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Gefäßmedizin

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Hämostaseologie • ­Konservative und endovaskuläre Therapie •
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TASC II - spät, aber doch
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Minar E, Schillinger M
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Zeitschrift für Gefäßmedizin 2007; mit Autoren-
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4 (1), 11-15

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www.kup.at/gefaessmedizin
TASC II – spät, aber doch

TASC II – spät, aber doch


E. Minar1, M. Schillinger2

Kurzfassung: Rezent ist das bereits seit längerem Kritisch muß angemerkt werden, daß die Klassifikation new document has been abbreviated in many points,
angekündigte TASC-II-Konsensusdokument zur Dia- der Läsionen in Hinblick auf die Differentialtherapie making it more easily readable also for the physician
gnose und Therapie der peripheren arteriellen Ver- zwischen Chirurgie und endovaskulärer Therapie im without special expertise in vascular medicine. The
schlußkrankheit (PAVK) publiziert worden. Die bereits Vergleich zur Erstfassung leider geändert wurde. Dies available data are summarized in 43 specific recom-
7 Jahre zurückliegende und somit vielfach nicht mehr erschwert die Vergleichbarkeit mit bereits publizierten mendations. This document demonstrates that only
ganz aktuelle Erstfassung machte eine Revision drin- Originalarbeiten. few large randomized studies have been performed in
gend notwendig. Dieses neue Konsensusdokument ist the field of PAOD. Therefore, only few recommenda-
in wesentlichen Punkten deutlich gekürzt und somit Abstract: TASC II – Late, but Coming After All. tions are classified as grade A. Unfortunately, the clas-
leichter lesbar. Die Datenlage wird in 43 konkreten Recently, the TASC II-Consensus document concerning sification of lesions with respect to differential therapy
Empfehlungen zusammengefaßt. Dieses Dokument diagnosis and treatment of patients with peripheral between surgery and endovascular treatment has
zeigt klar, daß auf dem Gebiet der PAVK nur wenige arterial occlusive disease (PAOD) has been published. been changed compared to TASC I, making comparison
große randomisierte Studien existieren, weswegen Since publication of TASC I was already in 2000, revi- with already published papers more difficult. Z Gefäß-
nur wenige Empfehlungen einen Grad-A-Status haben. sion of the guidelines became urgently necessary. The med 2007; 4 (1): 11–5.

„ Einleitung der Studienlage – als A, B bzw. C klassifiziert (siehe Tab. 1).


