disease (continued)
Recommendations Class Level
Revascularization
Routine revascularization is not recommended in RAS secondary to III A
atherosclerosis.
In cases of hypertension and/or signs of renal impairment related to renal IIa B
arterial fibromuscular dysplasia, balloon angioplasty with bailout stenting
should be considered.
Balloon angioplasty, with or without stenting, may be considered in selected IIb C
patients with RAS and unexplained recurrent congestive heart failure or
sudden pulmonary oedema.
In the case of an indication for revascularization, surgical revascularization IIa B
should be considered for patients with complex anatomy of the renal arteries,
after a failed endovascular procedure, or during open aortic surgery.

(European Heart Journal 2017; doi:10.1093/eurheartj/ehx095)

Clinical stages of lower extremity artery disease (LEAD)
Fontaine classification Rutherford classification
Stage Symptoms Grade Category Symptoms
I Asymptomatic ó 0 0 Asymptomatic
II IIa Non-disabling ó I 1 Mild claudication
intermittent
I 2 Moderate
claudication
claudication
IIb Disabling intermittent I 3 Severe claudication
claudication
III Ischaemic rest pain ó II 4 Ischaemic rest pain
IV Ulceration or gangrene ó III 5 Minor tissue loss
III 6 Major tissue loss
(European Heart Journal 2017; doi:10.1093/eurheartj/ehx095)
Ankle-brachial index measurement

Recommendations Class Level

Measurement of the ABI is indicated as a first-line non- I C
invasive test for screening and diagnosis of LEAD.
In the case of incompressible ankle arteries or ABI >1.40, I C
alternative methods such as the toe-brachial index,
Doppler waveform analysis or pulse volume recording
are indicated.

(European Heart Journal 2017; doi:10.1093/eurheartj/ehx095)

Imaging in patients with LEAD

Recommendations Class Level

DUS is indicated as first-line imaging method to confirm LEAD I C

lesions.
DUS and/or CTA and/or MRA are indicated for anatomical I C
characterization of LEAD lesions and guidance for optimal
revascularization strategy.

Data from an anatomical imaging test should always be analyzed I C

in conjunction with symptoms and haemodynamic tests prior to
treatment decision.

DUS screening for AAA should be considered. IIa C

(European Heart Journal 2017; doi:10.1093/eurheartj/ehx095)

Revascularization of aorto-iliac occlusive lesions

Recommendations Class Level

An endovascular-first strategy is recommended for short (i.e. <5 cm) I C

occlusive lesions.

In patients fit for surgery, aorto-(bi)femoral bypass should be IIa B

considered in aorto-iliac occlusion(s).

An endovascular-first strategy should be considered in long and/or IIa B

bilateral lesions in patients with severe comorbidities.

An endovascular-first strategy may be considered for aorto-iliac IIb B

occlusive lesions, if done by an experienced team and if it does not nr

compromise subsequent surgical options.

(European Heart Journal 2017; doi:10.1093/eurheartj/ehx095)

Revascularization of aorto-iliac occlusive lesions (continued)

Recommendations Class Level

Primary stent implantation, rather than provisional stenting, should IIa B
be considered.

Open surgery should be considered in fit patients with an aortic IIa C

occlusion extending up to the renal arteries.

In the case of ilio-femoral occlusive lesions, a hybrid procedure IIa C

combining iliac stenting and femoral endarterectomy or bypass
should be considered.
An endovascular-first strategy may be considered for aorto-iliac IIb C
occlusive lesions, if done by an experienced team and if it does not
compromise subsequent surgical options.
(European Heart Journal 2017; doi:10.1093/eurheartj/ehx095)
Stent ĐM Đùi chung trái
Revascularization of femoro-popliteal occlusive lesions

Recommendations Class Level

An endovascular-first strategy is recommended in short (i.e. <25 cm) I C

lesions.

Primary stent implantation should be considered in short (i.e. <25 cm) IIa A
lesions.

Drug-eluting balloons may be considered in short (i.e. <25 cm) lesions. IIb A

Drug-eluting stents may be considered for short (i.e. <25 cm) lesions. IIb B

Drug-eluting balloons may be considered for the treatment of in- IIb B

stent restenosis.

(European Heart Journal 2017; doi:10.1093/eurheartj/ehx095)

Revascularization of femoro-popliteal occlusive lesions

Recommendations Class Level

In patients who are not at high-risk for surgery, bypass surgery is I B

indicated for long (i.e. ≥25 cm) superficial femoral artery lesions
when an autologous vein is available and life expectancy is > 2 years.

The autologous saphenous vein is the conduit of choice for I A

femoro-popliteaI bypass.

When above-knee bypass is indicated, in the absence of any IIa A

autologous saphenous vein, the use of a prosthetic conduit should
be considered.
In patients unfit for surgery, endovascular therapy may be IIb C
considered in long (i.e. ≥25 cm) femoro-popliteal lesions.

