Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)

Weighted mean prevalence of intermittent claudication (symptomatic PAD) in large population-based studies.

Approximate range of odds ratios for risk factors for symptomatic peripheral arterial disease. Treatment of risk factors and the effect on the outcomes of PAD are described in Chapter B.

Fate of the claudicant over 5 years (adapted from ACC/AHA guidelines⁵). PAD – peripheral arterial disease; CLI – critical limb ischemia; CV – cardiovascular; MI – myocardial infarction. Adapted with permission from Hirsch AT et al. J Am Coll Cardiol 2006;47:1239–1312.

Approximate magnitude of the effect of risk factors on the development of critical limb ischemia in patients with peripheral arterial disease. CLI – critical limb ischemia.

Fate of the patients presenting with chronic critical leg ischemia. CLI – critical limb ischemia.

Fate of the patient with below-knee amputation.

Typical overlap in vascular disease affecting different territories.²⁶ Based on REACH data. PAD – peripheral arterial disease.

Survival of patients with peripheral arterial disease. IC – intermittent claudication; CLI – critical limb ischemia.

Adjusted odds of a cardiovascular event by ankle-brachial index.²⁹ Data from the placebo arm of the Appropriate Blood Pressure Control in Diabetes study²⁹ show an inverse correlation between ABI and odds of a major cardiovascular event. ABI – ankle-brachial index; CV – cardiovascular; MI – myocardial infarction. Reproduced with permission from Mehler PS et al. Circulation 2003;107:753–756.

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

All cause mortality as a function of baseline ABI. Excess mortality was observed at ABI values <1.00 and >1.40.³⁴ ABI – ankle-brachial index. Reproduced with permission from Resnick HE et al. Circulation 2004;109(6):733–739.

Percent abstinence for bupropion SR, nicotine replacement, or both, versus placebo.³⁸ Reproduced with permission from Jorenby DE et al. N Engl J Med 1999;340(9):685–691.

Measurement of the ABI. ABI – ankle-brachial index.

Algorithm for diagnosis of peripheral arterial disease. TBI – toe brachial index; VWF – velocity wave form; PVR – pulse volume recording. Reproduced with permission from Hiatt WR. N Engl J Med 2001;344:1608–1621.

Overall treatment strategy for peripheral arterial disease. BP – blood pressure; HbA1c – hemoglobin A1c; LDL – low density lipoprotein; MRA – magnetic resonance angiography; CTA – computed tomographic angiography. Reproduced with permission from Hiatt WR. N Engl J Med 2001;344:1608–1621.

Approximate frequencies of various ulcer etiologies.

Distribution of diabetic foot ulcers.¹²⁵ Copyright © 1999 American Diabetes Association from Diabetes Care, Vol. 22, 1999; 157–162. Modified with permission from The American Diabetes Association.

Relative prevalence of different diabetic ulcer etiologies.¹²⁷

Algorithm for treatment of the patient with critical limb ischemia. Contraindications are: patients not fit for revascularization; revascularization not technically possible; benefit cannot be expected (i.e. widespread ulceration-gangrene – see also section D7.5). CLI – critical limb ischemia; MRA – magnetic resonance angiography; CTA – computed tomographic angiography.

Etiology of acute limb ischemia. (Summarizes Berridge et al. 2002 and Campbell et al. 1998).

Time to presentation in relation to etiology.

Categories of acute limb ischemia on presentation. *Some of these patients are moribund. In some series this group is up to 15%.

Algorithm for management of acute limb ischemia. Category I – Viable Category IIA – Marginally Threatened Category IIB – Immediately Threatened; α Confirming either absent or severely diminished ankle pressure/signals; *In some centers imaging would be performed.

TASC classification of aorto-iliac lesions. CIA – common iliac artery; EIA – external iliac artery; CFA – common femoral artery; AAA – abdominal aortic aneurysm.

TASC classification of femoral popliteal lesions. CFA – common femoral artery; SFA – superficial femoral artery.

Bilateral bypass from infra renal abdominal aorta to both femoral arteries.

Axillo (bi) femoral bypass.

Cross-over femoral bypass.

Above-knee femoral popliteal bypass.

Femoral tibial bypass.

Results summary: Average results for surgical treatment. Ao-bi-fem – Aortobifemoral bypass; Fem-pop – femoropopliteal; BK – below knee; Ax-bi-fem – Axillobifemoral; PTA – Percutaneous Transluminal Angioplasty; Ax-uni-fem – Axillounifemoral bypass; pros – prosthetic.