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Evidence-based
Therapy in
Vascular Surgery
E.SebastianDebus
ReinhartT.Grundmann
SecondEdition
123

Evidence-based Therapy in Vascular Surgery

E.SebastianDebus • ReinhartT.Grundmann
Evidence-based Therapy in
Vascular Surgery
Second Edition

E.SebastianDebus
Department of Vascular Medicine
University Heart and Vascular Center
Hamburg, Germany
ReinhartT.Grundmann
Community Hospital Altoetting-Burghausen
Burghausen, Germany
ISBN 978-3-031-47396-8 ISBN 978-3-031-47397-5 (eBook)
https://doi.org/10.1007/978-3-031-47397-5
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland
AG 2023, 2017 Springer International Publishing AG
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specically the rights of translation, reprinting, reuse of
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does not imply, even in the absence of a specic statement, that such names are exempt from the relevant
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The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
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claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Paper in this product is recyclable

Preface
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The topic of the second edition of this book is vascular and endovascular surgery
and vascular medicine. Thereby, all prevalent arterial vascular diseases are discussed, from extracranial carotid artery stenosis to peripheral arterial occlusive disease and the diabetic foot. Furthermore, evidence-based therapy for hemodialysis
access, varicose veins, deep vein thrombosis, and venous leg ulcer is presented.
This is not a textbook that describes surgical techniques. Instead its intention is to
advise the reader on which surgical or endovascular procedure is currently the best
justied (indication) in specic situations and what the expected results should be
from a quality assurance perspective. This starts with the presentation of guideline
recommendations from the most recognized professional societies, which are not
necessarily the same in all countries. The second focus of this book is treatment
results, which serve as a rudiment for an evidence-based therapy decision. Clinical
studies are discussed and classied according to their signicance; all important
meta-analyses and Cochrane Reviews are presented, and the recent results of randomized and nonrandomized clinical studies, large cohort studies, and registries are
explained.
In terms of structure and objectives, nothing has changed in this issue since the
conception of the rst edition except for the extension of the number of chapters and
a new chapter on perioperative management. Nevertheless, it is much more than just
a re-edition—in fact we are presenting the reader with a completely new book. The
reason for this is another objective of this series, the timeliness. Based on a comprehensive, systematic literature search in PubMed, all the important publications of
the last 5years are presented here. This not only provides the reader with the evidence, but also the latest state of knowledge or discussion. In order not to go too far,
it was necessary to delete many publications from previous years, which may still
be of value, so that each new edition of this series is more of a supplement than a
replacement for the previous edition.
The book is aimed at a broad readership, including residents and junior doctors,
as well as experienced practitioners looking to stay informed about the latest developments in our eld—which can also have practical and possibly justiciable
v

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Preface
consequences, especially in the case of guideline recommendations or in medical
malpractice criticism.
In conclusion, we thank all employees of Springer Nature, who participated in
this project for their kind assistance, and especially Ms. Mahalakshmi and Ms.
Morton for their collaboration and coordination of this book project.
Hamburg, Germany E.SebastianDebus
Burghausen, Germany ReinhartT.Grundmann

