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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3876_Библиотеки_им_академика_М_И_Перельмана
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Contents
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8 Acute Mesenteric (Intestinal) Ischaemia . . . . . . . . . . . . . . . . . . . . . . . 193
8.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
8.1.1 American College of Cardiology Foundation/
American Heart Association . . . . . . . . . . . . . . . . . . . . . . . . 193
8.1.2 Clinical Practice Guidelines of the European
Society of Vascular Surgery (ESVS) . . . . . . . . . . . . . . . . . . 195
8.1.3 European Society of Cardiology (ESC)/European
Society for Vascular Surgery (ESVS) . . . . . . . . . . . . . . . . . 196
8.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
8.2.1 Meta-Analyses/Systematic Reviews . . . . . . . . . . . . . . . . . . 197
8.2.2 Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
8.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
9 Chronic Mesenteric (Intestinal) Ischaemia. . . . . . . . . . . . . . . . . . . . . . 205
9.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
9.1.1 European Society of Cardiology (ESC)/European
Society for Vascular Surgery (ESVS) . . . . . . . . . . . . . . . . . 205
9.1.2 Clinical Practice Guidelines of the European
Society of Vascular Surgery (ESVS) . . . . . . . . . . . . . . . . . . 206
9.1.3 Clinical Practice Guidelines of the Society for Vascular
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
9.1.4 European Guidelines on Chronic Mesenteric
Ischaemia: Joint United European
Gastroenterology etal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
9.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
9.2.1 Registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
9.2.2 Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
9.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
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10 Median Arcuate Ligament Syndrome (MALS) . . . . . . . . . . . . . . . . . . 217
10.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
10.1.1 The Appropriateness Criteria of the American
College of Radiology [1] Recommend . . . . . . . . . . . . . . . 217
10.1.2 European Guidelines on Chronic Mesenteric
Ischaemia—Joint United European Gastroenterology.
These Guidelines Recommend [2] . . . . . . . . . . . . . . . . . . . 218
10.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
10.2.1 Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
10.2.2 Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
10.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . 225
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
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11 Intermittent Claudication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
11.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
11.1.1 European Society of Cardiology (ESC)/
European Society for Vascular Surgery (ESVS) . . . . . . . . 229
11.1.2 American College of Cardiology/American Heart
Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
11.1.3 Society for Vascular Surgery (SVS) . . . . . . . . . . . . . . . . . . 231
11.1.4 “Appropriate Use”: Criteria of the SVS for IC . . . . . . . . . 233
11.1.5 Reporting Standards of the SVS for Endovascular
Treatment of Chronic Lower Extremity Peripheral
Artery Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
11.1.6 Optimal Exercise Programs for Patients with
Peripheral Artery Disease: A Scientic Statement
from the American Heart Association [6] . . . . . . . . . . . . . 235
11.1.7 French Guidelines for the Management of Ambulatory
Endovascular Procedures for Lower Extremity
Peripheral Artery Disease . . . . . . . . . . . . . . . . . . . . . . . . . 236
11.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
11.2.1 Meta-Analyses/Systematic Reviews/
Randomised Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
11.2.2 Studies/Registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
11.2.3 Drug-Coated Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
11.2.4 Special Issue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
11.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . 249
11.4 Perioperative Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
11.4.1 Antithrombotic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
11.4.2 Statin Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
11.4.3 Beta Blocker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
11.4.4 Antihypertensive Therapy . . . . . . . . . . . . . . . . . . . . . . . . . 256
11.4.5 Diabetes/Glycaemic Control . . . . . . . . . . . . . . . . . . . . . . . 257
11.4.6 Preoperative Anemia/Blood Transfusion . . . . . . . . . . . . . . 258
11.4.7 Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
11.4.8 Analgesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
11.4.9 Enhanced Recovery After Surgery (ERAS) . . . . . . . . . . . . 261
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
12 Chronic Limb-Threatening Ischemia (Critical Limb Ischemia) . . . . 267
12.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
12.1.1 Preliminary Remark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
12.1.2 European Society of Cardiology (ESC)
in Cooperation with the European Society for
