New guidance on monitoring patients after revascularisation for peripheral arterial diseases (PAD) has been produced by the European Society of Cardiology (ESC) Working Group on Aorta and Peripheral Vascular Diseases and the European Society for Vascular Surgery (ESVS) to enable “optimal surveillance of revascularised patients beyond the perioperative period”. The consensus document was published by Maarit Venermo (Department of Vascular Surgery, Helsinki University Hospital and University of Helsinki, Finland) and colleagues in the European Journal of Vascular and Endovascular Surgery.
PAD present in a variety of ways, with differing levels of severity, and a proportion of patients will experience symptoms that are disabling. Some patients will require revasularisation in addition to optimal medical treatment to manage their condition.
There are often problems with maintaining long-term patency after the procedure and complications may result in revascularisation failure. Non-invasive examinations should be used where appropriate to address revascularisation failure before loss of patency occurs and to prevent disease progression or other cardiovascular events. However, while ESC/ESVS guidance produced in 2017 advises about the indications of PAD requiring revascularisation, there is a lack of good evidence about optimal surveillance after treatment. The authors therefore sought to “systematically review the literature addressing follow-up after revascularisation and to propose a consensus document as a complement to the recent guidelines.”
Venermo and colleagues explain: “the opinion of the authors of this interdisciplinary consensus document is that the proposed surveillance strategy may be appropriate while awaiting better quality data to be acquired. Importantly, the regular follow-up of revascularised patients does not systematically imply the use of imaging techniques. Clinical assessment and implementation of preventive measures remain the pillars of the follow-up programme. These could either be performed by general practitioners or cardiovascular specialists (cardiologists, vascular physicians or vascular surgeons) according to the management of patients in different countries. The recommendations here apply irrespective of the healthcare systems.“
The document elucidates the optimal surveillance required to prevent local and general adverse events taking place in the mid-term (1–12 months) and long-term (>12 months) after revascularisation. General cardiovascular prevention is an important aspect of follow-up alongside imaging when needed. Venermo and coauthors describe the most appropriate follow-up according to the indication for revascularisation, namely, extracranial carotid artery disease, upper extremity artery disease, mesenteric artery disease, renal artery disease and lower extremity artery disease.
Major mid-term complications following revascularisation are acute thrombosis of the revascularised site despite antithrombotic therapy and embolism to the arteries distal to the revascularised site. Intimal hyperplasia can lead to restenosis, with intimal hyperplasia lesions being detectable from a few weeks up to two years after the procedure. Complications directly resulting from the revascularisation procedure can occur after a year but most long-term complications are related to disease progression and general cardiovascular events, many of which may be avoided with optimal cardiovascular prevention and medical management.
Clinical follow-up should include assessment of symptoms or signs that may suggest revascularisation failure or other cardiovascular condition, and ensuring that the patient is following optimal cardiovascular prevention and drug adherence advice. The authors explain that success of revascularisation in the long-term depends on the patient’s concordance with secondary prevention and exercise training, and an understanding of the symptoms that may indicate revascularisation failure and need them to seek immediate help from vascular specialists.
The document provides a useful checklist of the items that should be assessed regularly during patients’ follow-up visits in terms of cardiovascular prevention, hypertension, diabetes, cholesterol, other, symptoms and signs related to revascularisation site, and other cardiovascular conditions.
The main imaging technique used to identify revascularisation failures is duplex ultrasound scanning (DUS), which can be repeated over time either to detect abnormalities or to confirm whether symptoms are caused by revascularisation failure or disease progression. Other imaging tests available are ankle brachial index or toe brachial index for the lower limbs, and computed tomography angiography and magnetic resonance angiography for confirming or further investigating DUS findings.
Venermo and colleagues conclude: “This paper aims to provide a standardised follow-up approach, based on a combination of evidence and authors’ expertise, emphasising the importance of a multidisciplinary management of these patients with an optimal, clinically reasonable and cost-effective strategy. This collaborative work highlights many gaps in the evidence and suggests collaborative research to provide further data and evidence in this setting. This paper is a result of active work of the entire working group and we had extremely hard but reconstructive and fruitful discussions when building up the consensus. Furthermore, in order to achieve as high quality document as possible, we had an external reviewer group of highly respected professionals in this field.”