Es fällt auf, daß insbesondere die Empfehlungen zur Therapie
Ganz rezent ist das bereits seit längerem angekündigte „Trans- überwiegend als Grad C klassifiziert wurden, da leider immer
Atlantic Inter-Society Consensus Document on Management noch nur sehr wenige große randomisierte Studien zu den ver-
of Peripheral Arterial Disease“ (TASC II ) im Jänner 2007 im schiedenen Therapiemöglichkeiten bei Patienten mit PAVK
Journal of Vascular Surgery [1] sowie im European Journal of durchgeführt wurden.
Vascular and Endovascular Surgery [2] jeweils als Supple-
ment erschienen. Da das erste TASC-Konsensusdokument be-
Recommendation 1.
reits im Jahre 2000 erschienen ist, war eine Neufassung drin-
Smoking cessation in peripheral arterial disease
gend erforderlich. TASC II ist im Vergleich zu TASC I deut-
lich gekürzt und somit insgesamt – insbesondere auch für den • All patients who smoke should be strongly and repeatedly
Allgemeinmediziner – leichter lesbar. Das Dokument befaßt advised to stop smoking [B].
sich mit Risikofaktoren, Koinzidenzen mit anderen athero- • All patients who smoke should receive a program of physi-
sklerotischen Erkrankungen, Diagnose, Prophylaxe und The- cian advice, group counselling sessions, and nicotine re-
rapie der PAVK (Claudicatio intermittens, chronisch kritische placement [A].
Beinischämie sowie akute Beinischämie) und faßt die Daten- • Cessation rates can be enhanced by the addition of anti-
lage in 43 konkreten Empfehlungen zusammen. depressant drug therapy (bupropion) and nicotine replace-
ment [A].
Als Kritikpunkt muß hier allerdings auch angeführt werden,
daß insbesondere der Therapieteil des TASC-II-Dokumentes
Recommendation 2.
doch sehr stark „chirurgenlastig“ erscheint. Es muß auch be-
Lipid control in patients with peripheral arterial disease
sonders darauf hingewiesen werden, daß die Klassifikation
(PAD)
der Läsionen – und die davon abhängigen Empfehlungen zur
• All symptomatic PAD patients should have their low-den-
chirurgischen bzw. endovaskulären Therapie – im Vergleich
sity lipoprotein (LDL) cholesterol lowered to < 2.59 mmol/L
zu TASC I doch in wesentlichen Punkten geändert wurden,
(< 100 mg/dL) [A].
was leider zu einiger Verwirrung beitragen wird.
• In patients with PAD and a history of vascular disease in
In den kommenden Ausgaben der Zeitschrift für Gefäßmedi- other beds (e.g. coronary artery disease) it is reasonable to
zin wollen wir uns mit einigen der angeführten Empfehlungen lower LDL cholesterol levels to < 1.81 mmol/L (< 70 mg/dL)
etwas genauer auseinandersetzen und versuchen, diese für [B].
österreichische Verhältnisse zu adaptieren. • All asymptomatic patients with PAD and no other clinical
Im folgenden werden diese Empfehlungen in der englischen evidence of cardiovascular disease should also have their
Originalfassung für den eiligen Leser zusammenfassend dar-
gestellt*. Der Grad der Empfehlung ist – in Abhängigkeit von Tabelle 1: Einteilung der Empfehlungen im TASC-II-Dokument
in Abhängigkeit von der Datenlage
*Nachdruck aus [1]. © 2007, mit Genehmigung der „Society for Vascular Surgery“. A Based on the criterion of at least one randomized, controlled clinical
trial as part of the body of literature of overall good quality and
consistency addressing the specific recommendation.
Aus der 1Abteilung Angiologie, Universitätsklinik für Innere Medizin II,
B Based on well-conducted clinical studies but no good quality
Medizinische Universität Wien und der 23. Medizinischen Abteilung Kardiologie,
randomized clinical trials on the topic of recommendation.
Wilhelminenspital der Stadt Wien
C Based on evidence obtained from expert committee reports or
Korrespondenzadresse: Univ.-Prof. Dr. med. Erich Minar, Abteilung Angiologie,
opinions and/or clinical experiences of respected authorities (i.e.
Universitätsklinik für Innere Medizin II, Medizinische Universität Wien, no applicable studies of good quality).
A-1090 Wien, Währinger Gürtel 18–20; E-Mail: erich.minar@meduniwien.ac.at

Z GEFÄSSMED 2007; 4 (1) 11

For personal use only. Not to be reproduced without permission of Krause & Pachernegg GmbH.
TASC II – spät, aber doch