Contents
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1 Extracranial Carotid Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1.1 Guideline of the European Society for
Vascular Surgery (ESVS) [1] . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1.2 European Stroke Organisation Guideline on
Endarterectomy and Stenting for Carotid Artery
Stenosis [2]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.1.3 Society for Vascular Surgery Clinical Practice Guidelines
for Management of Extracranial Cerebrovascular
Disease [3] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.2.1 Randomised Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.2.2 Meta-Analyses Open Procedure and CAS . . . . . . . . . . . . . . 8
1.2.3 Registry Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.2.4 Transcervical Carotid Artery Revascularization (TCAR) . . 14
1.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.4 Perioperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.4.1 Imaging Strategies in Carotid Artery Disease . . . . . . . . . . . 17
1.4.2 Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.4.3 Perioperative Antibiotic Prophylaxis . . . . . . . . . . . . . . . . . . 18
1.4.4 Beta-Blocker Perioperative . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.4.5 Blood Pressure Management After Carotid |Intervention . . 19
1.4.6 Perioperative Management of Patients with
Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.4.7 Intraoperative Heparin and Reversal . . . . . . . . . . . . . . . . . . 23
1.4.8 Prevention of Venous Thromboembolism . . . . . . . . . . . . . . 24
1.4.9 Antiplatelet Therapy with CEA/CAS . . . . . . . . . . . . . . . . . 24
1.4.10 Patients with Atrial Fibrillation: Combination
Therapy with Oral Anticoagulants and
Antiplatelets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
1.4.11 Lipid-Lowering Therapy (Statins) . . . . . . . . . . . . . . . . . . . . 27
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Contents
1.4.12 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
1.4.13 Wound Drainage After CEA . . . . . . . . . . . . . . . . . . . . . . . . 28
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2 Thoracic-Outlet-Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.1.1 Society for Vascular Surgery . . . . . . . . . . . . . . . . . . . . . . . . 33
2.1.2 American College of Radiology
Appropriateness Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.2.1 Meta-Analyses/Systematic Reviews . . . . . . . . . . . . . . . . . . 37
2.2.2 Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
2.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
3 Distal Aortic Dissection Type Stanford B . . . . . . . . . . . . . . . . . . . . . . . 47
3.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3.1.1 Denition and Classication . . . . . . . . . . . . . . . . . . . . . . . . 47
3.1.2 2022 ACC/AHA Guideline for the Diagnosis
and Management of Aortic Disease . . . . . . . . . . . . . . . . . . . 48
3.1.3 Clinical Practice Guidelines of the European Society for
Vascular Surgery (ESVS) . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
3.1.4 Society of Thoracic Surgeons/American Association for
Thoracic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
3.2 Meta-Analyses/Systematic Reviews . . . . . . . . . . . . . . . . . . . . . . . . 54
3.2.1 Acute and Subacute Uncomplicated Type B Aortic
Dissection: BMT vs. TEVAR . . . . . . . . . . . . . . . . . . . . . . . . 54
3.2.2 TEVAR in Uncomplicated and Complicated TBAD . . . . . . 54
3.2.3 TEVAR in Acute/Chronic TBAD . . . . . . . . . . . . . . . . . . . . . 55
3.2.4 Acute TBAD: Open vs. Endovascular Repair . . . . . . . . . . . 55
3.2.5 Chronic TBAD: Open vs. Endovascular Repair . . . . . . . . . 56
3.3 Studies and Registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
3.3.1 Open Repair, Endovascular Repair, or Medical
Treatment of TBAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
3.3.2 TEVAR in Uncomplicated TBAD: Timing . . . . . . . . . . . . . 59
3.3.3 Complicated TBAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
3.3.4 Hospital Readmission Rate After Acute TBAD . . . . . . . . . . 61
3.3.5 Chimney Technique and Adjunctive Side Branch
Interventions with TEVAR . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.3.6 Anticoagulation and Antiplatelet Therapy After TEVAR . . 62
3.4 Technical Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
3.5 Aortic Fenestration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
3.6 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Contents
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4 Descending Thoracic Aortic Aneurysms (DTAA)
and Thoracoabdominal Aortic Aneurysms (TAAA) . . . . . . . . . . . . . . 69
4.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
4.1.1 Clinical Practice Guidelines of the European
Society for Vascular Surgery (ESVS) . . . . . . . . . . . . . . . . . 69
4.1.2 Clinical Practice Guidelines of the Society for
Vascular Surgery (SVS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
4.1.3 ACC/AHA Guideline for the Diagnosis and
Management of Aortic Disease . . . . . . . . . . . . . . . . . . . . . . 72
4.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
4.2.1 Meta-Analyses and Systematic Reviews . . . . . . . . . . . . . . . 73
4.2.2 Registry Data/Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
4.2.3 Specic Issues with TAAA . . . . . . . . . . . . . . . . . . . . . . . . . 82
4.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
4.4 Perioperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
4.4.1 Diagnostic Methods in Descending Thoracic Aortic
Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
4.4.2 Preoperative Statin Therapy and Survival After TEVAR . . . 85
4.4.3 Anaesthesia and Analgesia . . . . . . . . . . . . . . . . . . . . . . . . . . 86
4.4.4 Neurophysiological Monitoring . . . . . . . . . . . . . . . . . . . . . . 87
4.4.5 Prevention of Spinal Cord Ischaemia . . . . . . . . . . . . . . . . . . 88
4.4.6 Transfusion Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
4.4.7 Minimally Invasive Segmental Artery Coil
Embolisation to Prevent Spinal Cord Ischaemia . . . . . . . . . 93
4.4.8 Thromboprophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
4.4.9 Endoleak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
ix
5 Abdominal Aortic Aneurysm (AAA) . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
5.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
5.1.1 European Society for Vascular Surgery (ESVS)
2019 Clinical Practice Guidelines on the Management of
Abdominal Aorto- iliac Artery Aneurysms [1] . . . . . . . . . . . 101
5.1.2 Society for Vascular Surgery . . . . . . . . . . . . . . . . . . . . . . . . 103
5.1.3 ACC/AHA Guideline for the Diagnosis and
Management of Aortic Disease . . . . . . . . . . . . . . . . . . . . . . 106
5.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
5.2.1 AAA-Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
5.2.2 Intact AAA: Randomized Trials . . . . . . . . . . . . . . . . . . . . . 109
5.2.3 Intact AAA: Meta-Analyses . . . . . . . . . . . . . . . . . . . . . . . . . 111
5.2.4 Ruptured AAA: Meta-Analyses . . . . . . . . . . . . . . . . . . . . . . 113
5.2.5 Studies and Registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
5.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

