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.

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Men 65 to 75 years of age who have smoked more than 100 cigarettes in their lifetime should be offered a one-time screening for AAA with ultrasonography.2

B

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

B

USPSTF grade C recommendation based on four large RCTs, with only one reporting outcomes by smoking status in the screened group

AAA screening should not be offered to women who have never smoked and do not have a family history of AAA.2

B

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

Patients with an AAA ≥ 5.5 cm (2.2 in) in diameter should be referred for surgical repair.2,8

B

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

Do not screen adults who are asymptomatic for carotid artery stenosis.15

B

USPSTF D recommendation based on multiple trials demonstrating the harms of treatment of asymptomatic carotid stenosis outweigh the benefits

Symptomatic patients with > 50% internal carotid

The Authors

show all author info

JONATHON M. FIRNHABER, MD, MAEd, MBA, FAAFP, is a professor and residency program director in the Department of Family Medicine at the Brody School of Medicine at East Carolina University, Greenville, N.C....

C. S. POWELL, MD, is a professor in the Department of Cardiovascular Sciences at the Brody School of Medicine at East Carolina University and Chief of the Division of Vascular Surgery at the East Carolina Heart Institute, Greenville.

Address correspondence to Jonathon M. Firnhaber, MD, MAEd, MBA, East Carolina University, Family Medicine Center, 101 Heart Dr., Greenville, NC 27834 (email: firnhaberj@ecu.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

References

show all references

1. Herrington W, Lacey B, Sherliker P, et al. Epidemiology of atherosclerosis and the potential to reduce the global burden of atherothrombotic disease. Circ Res. 2016;118(4):535–546....

2. Owens DK, Davidson KW, Krist AH, et al.; US Preventive Services Task Force. Screening for abdominal aortic aneurysm: US Preventive Services Task Force recommendation statement. JAMA. 2019;322(22):2211–2218.

3. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2017;135(12):e791–e792]. Circulation. 2017;135(12):e726–e779.

4. Robertson L, Nandhra S. Laparoscopic surgery for elective abdominal aortic aneurysm repair. Cochrane Database Syst Rev. 2017;(5):CD012302.

5. American Academy of Family Physicians. Clinical preventive service recommendation. Abdominal aortic aneurysm. Accessed August 10, 2021. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/aaa.html

6. Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007;(2):CD002945.

7. Guirguis-Blake JM, Beil TL, Senger CA, et al. Primary care screening for abdominal aortic aneurysm: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2019;322(22):2219–2238.

8. Ulug P, Powell JT, Martinez MA, et al. Surgery for small asymptomatic abdominal aortic aneurysms. Cochrane Database Syst Rev. 2020;(7):CD001835.

9. Paravastu SCV, Jayarajasingam R, Cottam R, et al. Endovascular repair of abdominal aortic aneurysm. Cochrane Database Syst Rev. 2014;(1):CD004178.

10. Schermerhorn ML, Buck DB, O'Malley AJ, et al. Long-term outcomes of abdominal aortic aneurysm in the Medicare population. N Engl J Med. 2015;373(4):328–338.

11. Lederle FA, Freischlag JA, Kyriakides TC, et al.; OVER Veterans Affairs Cooperative Study Group. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. N Engl J Med. 2012;367(21):1988–1997.

12. Kim AS, Johnston SC. Temporal and geographic trends in the global stroke epidemic. Stroke. 2013;44(6 suppl 1):S123–S125.

13. Rerkasem A, Orrapin S, Howard DP, et al. Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database Syst Rev. 2020;(9):CD001081.

14. Bonati LH, Dobson J, Featherstone RL, et al.; International Carotid Stenting Study investigators. Long-term outcomes after stenting versus endarterectomy for treatment of symptomatic carotid stenosis: the International Carotid Stenting Study (ICSS) randomised trial. Lancet. 2015;385(9967):529–538.

15. LeFevre ML. U.S. Preventive Services Task Force. Screening for asymptomatic carotid artery stenosis: U.S. Preventive Services Task Force recommendation statement [published correction appears in Ann Intern Med. 2015;162(4):323]. Ann Intern Med. 2014;161(5):356–362.