LDL cholesterol level lowered to < 2.59 mmol/L (< 100 mg/ Recommendation 7.
dL) [C]. Management of coronary artery disease (CAD)
• In patients with elevated triglyceride levels where the LDL in peripheral arterial disease patients
cannot be accurately calculated, the LDL level should be • Patients with clinical evidence of CAD (angina, ischemic
directly measured and treated to values listed above. Alter- congestive heart failure) should be evaluated and managed
natively, the non-HDL (high-density lipoprotein) choles- according to current guidelines [C].
terol level can be calculated with a goal of < 3.36 mmol/L • Patients with PAD considered for vascular surgery may un-
(< 130 mg/dL), and in high-risk patients the level should be dergo further risk stratification and those found to be at very
< 2.59 mmol/L (< 100 mg/dL). high risk managed according to current guidelines for coro-
• Dietary modification should be the initial intervention to nary revascularization [C].
control abnormal lipid levels [B]. • Routine coronary revascularization in preparation for vas-
• In symptomatic PAD patients, statins should be the primary cular surgery is not recommended [A].
agents to lower LDL cholesterol levels to reduce the risk of
cardiovascular events [A]. Recommendation 8.
• Fibrates and/or niacin to raise HDL cholesterol levels and Use of beta-blocking agents before vascular surgery
lower triglyceride levels should be considered in patients • When there are no contraindications, betaadrenergic blockers
with PAD who have abnormalities of those lipid fractions should be given perioperatively to patients with peripheral
[B]. arterial disease undergoing vascular surgery in order to de-
crease cardiac morbidity and mortality [A].
Recommendation 3.
Control of hypertension in peripheral arterial disease Recommendation 9.
(PAD) patients Management of carotid artery disease in peripheral
• All patients with hypertension should have blood pressure arterial disease (PAD) patients
controlled to < 140/90 mmHg or < 130/80 mmHg if they • The management of symptomatic carotid artery disease in
also have diabetes or renal insufficiency [A]. patients with PAD should be based on current guidelines
• JNC VII and European guidelines for the management of [C].
hypertension in PAD should be followed [A].
• Thiazides and ACE inhibitors should be considered as ini- Recommendation 10.
tial blood-pressure lowering drugs in PAD to reduce the risk Management of renal artery disease in peripheral arterial
of cardiovascular events [B]. disease (PAD) patients
• Beta-adrenergic-blocking drugs are not contraindicated in • When renal artery disease is suspected in PAD patients, as
PAD [A]. evidenced by poorly controlled hypertension or renal insuf-
ficiency, patients should be treated according to current
Recommendation 4. guidelines and consider referral to a cardiovascular physi-
Control of diabetes in peripheral arterial disease (PAD) cian [C].
• Patients with diabetes and PAD should have aggressive con-
trol of blood glucose levels with a hemoglobin A1c goal of Recommendation 11.
< 7.0 % or as close to 6 % as possible [C]. History and physical examination in suspected
peripheral arterial disease (PAD)
Recommendation 5. • Individuals with risk factors for PAD, limb symptoms on
Use of folate supplementation in peripheral arterial exertion or reduced limb function should undergo a vascular
disease (PAD) history to evaluate for symptoms of claudication or other
• Patients with PAD and other evidence of cardiovascular dis- limb symptoms that limit walking ability [B].
ease should not be given folate supplements to reduce their • Patients at risk for PAD or patients with reduced limb func-
risk of cardiovascular events [B]. tion should also have a vascular examination evaluating pe-
ripheral pulses [B].
Recommendation 6. • Patients with a history or examination suggestive of PAD
Antiplatelet therapy in peripheral arterial disease (PAD) should proceed to objective testing including an ankle-bra-
• All symptomatic patients with or without a history of other chial index [B].
cardiovascular disease should be prescribed an antiplatelet
drug long term to reduce the risk of cardiovascular morbid- Recommendation 12.
ity and mortality [A]. Recommendations for ankle-brachial index (ABI)
• Aspirin/ASA is effective in patients with PAD who also screening to detect peripheral arterial disease in the in-
have clinical evidence of other forms of cardiovascular dis- dividual patient
ease (coronary or carotid) [A]. An ABI should be measured in:
• The use of aspirin/ASA in patients with PAD who do not • All patients who have exertional leg symptoms [B].
have clinical evidence of other forms of cardiovascular dis- • All patients between the age of 50–69 and who have a
ease can be considered [C]. cardiovascular risk factor (particularly diabetes or smoking)
• Clopidogrel is effective in reducing cardiovascular events [B].
in a subgroup of patients with symptomatic PAD, with or • All patients age ≥ 70 years regardless of risk factor status
without other clinical evidence of cardiovascular disease [B].
[B]. • All patients with a Framingham risk score 10–20 % [C].

12 Z GEFÄSSMED 2007; 4 (1)


TASC II – spät, aber doch

Recommendation 13. Recommendation 20.


Determining success of treatment for intermittent Indications for evaluation of critical limb ischemia
claudication • All patients with ischemic rest pain symptoms or pedal ulcers
Patient-based outcome assessment (including a focused his- should be evaluated for CLI [B].
tory of change in symptoms) is the most important measure;
however, if quantitative measurements are required the fol- Recommendation 21.
lowing may be used: Importance of early identification of peripheral arterial
1. Objective measures include an increase in peak exercise disease (PAD)
performance on a treadmill [B]. • Early identification of patients with PAD at risk of develop-
2. Patient-based measures would include an improvement on ing foot problems is essential for limb preservation [C].
a validated, disease-specific health status questionnaire; or This can be achieved by daily visual examination by the
the physical functioning domain on a validated generic patients or their family and, at every visit, referral to the foot
health status questionnaire [B]. specialist.

Recommendation 22.
Recommendation 14.
Early referral in critical limb ischemia (CLI)
Exercise therapy in intermittent claudication
• Patients with CLI should be referred to a vascular specialist
• Supervised exercise should be made available as part of the
early in the course of their disease to plan for revasculari-
initial treatment for all patients with peripheral arterial dis-
zation options [C].
ease [A].
• The most effective programs employ treadmill or track Recommendation 23.
walking that is of sufficient intensity to bring on claudica- Multidisciplinary approach to treatment of critical limb
tion, followed by rest, over the course of a 30–60 minute ischemia
session. Exercise sessions are typically conducted three • A multidisciplinary approach is optimal to control pain, car-
times a week for 3 months [A]. diovascular risk factors and other co-morbid disease [C].

