SVS issues new guidelines covering carotid disease and popliteal aneurysms

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Ali AbuRahma

The Society for Vascular Surgery (SVS) has released updated clinical practice guidelines for the management of extracranial cerebrovascular disease and popliteal artery aneurysms in a special supplement, “The Care of Patients with Extracranial Cerebrovascular Disease and Popliteal Artery Aneurysms: The Society for Vascular Surgery Clinical Practice Guidelines,” published in the January issue of the Journal of Vascular Surgery (JVS).

The supplement also includes a systematic review supporting the SVS guidelines on managing carotid artery disease, plus a systematic review and meta-analysis of treatment and the natural history of popliteal artery aneurysms.

Ali AbuRahma, MD, SVS president, and Alik Farber, MD, led the respective writing groups in developing the clinical practice documents which offer recommendations to inform the diagnosis, evaluation, treatment options and follow-up of affected patients. “The expert writing groups included world-renowned vascular surgeons who analyzed the most recent evidence and performed systematic reviews to bring forth these clinical practice guidelines (CPGs),” said Ruth Bush, MD, chair, and Marc Schermerhorn, MD, vice chair, of the SVS Document Oversight Committee (DOC).

The carotid guideline includes an update of the 2011 guideline and provides graded evidence-based recommendations that address the following areas of patient care:

  • The role of surgical therapy over medical therapy alone for asymptomatic low-risk patients
  • The role of carotid endarterectomy vs. stenting for symptomatic low-risk patients
  • The optimal timing of interventions after acute stroke
  • Screening for carotid artery stenosis in asymptomatic patients
  • The sequence of carotid and coronary interventions for patients undergoing intervention for diseases in both vascular beds

The guideline “is concise and practical and will be of great use to clinicians for real-time decision-making,” said Bush and Schermerhorn.  Because of the volume of the literature, information, and additional topics with more critical details, the writing group also created a separate implementation document as a supporting companion resource.

The JVS supplement also includes an editorial, “Emerging evidence suggests that patients with high-grade asymptomatic carotid stenosis should be revascularized.”

The clinical practice guidelines on popliteal artery aneurysms present evidence and consensus-based recommendations regarding the evaluation of patients with popliteal aneurysms and size thresholds for repair. They provide recommendations for open surgical repair vs endovascular stent-graft repair for specific patient populations according to life expectancy, plus recommendations for urgent treatment of thrombosed popliteal aneurysms according to the Rutherford acute ischemia stage at presentation.

“This [clinical practice guidelines] is a unique contribution that has amassed the available data and current treatments for this disease process,” said Bush and Schermerhorn.

Since publication of the SVS’ 2011 update of the clinical practice guidelines for carotid artery disease, several pivotal studies comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS) have been published. In addition, the literature has demonstrated a confirmation of the need for optimization of medical therapy. Therefore, the updated SVS guidelines provides graded recommendations that address five very relevant questions: the role of surgical therapy over medical therapy alone in asymptomatic low risk patients, the role of CEA vs. CAS in symptomatic low risk patients, the optimal timing of interventions after acute stroke, screening for carotid artery stenosis in asymptomatic patients, and the sequence of carotid and coronary interventions in patients undergoing intervention for diseases in both vascular territories.

According to AbuRahma, writing group chair, “These guideline recommendations address the latest technology in the management of carotid disease, such as transcarotid artery stenting with flow reversal and how its outcomes compare to transfemoral stenting and the gold-standard, carotid endarterectomy.”

The 2021 SVS guidelines propose that CEA remains the preferred intervention over CAS in low-risk patients with symptomatic and asymptomatic disease.

Evidence suggests that once the perioperative period has elapsed, late ipsilateral stroke (at five and nine years) is no different between CEA and CAS, but 30-day death/stroke is significantly higher after transfemoral CAS vs. CEA, especially in the first seven to 14 days after symptom onset.

This is why the SVS and European Society for Vascular Surgery (ESVS) guidelines retain CEA as the first-line option.

Aneurysms of the popliteal artery are the most common aneurysms outside of the brain and abdominal aorta. Popliteal artery aneurysms can cause limb loss and therefore early diagnosis, careful follow up, and timely treatment of this condition are paramount.

These SVS practice guidelines offer recommendations to inform the diagnosis, evaluation, treatment options, and follow up of patients with popliteal artery aneurysms. Evidence-based recommendations regarding the evaluation of patients with known popliteal aneurysms, as well as size thresholds for repair, are included. Specific circumstances under which aneurysms may be considered for repair at a smaller size are also provided. Recommendations for open versus endovascular repair are given for specific patient populations based on life expectancy, as are recommendations for urgent treatment of thrombosed popliteal aneurysms based on the Rutherford acute ischemia stage at presentation.

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