Vascular Surgery (ESVS) [2]
12.1.3 American College of Cardiology (ACC)/American
Heart Association/AHA) [3] . . . . . . . . . . . . . . . . . . . . . . . 269
. . . . . . . . . . . . . . . . . . . . . . . 268
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12.1.4 Global Vascular Guidelines on the Management
of Chronic Limb-Threatening Ischemia—Joint
Guidelines of the Society for Vascular Surgery,
European Society for Vascular Surgery,
and World Federation of Vascular Societies [4] . . . . . . . . . 270
12.2 Suggested Objective Performance Goals (OPG) for
Evaluating New Catheter-Based Treatments in Critical
Limb Ischemia (CLI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
12.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
12.3.1 Randomized Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
12.3.2 Systematic Reviews/Meta-Analyses . . . . . . . . . . . . . . . . . 275
12.3.3 Registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
12.3.4 Clinical Trials with Specic Questions . . . . . . . . . . . . . . . 287
12.4 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . 290
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
13 Acute Limb Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
13.1 Clinical Categories and Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . 295
13.2 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
13.2.1 European Society of Cardiology (ESC) in
Collaboration with the European Society for
Vascular Surgery (ESVS) [1] . . . . . . . . . . . . . . . . . . . . . . . 296
13.2.2 American College of Cardiology (ACC) /
American Heart Association /AHA) [2] . . . . . . . . . . . . . . 296
13.2.3 European Society for Vascular Surgery (ESVS) [3] . . . . . 298
13.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
13.3.1 Systematic Reviews/Meta-Analyses . . . . . . . . . . . . . . . . . 300
13.3.2 Studies/Registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
13.3.3 Special Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
13.4 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . 310
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310
14 Popliteal Artery Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
14.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
14.1.1 Society for Vascular Surgery . . . . . . . . . . . . . . . . . . . . . . . 313
14.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
14.2.1 Meta-Analyses and Systematic Reviews . . . . . . . . . . . . . . 314
14.2.2 Registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
14.2.3 Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
14.2.4 Special Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
14.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . 324
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
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15 Popliteal Entrapment Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
15.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
15.2 Denitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
15.3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
15.3.1 Systematic Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328
15.3.2 Case Series . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
15.3.3 Functional PAES and Chronic Exertional
Compartment Syndrome (CECS) . . . . . . . . . . . . . . . . . . . 330
15.4 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . 334
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
16 Vascular Access for Haemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
16.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
16.1.1 Clinical Practice Guidelines of the European
Society for Vascular Surgery (ESVS) . . . . . . . . . . . . . . . . 337
16.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
16.2.1 Meta-Analyses and Systematic Reviews . . . . . . . . . . . . . . 341
16.2.2 Clinical Trials and Registries . . . . . . . . . . . . . . . . . . . . . . . 346
16.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . 355
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
17 The Diabetic Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
17.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
17.1.1 Society for Vascular Surgery . . . . . . . . . . . . . . . . . . . . . . . 359
17.1.2 International Working Group on the Diabetic Foot
(IWGDF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
17.1.3 International Working Group on the Diabetic Foot
(IWGDF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
17.1.4 International Working Group on the Diabetic Foot
(IWGDF 2019 Update) [4, 5]. . . . . . . . . . . . . . . . . . . . . . . 365
17.1.5 Guidelines on the Classication of Foot Ulcers in
People with Diabetes (IWGDF 2023 Update) [6] . . . . . . . 368
17.1.6 WIfI Classication System . . . . . . . . . . . . . . . . . . . . . . . . 369
17.2 Systematic Reviews and Studies . . . . . . . . . . . . . . . . . . . . . . . . . . 371
17.2.1 Classication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
17.2.2 Epidemiology and Prognosis . . . . . . . . . . . . . . . . . . . . . . . 371
17.2.3 Topical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
17.2.4 Free Tissue Transfer in Diabetic Foot Ulcers . . . . . . . . . . 375
17.2.5 Effectiveness of Revascularisation for the
