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There is currently a degree of divergence among the main clinical practice guidelines on the management of risk factors for peripheral arterial disease (PAD). This project aims to gain understanding of the management of PAD risk factors in clinical practice and to reach a multidisciplinary consensus on the strategies to be followed in order to optimize its identification, treatment, and follow-up.A multidisciplinary consensus following the Delphi methodology.Professionals (n = 130) with extensive experience in PAD participated in this consultation. The results suggest that in order to optimize the control of risk factors, efforts should be aimed at: (1) promoting the involvement and awareness of all specialists in the identification of and screening for the disease; (2) guaranteeing the possibility of evaluating the ankle-brachial index (ABI) in all the medical specialties involved; (3) promoting strategies for patients to quit smoking through the use of drugs, programs, or referrals to specialized units; (4) promoting an appropriate Mediterranean-based diet and the prescription of daily exercise; (5) raising awareness of the importance of ensuring LDL cholesterol values below 70 mg/dL, especially in symptomatic but also in asymptomatic patients (55 mg/dL following the publication of the ESC/EAS guide); (6) recommending the use of antiplatelet therapy in asymptomatic patients with diabetes mellitus (DM) and/or a pathological ABI; and (7) protocolizing the annual evaluation of ABI in high-risk patients.This document presents the 22 agreed-upon strategies which are intended to help professionals optimize multidisciplinary management of PAD risk factors.

Greater population life expectancy and consistent improvement in diagnostic techniques have increased the diagnosis of abdominal aortic aneurysms (AAAs) in the elderly population. The aim was to study the natural history of small (55 mm) incidental AAAs in octogenarian and nonagenarian patients to assess the need for follow up and/or invasive treatment.This was a retrospective analysis of a prospective registry. Patients ≥ 80 years old at the time of diagnosis of a55 mm AAA in 1988-2018 were selected. Clinical and anatomical characteristics were registered. Patients were divided in three groups: 30 - 39 mm, 40 - 49 mm, and 50 - 54 mm AAA. The outcome variables were aorto-iliac rupture, AAA reaching a surgical threshold (≥ 55 mm), and death. A descriptive statistical analysis was performed and life tables, Kaplan-Meier curves, and uni- and multivariable Cox regression were used.Three hundred and ten patients were included, 256 (82.6%) men, with mean index age of 84.5 years (standard deviation [SD] 3.5), and median follow up of 37.9 months (interquartile range [IQR] 18.2 - 65.4). Eighteen (5.8%) AAAs ruptured; four of these patients were operated on and only one survived. Sixty-two (20%) AAA reached a surgical size; eight were repaired electively, with 0% early mortality. The survival rates were 81%, 70%, and 38% at one, two, and five years. The rupture rates were 1%, 2%, and 6% and the AAAs reaching surgical threshold were 1%, 4%, and 19% for the same time periods. AAA size40 mm was an independent protective factor from rupture (0.13; 95% confidence interval [CI] 0.03 - 0.48), reaching surgical threshold (0.08; 95% CI 0.04 - 0.16) and death (0.63; 95% CI 0.42 - 0.95).The risk of late rupture of small incidental AAA diagnosed in octogenarian and nonagenarian patients is very small, especially when the AAA is40 mm in diameter. In contrast, global mortality is high. Conservative management seems sensible, with strict selection of the patients who would benefit from follow up and eventual repair.

