Arterial Atherosclerosis: Vascular Surgery Interventions

Jonathon M. Firnhaber; C. S. Powell

JONATHON M. FIRNHABER, MD, MAEd, MBA, AND C. S. POWELL, MD

Am Fam Physician. 2022;105(1):65-72

This clinical content conforms to AAFP criteria for CME.

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.

Clinical recommendation	Evidence rating	Comments
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 artery stenosis should be referred for consideration of carotid revascularization.¹³	A	Moderate- or high-quality evidence from three nonblinded trials demonstrating significant reduction in five-year risk of stroke or operative death with carotid revascularization Carotid artery revascularization is most beneficial for patients with ≥70% stenosis
Patients with signs of critical and acute limb ischemia should be referred for revascularization to preserve limb integrity with acute ischemia being an emergent indication.³	C	American Heart Association/American College of Cardiology clinical practice guideline

Recommendation	Sponsoring organization
Do not screen for carotid artery stenosis in adult patients who are asymptomatic.	American Academy of Family Physicians
Do not screen for renal artery stenosis in patients without resistant hypertension and with normal renal function, even if known atherosclerosis is present.	Society for Vascular Medicine

Abdominal Aortic Disease

AAA affects 1% of women and nearly 10% of men between 65 and 80 years of age.⁴ AAA is rare in people younger than 50 years.⁴ The prevalence of AAA in European countries has declined, likely due to decreased smoking. Because recommended screening is rarely performed, the current prevalence of AAA in the United States is uncertain.²

Screening for AAA with ultrasonography has a sensitivity of 94% or greater and a specificity of 98% or greater.² The U.S. Preventive Services Task Force (USPSTF) recommends one-time screening for AAA with ultrasonography in men 65 to 75 years of age who have smoked 100 or more cigarettes in their lifetime.² One-time screening for AAA with ultrasonography may be considered in men 65 to 75 years of age who have never smoked, but screening is not recommended in women who have never smoked or do not have a family history of AAA.The evidence is insufficient to recommend for or against screening women who have ever smoked or have a family history of AAA. Consider not screening patients with a lower life expectancy or those who are not good candidates for surgical intervention. The USPSTF recommends using sex and not gender identity for screening decisions.² The American Academy of Family Physicians (AAFP) endorses the USPSTF recommendations.⁵

For men 65 to 79 years of age, screening for AAA prevents aneurysm rupture (number needed to screen = 294) and mortality from AAA (number needed to screen = 917). These benefits have not been demonstrated in women.⁶

Rupture of AAA is a surgical emergency with high mortality. For patients who survive long enough to reach a hospital, 80% die before discharge.⁴ The annual risk of rupture is 1% for smaller aneurysms but increases to 11% when the diameter reaches 5 cm (2 in).⁷ Elective repair of an AAA less than 5.5 cm (2.2 in) has not been shown to decrease mortality.⁸

Surgical repair is standard practice for patients with an AAA of 5.5 cm (2.2 in) or larger in diameter or any AAA larger than 4.0 cm (1.6 in) that has increased by 1.0 cm (0.4 in) or more over one year.² Because most trials were conducted in men, the threshold for surgical intervention in women is not well established.²

Open surgical repair has been the traditional approach when a repair is indicated; however, endovascular aneurysm repair (EVAR) has become more common than open repair over the past two decades.⁷ During the EVAR procedure, bilateral femoral artery catheters are used to place an endograft across the aneurysmal portion to act as an artificial lumen and protect the aneurysm from vascular pressure (Figure 1 and Figure 2).

In the United States, EVAR is currently used for 80% of intact AAA repairs and 52% of ruptured AAA repairs.⁷ EVAR has about one-third of the 30-day mortality rate vs. open repair.⁹ EVAR has lower mortality rates compared with open repair until approximately four years, when survival after both procedures is equivalent.¹⁰ When outcomes are separated by age, overall survival is higher with EVAR for patients younger than 70 years, and the two procedures are equivalent in people 70 years and older.¹¹ Repeat interventions to address complications such as a leak or device migration are more common with EVAR.⁹

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