Ulcerated Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375
17.2.6 Amputation Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
17.2.7 Ofoading Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . 376
17.2.8 Diabetic Peripheral Neuropathy . . . . . . . . . . . . . . . . . . . . . 377
17.2.9 Achilles Tendon Lengthening and Fascia Release . . . . . . . 379
17.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . 380
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
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18 Chronic Venous Disease and Varicose Veins . . . . . . . . . . . . . . . . . . . . . 383
18.1 Guideline Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
18.1.1 Clinical Practice Guidelines of the European
Society for Vascular Surgery (ESVS) on the
Management of Chronic Venous Disease of the
Lower Limbs [1] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383
18.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
18.2.1 Meta-Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
18.2.2 Randomized Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
18.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . 401
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402
19 Deep Vein Thrombosis of the Lower Limb and
Post-Thrombotic Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
19.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
19.1.1 European Society of Cardiology . . . . . . . . . . . . . . . . . . . . 405
19.1.2 The Postthrombotic Syndrome—A Scientic
Statement from the American Heart Association [2] . . . . . 408
19.1.3 CHEST Guideline for Antithrombotic
Management of Venous Thromboembolism [3] . . . . . . . . 410
19.1.4 Clinical Practice Guidelines of the European
Society for Vascular Surgery (ESVS) on the
Management of Chronic Venous Diseases of the
Lower Limbs [4]. They Recommend . . . . . . . . . . . . . . . . . 411
19.1.5 European Society for Vascular Surgery (ESVS)
Clinical Practice Guidelines on the Management
of Venous Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412
19.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
19.2.1 Deep Vein Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
19.2.2 Postthrombotic Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . 419
19.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . 423
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
20 Vena Cava Filter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
20.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
20.1.1 Society of Interventional Radiology Clinical Practice
Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
20.1.2 International Clinical Practice Guidelines for the
Treatment and Prophylaxis of Venous
Thromboembolism in Patients with Cancer . . . . . . . . . . . . 430
20.1.3 NICE (National Institute for Health and
Care Excellence)
20.1.4 European Society of Cardiology (ESC)
Guidelines for the Diagnosis and Management
of Acute Pulmonary Embolism [4] . . . . . . . . . . . . . . . . . . 431
20.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
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20.2.1 Meta-Analyses and Systematic Reviews . . . . . . . . . . . . . . 432
20.2.2 Randomized Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432
20.2.3 Studies and Registries . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
20.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . 439
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439
21 Venous Leg Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
21.1 Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
21.1.1 Society for Vascular Surgery and the American
Venous Forum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
21.1.2 European Society for Vascular Surgery . . . . . . . . . . . . . . . 444
21.2 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
21.2.1 Randomized Studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
21.2.2 Meta-Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
21.3 Conclusions for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . 451
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
Chapter 1
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Extracranial Carotid Stenosis
1.1 Guidelines
1.1.1 Guideline oftheEuropean Society forVascular Surgery
(ESVS) [1]
1.1.1.1 Unchanged Recommendations
• No. 19: For average surgical risk patients with an asymptomatic 60–99% steno-
sis, carotid endarterectomy should be considered in the presence of one or more
imaging or clinical characteristics that may be associated with an increased risk
of late stroke, provided 30day stroke/death rates are ≤3% and patient life expectancy exceeds 5 years. (Class IIa/Level B).
• No. 20: For average surgical risk patients with an asymptomatic 60–99% steno-
sis in the presence of one or more imaging or clinical characteristics that may be
associated with an increased risk of late stroke, carotid stenting may be an alternative to carotid endarterectomy, provided 30 day stroke/death rates are ≤3%
and patient life expectancy exceeds 5 years. (Class IIb/Level B).
• No. 40: For patients reporting carotid territory symptoms within the preceding 6
months and who have a 70–99% carotid stenosis, carotid endarterectomy is
recommended provided the 30 day risk of death/stroke rate is <6%. (Class
I/Level A).