European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

Objectives Carotid stenosis patients are at risk of vascular events despite antiplatelet therapy. Data on prescribed antiplatelet regimens have not been comprehensively collated from trials to guide optimal therapy in this population. Methods This review was conducted in line with the current Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Medline, Ovid, Embase, Web of Science, and Google Scholar from 1988 to 2018 were searched using the search terms “carotid stenosis”, “asymptomatic”, “symptomatic”, “antiplatelet”, and “anti-platelet” to identify randomised trials in patients with asymptomatic or symptomatic extracranial moderate–severe carotid stenosis on any form of antiplatelet therapy in which vascular events and pre specified composite outcome events were reported. Results Twenty-five studies were judged eligible for inclusion. Data from one randomised controlled trial showed no significant difference in benefit with aspirin versus placebo in asymptomatic carotid stenosis, but it is still reasonable to recommend aspirin (81–325 mg daily) for prevention of vascular events in these patients. Low to medium dose aspirin (81–325 mg daily) is superior to higher doses (>650 mg daily) at preventing recurrent vascular events in patients undergoing endarterectomy. Data from endovascular treatment (EVT) trials support peri-procedural treatment of asymptomatic and symptomatic patients with 81–325 mg of aspirin daily. The use of peri-procedural aspirin–clopidogrel in patients undergoing EVT is based on one pilot trial, but appears safe. Short-term aspirin–dipyridamole or aspirin–clopidogrel treatments are equally effective at reducing micro-embolic signals on transcranial Doppler ultrasound in patients with ≥50% symptomatic carotid stenosis. There is insufficient evidence to recommend routine aspirin–clopidogrel combination therapy to reduce the risk of recurrent clinical ischaemic events in patients with symptomatic moderate–severe carotid stenosis. Conclusions This comprehensive review outlines an evidence based approach to antiplatelet therapy in carotid stenosis patients. Future trials should randomise such patients to receive different antiplatelet regimens to assess their efficacy and safety and to optimise peri-procedural and long-term preventive treatment in this patient cohort.

Objective The aim of this paper was to provide recommendations for diagnosis and management in the setting of infection following open or endovascular reconstructions of the supra-aortic trunks. Methods A review of the Medline database was performed from 1997 to 2017 by a combined strategy of MeSh terms. Results The literature search identified 49 publications: 36 studies addressing prosthetic material infections and 13 studies addressing stent infections. A total of 140 cases of prosthetic material infections were reported, mostly involving carotid patches. Surgical treatment was mostly based on complete removal of the infected material followed by in situ arterial reconstruction (86 cases, 62.3%). Peri-operative complications included cranial nerve injury in 17 cases (12.5%), stroke in eight (6.7%), bleeding in four (2.9%), re-infection in five (3.6%), and cardiac failure in three cases (2.2%). Stent infections were reported in 12 patients: eight carotid stents, three subclavian stents and one tandem brachiocephalic subclavian stent. Treatment was not described for one case, was conservative in one case, consisted of stent removal with venous reconstruction in six cases, stent removal without reconstruction because of carotid thrombosis in two cases, and carotid embolisation in two cases. Complications included intra-operative death in one case (9.1%), stroke in two (18.2%), reinfection in one (9.1%), bleeding in one (9.1%), and cardiac failure in one case (9.1%). Conclusion Appropriate pre-operative imaging is mandatory and treatment modality should be determined by patient condition. Complete removal of the infected material, followed by in situ arterial reconstruction with venous material seems advisable, despite high morbidity. However, alternative strategies may be considered for fragile and high risk patients. A multidisciplinary approach is mandatory to ensure optimum results.

Carlos Lahoza,∗, Carlos Esteban Graciab, Leonardo Reinares Garciac, Sergi Bellmunt Montoyad, Angel Brea Hernandoe, Alvaro Fernandez Herederof, Manuel Suarez Tembrag, Marta Botas Velascoh, Carlos Guijarro i, Esther Bravo Ruiz j, Xavier Pintok, Melina Vega de Ceniga l y Guillermo Monux Ducajum, en representacion del grupo de prevencion secundaria de la Sociedad Espanola de Arteriosclerosis y de la seccion de medicina vascular de la Sociedad Espanola de Angiologia y Cirugia Vascular