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5.4 Perioperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
5.4.1 Modiable Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
5.4.2 Preoperative Coronary Revascularisation . . . . . . . . . . . . . . 128
5.4.3 Preoperative Carotid Intervention . . . . . . . . . . . . . . . . . . . . 129
5.4.4 Open Repair of Nonruptured AAA . . . . . . . . . . . . . . . . . . . 130
5.4.5 Endovascular Repair of Nonruptured AAA . . . . . . . . . . . . . 138
5.4.6 Ruptured Abdominal Aortic Aneurysm (rAAA) . . . . . . . . . 147
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
6 Renal Artery Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
6.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
6.1.1 American College of Cardiology Foundation/
American Heart Association . . . . . . . . . . . . . . . . . . . . . . . . 161
6.1.2 European Society of Cardiology (ESC) and
European Society for Vascular Surgery (ESVS) . . . . . . . . . 163
6.1.3 Society for Cardiovascular Angiography
and Interventions (SCAI) . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
6.1.4 Fibromuscular Dysplasia- Statement from the AHA . . . . . . 165
6.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
6.2.1 Endovascular Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . 166
6.2.2 Registry Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
6.2.3 Fibromuscular Dysplasia (FMD) . . . . . . . . . . . . . . . . . . . . . 172
6.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
7 Visceral Artery Aneurysms (Including Renal Artery Aneurysms) . . . 177
7.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
7.1.1 Renal Artery Aneurysm (RAA) . . . . . . . . . . . . . . . . . . . . . . 177
7.1.2 Splenic Artery Aneurysm (SAA) . . . . . . . . . . . . . . . . . . . . . 178
7.1.3 Celiac Artery Aneurysm (CAA). . . . . . . . . . . . . . . . . . . . . . 179
7.1.4 Gastric and Gastroepiploic Artery Aneurysms . . . . . . . . . . 179
7.1.5 Hepatic Artery Aneurysm (HAA) . . . . . . . . . . . . . . . . . . . . 180
7.1.6 Superior Mesenteric Artery Aneurysm (SMAA) . . . . . . . . . 180
7.1.7 Jejunal, Ileal, and Colic Artery Aneurysms . . . . . . . . . . . . . 181
7.1.8 Pancreaticoduodenal Artery Aneurysm (PDAA) and
Gastroduodenal Artery Aneurysm (GDAA) . . . . . . . . . . . . 181
7.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
7.2.1 Meta-Analyses/Systematic Reviews . . . . . . . . . . . . . . . . . . 182
7.2.2 Registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
7.2.3 Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
7.2.4 Special Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
7.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
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