16. American Academy of Family Physicians. Clinical preventive service recommendation. Carotid artery stenosis. Accessed August 10, 2021. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/carotid-artery-stenosis.html

17. Moresoli P, Habib B, Reynier P, et al. Carotid stenting versus endarterectomy for asymptomatic carotid artery stenosis: a systematic review and meta-analysis. Stroke. 2017;48(8):2150–2157.

18. Lal BK, Roubin GS, Rosenfield K, et al. Quality assurance for carotid stenting in the CREST-2 registry. J Am Coll Cardiol. 2019;74(25):3071–3079.

19. Cohen ME, Liu Y, Ko CY, et al. An examination of American College of Surgeons NSQIP Surgical Risk Calculator Accuracy. J Am Coll Surg. 2017;224(5):787–795.e1.

20. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association [published correction appears in Stroke. 2021 52(7):e483–e484]. Stroke. 2021;52(7):e364–e467.

21. Müller MD, Lyrer P, Brown MM, et al. Carotid artery stenting versus endarterectomy for treatment of carotid artery stenosis. Cochrane Database Syst Rev. 2020;(2):CD000515.

22. Rantner B, Goebel G, Bonati LH, et al.; Carotid Stenting Trialists' Collaboration. The risk of carotid artery stenting compared with carotid endarterectomy is greatest in patients treated within 7 days of symptoms. J Vasc Surg. 2013;57(3):619–626.e2, discussion 625–626.

23. Bonati LH, Fraedrich G; Carotid Stenting Trialists' Collaboration. Age modifies the relative risk of stenting versus endarterectomy for symptomatic carotid stenosis – a pooled analysis of EVA-3S, SPACE and ICSS. Eur J Vasc Endovasc Surg. 2011;41(2):153–158.

24. Reddy RP, Karnati T, Massa RE, et al. Association between perioperative stroke and 30-day mortality in carotid endarterectomy: a meta-analysis. Clin Neurol Neurosurg. 2019;181:44–51.

25. Kashyap VS, Schneider PA, Foteh M, et al.; ROADSTER 2 Investigators. Early outcomes in the ROADSTER 2 study of transcarotid artery revascularization in patients with significant carotid artery disease. Stroke. 2020;51(9):2620–2629.

26. Benjamin EJ, Virani SS, Callaway CW, et al.; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2018 update: a report from the American Heart Association [published correction appears in Circulation. 2018; 137(12): e493]. Circulation. 2018;137(12):e67–e492.

27. Fowkes FGR, Murray GD, Butcher I, et al.; Ankle Brachial Index Collaboration. Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA. 2008;300(2):197–208.

28. Foley TR, Armstrong EJ, Waldo SW. Contemporary evaluation and management of lower extremity peripheral artery disease. Heart. 2016;102(18):1436–1441.

29. Curry SJ, Krist AH, Owens DK, et al.; US Preventive Services Task Force. Screening for peripheral artery disease and cardiovascular disease risk assessment with the ankle-brachial index: US Preventive Services Task Force recommendation statement. JAMA. 2018;320(2):177–183.

30. American Academy of Family Physicians. Clinical preventive service recommendation. Peripheral arterial disease. Accessed August 10, 2021. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/pad.html

31. Sigvant B, Lundin F, Wahlberg E. The risk of disease progression in peripheral arterial disease is higher than expected: a meta-analysis of mortality and disease progression in peripheral arterial disease. Eur J Vasc Endovasc Surg. 2016;51(3):395–403.

32. Antoniou GA, Georgiadis GS, Antoniou SA, et al. Bypass surgery for chronic lower limb ischaemia. Cochrane Database Syst Rev. 2017;(4):CD002000.

33. Gupta R, Assiri S, Cooper CJ. Renal artery stenosis: new findings from the CORAL Trial. Curr Cardiol Rep. 2017;19(9):75.

34. Cooper CJ, Murphy TP, Cutlip DE, et al.; CORAL Investigators. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2014;370(1):13–22.

35. Lee ES, Dawson DL, Pevec WC. Vascular surgery: an update. Am Fam Physician. 2007;75(1):85–90. Accessed July 23, 2021. https://www.aafp.org/afp/2007/0101/p85.html

 

 

Copyright © 2022 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


May 2022

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article