(European Heart Journal 2017; doi:10.1093/eurheartj/ehx095)

Revascularization of infra-popliteal occlusive lesions

Recommendations Class Level

In the case of chronic limb threatening ischaemia (CLTI), infra-popliteal I A

revascularization is indicated for limb salvage.

For revascularization of infra-popliteal arteries:

• bypass using the great saphenous vein is indicated, I A

• endovascular therapy should be considered. IIa B

(European Heart Journal 2017; doi:10.1093/eurheartj/ehx095)

Management of patients with intermittent claudication

Recommendations Class Level

On top of general prevention, statins are indicated to improve I A

walking distance.
In patients with intermittent claudication:
• supervised exercise training is recommended, I A
• unsupervised exercise training is recommended when supervised I C
exercise training is not feasible or available.
When daily life activities are compromised despite exercise therapy, IIa C
revascularization should be considered.
When daily life activity is severely compromised, revascularization IIa B
should be considered, in association with exercise therapy.
(European Heart Journal 2017; doi:10.1093/eurheartj/ehx095)
Management of patients with intermittent claudication
Claudication

Assessment of risk factors and medication

Control of the risk factors (smoking, hypertension, dyslipidaemia, diabetes)
Antiplatelet and lipid lowering therapy
Initiation of exercise therapy, preferably supervised

Claudication does impact daily life at the Claudication does not impact daily life at the
baseline or after exercise therapy baseline or after exercise therapy

Patient's general condition Patient's general condition does Exercise, preventive

allows invasive treatment not allow invasive treatment and medical therapies

Assessment of lower limb arteries

Aortoiliac lesions Femoro-popliteal lesions Isolated crural lesions

I (continued)
Risk of amputation: the WIFI classification
Component Score Description
W (Wound) 0 No ulcer (ischaemic rest pain).
1 Small. Shallow ulcer on distal leg or foot without gangrene.
2 Deeper ulcer (exposed bone), joint or tendon ± gangrenous changes limited to toes.
3 Extensive deep ulcer, full thickness heel ulcer ± calcaneal involvement ± extensive
gangrene.
I (Ischaemia) ABI Ankle pressure (mmHg) Toe pressure or TcPO2
0 ≥ 0.80 > 100 ≥ 60
1 0.60 – 0.79 70 – 100 40 – 59
2 0.40 – 0.59 50 – 70 30 – 39
3 < 0.40 < 50 < 30
fl 0 No symptoms/ signs of infection.
(foot 1 Local infection involving only skin and subcutaneous tissue.
infection)
2 Local infection involving deeper than skin/subcutaneous tissue.
3 Systemic inflammatory response syndrome.
Interpretation of the WIFI classification

Estimate risk of amputation at 1 year for each combination

Ischaemia - 0 Ischaemia - 1 Ischaemia - 2 Ischaemia - 3
W-0 VL VL L M VL L M H L L M M L M M H
W-1 VL VL L M VL L M H L M H H M M H H
W-2 L L M H M M H H M H H H H H H H
W-3 M M H H H H H H H H H H H H H H
fl-0 fl-1 fl-2 fl-3 fl-0 fl-1 fl-2 fl-3 fl-0 fl-1 fl-2 fl-3 fl-0 fl-1 fl-2 fl-3
•

fr = foot infection; H = high-risk; L = low-risk; M = moderate risk; VL -= very low risk; W = wound.

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Management of patients with chronic limb-threatening
ischaemia
Chronic limb-treathening ischaemia (CLTI)
Pain control, risk factor management, wound care, antibiotics if needed, drainage of septic foot if needed

Patient candidate for revascularization

Urgent imaging

Revascularization Revascularization non feasible

Stenotic lesions, Long occlusions

Short occlusions

No GSV or increased risk GSV available

for open surgery and patients fit
for surgery
Endovascular first Endovascular first
(continued)
Management of patients with chronic limb-threatening
ischaemia (continued)
Endovascular first Bypass first Revascularization Patient candidate for
non feasible revascularization
Successful
revascularization
Failure Failure
Wound care
Maintenance of
revascularization Redo-EVT or
New procedures open bypass Redo surgery or
if mandatory if possible EVT if possible
Management of
risk factors
Impossible
Amputation mandatory?

Yes No

Amputation Pain control, Wound care

Rehabilitation Management of risk factors
Management of Chronic Limb-Threatening Ischaemia (CLTI)

Recommendations Class Level

Early recognition of tissue loss and/ or infection and referral to the vascular team is I C
mandatory to improve limb salvage

In patient with CLTI, assessment of the risk of amputation is indicated. I C

In patient with CLTI and diabetes, optimal glycaemic control is recommended. I C

For limb salvage, revascularization is indicated wherever feasible. I B

In CLTI patients with below-the-knee lesions, angiography including foot runoff IIa C
should be considered prior to revascularization.