• No.41: For patients reporting carotid territory symptoms within the preceding 6
months and who have a 50–69% carotid stenosis, carotid endarterectomy should
be considered provided the documented 30day risk of death/stroke rate is <6%.
(Class IIa/Level A).
• No. 42: For patients aged ≥70years who have experienced a carotid territory
transient ischaemic attack or ischaemic stroke within the preceding 6months in
association with a 50–99% carotid stenosis, it is recommended that they should
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1© The Author(s), under exclusive license to Springer Nature
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1 Extracranial Carotid Stenosis
be treated by carotid endarterectomy, rather than carotid stenting. (Class I/
Level A).
• No. 43: For patients aged <70years who have experienced a carotid territory
transient ischaemic attack or ischaemic stroke within the preceding 6months in
association with a 50–99% carotid stenosis, carotid artery stenting may be considered an alternative to endarterectomy, provided the documented 30day risk of
death/stroke is <6%. (Class IIb/Level A).
• N0. 44: For symptomatic patients with a 50–99% stenosis in whom a carotid
intervention is considered appropriate, it is recommended that this be performed
as soon as possible, preferably within 14 days of symptom onset. (Class I/
Level A).
• No. 45: For patients who are undergoing revascularisation within the rst 14days
after onset of symptoms, it is recommended that they should undergo carotid
endarterectomy, rather than carotid stenting. (Class I/Level A).
• No. 46: For patients with 50–99% stenoses who experience a disabling stroke
(modied Rankin score≥3), or whose area of infarction exceeds one third of the
ipsilateral middle cerebral artery territory, or who have altered consciousness/
drowsiness, it is recommended to defer carotid interventions to minimise the
risks of post-operative parenchymal haemorrhage. (Class I/Level C).
• No. 47: For patients with 50–99% stenoses who present with stroke in evolution
or crescendo transient ischaemic attacks, urgent carotid endarterectomy should
be considered, preferably within 24h. (Class IIa/Level C).
1.1.1.2 New Class IRecommendations Are Among Others
• No. 23: For symptomatic carotid stenosis patients who are not being considered
for carotid endarterectomy or stenting following a transient ischaemic attack or
minor ischaemic stroke, short term aspirin plus clopidogrel for 21days followed
by clopidogrel monotherapy, or long term aspirin plus dipyridamole modied
release is recommended.
• No. 24: For recently symptomatic carotid stenosis patients who are not being
considered for carotid endarterectomy or stenting who are intolerant of, or allergic to, aspirin and clopidogrel, dipyridamole monotherapy or ticagrelor monotherapy is recommended.
• No. 25: For recently symptomatic carotid stenosis patients in whom carotid end-
arterectomy is being considered, it is recommended that neurologists/stroke physicians and vascular surgeons develop local protocols to specify preferred
antiplatelet regimens (combination therapy vs. monotherapy), so as not to delay
urgent carotid surgery.
• No. 58: For patients presenting with recent carotid territory symptoms and evi-
dence of free oating thrombus within the carotid artery, therapeutic anticoagulation is recommended.
• No. 63: For patients with a transient ischaemic attack or minor ischaemic stroke
in the presence of newly diagnosed or known atrial brillation and an ipsilateral
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50–99% carotid stenosis, comprehensive neurovascular work up with
multidisciplinary team review is recommended to determine whether urgent
carotid revascularisation or anticoagulation alone is indicated.
• No. 64: For patients who have been started on anticoagulation (on the basis that
cardiac embolism was considered the most likely cause of their transient ischaemic attack or stroke) but who then report recurrent event(s) in the territory
ipsilateral to a 50–99% carotid stenosis whilst on therapeutic levels of anticoagulation, carotid endarterectomy or carotid artery stenting is recommended.
• No. 66: For patients undergoing carotid endarterectomy, it is recommended that
the operation be performed by trained vascular surgeons, rather than by surgeons
from other specialties.
• No. 91: For patients experiencing a peri-operative stroke, it is recommended to
differentiate between an intra-operative and a post-operative stroke.
