Arterial Atherosclerosis: Vascular Surgery Interventions
Am Fam Physician. 2022 Jan ;105(1):65-72.
Author disclosure: No relevant financial relationships.
Atherosclerotic vascular disease is a leading cause of death worldwide. Atherosclerotic stenosis of the internal carotid or intracranial arteries causes up to 15% of strokes. Peripheral artery disease affects up to one in five people in the United States who are 60 years and older and nearly one-half of those who are 85 years and older. Renal artery stenosis may affect up to 5% of people with isolated hypertension and up to 40% of people with other atherosclerotic diseases. All patients with atherosclerotic vascular disease should receive a comprehensive program of guideline-directed medical therapy, including structured physical activity and lifestyle modification, an antiplatelet agent, a statin, antihypertensive therapy, and smoking cessation counseling. The U.S. Preventive Services Task Force recommends one-time screening for abdominal aortic aneurysm with ultrasonography in men 65 to 75 years of age who have smoked at least 100 cigarettes, but screening is not recommended for carotid, peripheral, and renal disease. Surgical revascularization decreases adverse outcomes and mortality in selected patients with advanced vascular disease. Endovascular repair has become more common for patients younger than 70 years because of decreased short-term mortality. Carotid revascularization with carotid endarterectomy or carotid artery stenting is recommended for symptomatic patients with greater than 50% internal carotid artery stenosis. Carotid artery stenting is preferred in patients with multiple comorbidities, tracheostomy, or previous neck radiation or dissection. In patients older than 70 years, carotid endarterectomy is associated with a lower risk of periprocedural stroke or death than carotid artery stenting. Revascularization is a reasonable treatment option for patients with lifestyle-limiting claudication and an inadequate response to guideline-directed therapies. Revascularization is indicated for patients with critical limb ischemia and is emergently indicated for acute limb ischemia. Renal artery revascularization offers no proven clinical benefit when added to optimal medical therapy.
Atherosclerotic vascular disease is a leading cause of death worldwide. However, over the past few decades, the incidence of vascular disease and resultant mortality have declined in higher-income countries. The most significant risk factors for atherosclerotic vascular disease are hypertension, diabetes mellitus, hyperlipidemia, and smoking.1 For abdominal aortic aneurysm (AAA), smoking is the strongest predictor of prevalence, growth, and rupture, with a clear dose-response relationship.2 A family history of vascular disease increases risk, and the risk of developing AAA is doubled if a first-degree relative has an AAA. Standard medical treatment of atherosclerotic vascular disease, or guideline-directed medical therapy, includes structured physical activity and lifestyle modification, an antiplatelet agent, a statin, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and smoking cessation counseling with medical and psychological support (Table 1).3 Surgical revascularization decreases adverse outcomes and mortality in some patients with advanced vascular disease.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
|Clinical recommendation||Evidence rating||Comments|
USPSTF grade B recommendation based on four large RCTs showing a 35% reduction in AAA-related mortality
Men 65 to 75 years of age who have never smoked can be offered one-time screening for AAA with ultrasonography; consider not screening patients with a reduced life expectancy or those who are not good candidates for surgical intervention.2
USPSTF grade C recommendation based on four large RCTs, with only one reporting outcomes by smoking status in the screened group
USPSTF grade D recommendation based on one trial demonstrating no benefit from screening in women who have never smoked and do not have a family history of AAA; evidence of benefit in women who have ever smoked or who have a family history of AAA is too limited to make a recommendation
AAA repair for aneurysms ≥ 5.5 cm (2.2 in) decreases mortality, but there is no evidence of benefit for AAA repair of aneurysms < 5.5 cm; most available data are from RCTs conducted in men
USPSTF D recommendation based on multiple trials demonstrating the harms of treatment of asymptomatic carotid stenosis outweigh the benefits
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