In patient with CLTI, stem cell/gene therapy is not indicated. III B

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 Clinical categories of acute limb ischaemia

Grade Category Sensory loss Motor deficit Prognosis

I Viable None None Not immediate threat

Marginally None or None

IIa Salvage if promptly treated
threatened minimal (toe)
Immediately More than Salvage if promptly
IIb Mild/moderate
threatened toe revascularized
Major tissue loss,
Profound, Profound,
III Irreversible permanent nerve damage
aneasthetic paralysis (rigor)
inevitable

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Management of patients presenting with acute limb ischaemia

Recommendations Class Level

In the case of neurological deficit, urgent revascularization is I C

indicated.

In the absence of neurological deficit, revascularization is indicated I C

within hours after initial imaging in a case to case decision.

Heparin and analgesics are indicated as soon as possible. I C

;-

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Management of acute limb ischaemia

Acute limb ischaemia

Heparin and pain management

Viable, no neurological Viable with neurological Irreversible

deficit (Rutherford I) deficit (Ruherford II) (Rutherford III)

Initial work-up Urgent revascularization: Amputation

(DUS, CTA, DSA) Thrombectomy/bypass

(continued)
 (continued)

Viable, no neurological Viable with neurological Irreversible

deficit (Rutherford I) deficit (Rutherford II) (Rutherford III)

Initial work-up Urgent revascularization:

Amputation
(DUS, CTA, DSA) Thrombectomy/bypass

Revascularization Underlying
within hours: vascular lesion?
(Thrombolysis/
thrombectomy/ bypass)
Present Absent

Endovascular therapy Medical therapy

and/or surgery and follow-up
Screening for carotid disease in patients undergoing CABG

Recommendations Class Level

In patients undergoing CABG, DUS is recommended in patients with a I B

recent (<6 months) history of TIA/stroke.

In patients with no recent (< 6 months) history of TIA/stroke, DUS may IIb B
be considered in the following cases: age ≥ 70 years, multivessel
coronary artery disease, concomitant LEAD, or carotid bruit.

Screening for carotid stenosis is not indicated in patients requiring III C

urgent CABG with no recent stroke/TIA.
Management for carotid stenosis in pts undergoing CABG

Recommendations Class Level

It is recommended that the indication (and if so the method and timing) I C
for carotid revascularization be individualized after discussion within a
multidisciplinary team, including a neurologist.

In patients scheduled for CABG, with recent (<6 months) history of TIA/stroke:
• Carotid revascularization should be considered in patients with 50 – 99% IIa B
carotid stenosis,
• Carotid revascularization with CEA should be considered as first choice IIa B
in patients with 50-99% carotid stenosis,
• Carotid revascularization is not recommended in patients with carotid III C
stenosis <50%.
Management for carotid stenosis in pts undergoing CABG
(continued)

Recommendations Class Level

In neurologically asymptomatic patients scheduled for CABG:
• Routine prophylactic carotid revascularization in patients with a 70- III B
99% carotid stenosis is not recommended.
• Carotid revascularization may be considered in patients with IIb B
bilateral 70-99% carotid stenoses or 70-99% carotid stenosis +
contralateral occlusion.
• Carotid revascularization may be considered in patients with a 70- IIb C
99% carotid stenosis, in the presence of one or more characteristics
that may be associated with an increased risk of ipsilateral stroke,
in order to reduce stroke risk beyond the perioperative period.
Screening and management of concomitant LEAD and CAD

Recommendations Class Level

In patients with LEAD, radial artery access is recommended as the I C

first option for coronary angiography/intervention.

In patients with LEAD undergoing CABG, sparing the autologous IIa C

great saphenous vein for potential future use for surgical
peripheral revascularization should be considered.
In patients undergoing CABG and requiring saphenous vein IIa C
harvesting, screening for LEAD should be considered.

In patients with CAD, screening for LEAD by ABI measurement IIB B

may be considered for risk stratification.
Screening for CAD in patients with carotid artery disease

Recommendations Class Level

In patients undergoing elective CEA, preoperative CAD screening, IIb B

including coronary angiography, may be considered
Management of HF associated with PADs

Recommendations Class Level

Full vascular assessment is indicated in all patients considered for

I C
heart transplantation or cardiac assist device implantation

In patients with symptomatic PADs, screening for heart failure with IIa
C
TTE and/or natriuretic peptides assessment should be considered
IIb
Screening for LEAD may be considered in patients with heart failure C

Testing for renal artery disease may be considered in patients with IIb
C
flash pulmonary oedema.
Management of AF associated with PADs

Recommendations Class Level

In patients with LEAD and atrial fibrillation, oral anticoagulation:

• Is recommended when CHA2DS2-VASc score >=2, I A

• Should be considered in all other patients IIa B

Management of valvular HD associated with PADs

Recommendations Class Level

Screening for LEAD and UEAD is indicated in patients I B

undergoing TAVI or other structural interventions requiring
an arterial approach
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