• No. 92: For patients who develop an ipsilateral neurological decit after ow is
restored following carotid clamp release when carotid endarterectomy is performed under locoregional anaesthesia, immediate re-exploration of the carotid
artery is recommended.
• No. 93: For patients who develop an ipsilateral or contralateral stroke at any time
period following carotid endarterectomy or carotid artery stenting, urgent diagnostic neurovascular imaging of both carotid arteries and the brain is
recommended.
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1.1.1.3 New Class IIa Recommendations
• No. 49: For patients with acute ischaemic stroke due to a symptomatic 50–99%
carotid stenosis who have received intravenous thrombolysis, delaying carotid
endarterectomy or carotid stenting by 6 days following completion of thrombolysis should be considered.
• No. 54: For recently symptomatic patients with 50–99% stenoses and contralat-
eral carotid occlusion or previous cervical radiation therapy, the choice of carotid
endarterectomy or carotid artery stenting should be considered on an individual basis.
• No. 62: For patients with conrmed ocular ischaemia syndrome and a 50–99%
ipsilateral carotid stenosis, carotid endarterectomy or carotid stenting should be
considered to prevent further ischaemia induced retinal neovascularisation.
• No. 77: For patients undergoing carotid endarterectomy, intra-operative comple-
tion imaging with angiography, duplex ultrasound or angioscopy should be considered in order to reduce the risk of peri-operative stroke.
• No. 82: For patients selected to undergo carotid artery stenting, transradial or
transcarotid artery revascularisation should be considered as an alternative to
transfemoral carotid artery stenting, especially where transfemoral access may
confer a higher risk of complications.
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1 Extracranial Carotid Stenosis
• No. 83: For patients undergoing carotid artery stenting, decisions regarding stent
design (open cell, closed cell) should be considered at the discretion of the
operator.
• No. 85: For patients undergoing carotid artery stenting, when pre-dilatation is
planned, balloon diameters <5mm should be considered in order to reduce the
risk of peri-procedural stroke or transient ischaemic attack.
• No. 88: For patients undergoing carotid artery stenting, decisions regarding
choice of cerebral protection (lter, proximal ow reversal) should be considered
at the discretion of the operator.
1.1.1.4 New Class IIb Recommendations
• No. 51: For a patient with acute ischaemic stroke undergoing intracranial
mechanical thrombectomy with a tandem 50–99% carotid stenosis and a small
area of ipsilateral infarction, synchronous carotid stenting may be considered in
the presence of poor antegrade internal carotid artery ow or poor collateralisation via the circle of Willis after mechanical thrombectomy.
• No. 57: For patients with carotid near occlusion and distal vessel collapse with
recurrent carotid territory symptoms (despite best medical therapy), carotid endarterectomy or carotid artery stenting may be considered only after multidisciplinary team review.
• No. 59: For patients presenting with recent carotid territory symptoms and free
oating thrombus who develop recurrent symptoms whilst receiving anticoagulation therapy, surgical or endovascular removal of the thrombus may be
considered.
• No. 61: For symptomatic patients with a carotid web [=shelf-like protrusions of
intimal brous tissue arising at the posterior wall of the carotid bulb/focal intimal
variant of bromuscular dysplasia] in whom no other cause for stroke can be
identied after detailed neurovascular work up, carotid endarterectomy or carotid
artery stenting may be considered to prevent recurrent stroke.
• No. 90: For patients undergoing transfemoral carotid stenting, at least twelve
carotid stent procedures per year (per operator) may be considered an appropriate operator volume threshold to maintain optimal outcomes.
• No. 101: In selected high risk for surgery patients or emergency patients with
suspected prosthetic patch infection, insertion of a covered stent may be considered, as part of the three stage EndoVAC technique.
1.1.1.5 Class III: Non-recommendations
• No. 60: For patients presenting with recent carotid territory symptoms and evi-
dence of free oating thrombus, intravenous thrombolysis is not recommended.
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