Background Ultrasound screening of abdominal aortic aneurysm (AAA) has proved to reduce mortality from AAA rupture and has been implemented in several countries. Recent reports show a decreasing prevalence of AAA in Western countries. We report the results from a screening program among 65-year-old men in a defined area in the North of Spain. Methods We invited the 1,413 men born in 1943 and registered in the health area under our care to participate in the study. We registered their medical history and cardiovascular risk factors and we performed an abdominal ultrasound scan. We diagnosed an AAA when the infrarenal aortic diameter was ≥3 cm. We performed univariate and multivariate analysis to assess independent factors associated with the development of an AAA, using logistic regression. Results The participation rate was 70.8%. The prevalence of active smoking, hypertension, diabetes, and hypercholesterolemia was 19.6%, 52.1%, 25.7%, and 76.9%, respectively. Including 3 previously known and repaired AAAs, the total prevalence of AAA was 4.7% ( n = 37). The mean diameter of the AAA was 35.7 ± 7.9 mm (range, 30–62 mm). Multivariate analysis confirmed the independent impact of active smoking (Exp[B], 3.47 [95% confidence interval {CI}: 1.67–7.22]), hypertension (Exp[B], 2.43 [95% CI: 1.08–5.45]), and peripheral arterial disease (Exp[B], 3.00 [95% CI: 1.16–7.80]) on the incidence of AAA. Conclusions The prevalence of AAA remains high in the studied area in the North of Spain. The potential benefit of lowering smoking rates has not been observed yet. The current international recommendations of screening for 65-year-old men are still applicable in our population.

Resumen Fundamento y objetivo Analizar variables clinicas y serologicas (perfil lipidico, marcadores inflamatorios) como potenciales factores de riesgo para el desarrollo de eventos cardiovasculares y mortalidad a corto plazo en pacientes con claudicacion intermitente. Pacientes y metodo Incluimos todos los pacientes con diagnostico inicial de claudicacion intermitente vascular en nuestro centro durante 2005-2006. Analizamos datos clinicos, parametros serologicos (creatinina, colesterol total, colesterol unido a lipoproteinas de baja densidad [colesterol LDL], colesterol unido a lipoproteinas de alta densidad [colesterol HDL], apolipoproteina A1, apolipoproteina B100, lipoproteina(a), homocisteina, proteina C reactiva, velocidad de sedimentacion globular [VSG], fibrinogeno), eventos cardiovasculares y mortalidad durante el seguimiento a 1-3 anos. Resultados Incluimos 162 pacientes, de los que 143 (88,3%) eran varones. La edad media (DE) fue de 66 (10,4) anos (extremos 41-86), 76 (46,9%) eran fumadores activos, 96 (59,3%) hipertensos, 56 (34,6%) diabeticos y 129 (79,6%) hipercolesterolemicos. Registramos 16 (9,9%) eventos coronarios/cerebrovasculares, 18 (11,1%) eventos vasculares en extremidades inferiores y 9 (5,9%) muertes tardias durante el seguimiento (media de 18,2 [8] meses). La hipertension arterial fue el unico predictor de eventos coronarios o cerebrovasculares (p = 0,013); la cardiopatia y el colesterol HDL 20 mm/h a mortalidad (p = 0,008). Conclusiones Las cifras reducidas de colesterol HDL y elevadas de VSG han resultado factores de riesgo independientes para eventos vasculares perifericos y mortalidad a corto plazo.

Las enfermedades cardiovasculares son la primera causa de muerte en el mundo occidental. El proceso patologico que subyace a ellas es un engrosamiento de la pared arterial debido a la formacion de placas ateroscleroticas, las cuales se complican frecuentemente con un trombo y pueden dar lugar a sindrome coronario agudo o accidente cerebrovascular. Uno de los mayores retos de la medicina cardiovascular es encontrar la manera de predecir el riesgo de un sujeto de sufrir un evento trombotico agudo. En las ultimas decadas, hay un gran interes en la busqueda de biomarcadores diagnosticos y pronosticos que puedan ser identificados en sangre. Entre ellos, la proteina C reactiva es la mas conocida. Otros, como el ligando de CD40 soluble, pueden predecir eventos cardiovasculares. En cambio, hasta el momento no hay un biomarcador aceptado en la practica clinica. Actualmente, existen diversas tecnicas de alto rendimiento como la proteomica, que permite la deteccion de multiples biomarcadores potenciales. Estas aproximaciones pueden identificar en un futuro proximo nuevos biomarcadores que, junto con las tecnicas de imagen, pueden ayudar a mejorar la prediccion de eventos vasculares agudos.