Recommendation 15. Recommendation 24.


Pharmacotherapy for symptoms of intermittent Optimal treatment for patients with critical limb
claudication ischemia (CLI)
• A 3- to 6-month course of cilostazol should be first-line • Revascularization is the optimal treatment for patients with
pharmacotherapy for the relief of claudication symptoms, CLI [B].
as evidence shows both an improvement in treadmill exer-
cise performance and in quality of life [A]. Recommendation 25.
• Naftidrofuryl can also be considered for treatment of clau- Treatment for infections in critical limb ischemia (CLI)
dication symptoms [A]. • Systemic antibiotic therapy is required in CLI patients who
develop cellulitis or spreading infection [B].
Recommendation 16. Recommendation 26.
Clinical definition of critical limb ischemia (CLI) Multidisciplinary care in critical limb ischemia (CLI)
• The term critical limb ischemia should be used for all • Patients with CLI who develop foot ulceration require
patients with chronic ischemic rest pain, ulcers or gangrene multidisciplinary care to avoid limb loss [C].
attributable to objectively proven arterial occlusive disease.
The term CLI implies chronicity and is to be distinguished Recommendation 27.
from acute limb ischemia [C]. Amputation decisions in critical limb ischemia (CLI)
• The decision to amputate and the choice of the level should
Recommendation 17. take into consideration the potential for healing, rehabilita-
Cardiovascular risk modification in critical limb ischemia tion and return of quality of life [C].
(CLI)
• CLI patients should have aggressive modification of their Recommendation 28.
cardiovascular risk factors [A]. Use of prostanoids in critical limb ischemia (CLI)
• Previous studies with prostanoids in CLI suggested im-
proved healing of ischemic ulcers and reduction in amputa-
Recommendation 18.
tions [A].
Evaluation of peripheral arterial disease (PAD) in patients
• However, recent trials do not support the benefit of pro-
with diabetes
stanoids in promoting amputationfree survival [A].
• All diabetic patients with an ulceration should be evaluated • There are no other pharmacotherapies that can be recom-
for PAD using objective testing [C]. mended for the treatment of CLI [B].

Recommendation 19. Recommendation 29.


Diagnosis of critical limb ischemia (CLI) Assessment of acute limb ischemia (ALI)
• CLI is a clinical diagnosis but should be supported by objec- • Due to inaccuracy of pulse palpation and the physical ex-
tive tests [C]. amination, all patients with suspected ALI should have

Z GEFÄSSMED 2007; 4 (1) 13


TASC II – spät, aber doch

Doppler assessment of peripheral pulses immediately at Recommendation 37.


presentation to determine if a flow signal is present [C]. Treatment of femoral popliteal lesions
• TASC A and D lesions: Endovascular therapy is the treat-
Recommendation 30. ment of choice for type A lesions and surgery is the treat-
Cases of suspected acute limb ischemia (ALI) ment of choice for type D lesions [C].
• All patients with suspected ALI should be evaluated imme- • TASC B and C lesions: Endovascular treatment is the pre-
diately by a vascular specialist who should direct immediate ferred treatment for type B lesions and surgery is the pre-
decision making and perform revascularization because ferred treatment for good-risk patients with type C lesions.
irreversible nerve and muscle damage may occur within The patient’s co-morbidities, fully informed patient prefer-
hours [C]. ence and the local operator’s long-term success rates must
be considered when making treatment recommendations for
Recommendation 31. type B and type C lesions [C].
Anticoagulant therapy in acute limb ischemia (ALI)
Recommendation 38.
• Immediate parenteral anticoagulant therapy is indicated in
In-flow artery for femorodistal bypass
all patients with ALI. In patients expected to undergo immi-
• Any artery, regardless of level (i.e. not only the common
nent imaging/therapy on arrival, heparin should be given
femoral artery), may serve as an in-flow artery for a distal
[C].
bypass provided flow to that artery and the origin of the
graft is not compromised [C].
Recommendation 32.
Completion arteriography Recommendation 39.
• Unless there is good evidence that adequate circulation has Femoral distal bypass out-flow vessel
been restored, intraoperative angiography should be per- • In a femoral tibial bypass, the least diseased distal artery
formed to identify any residual occlusion or critical arterial with the best continuous run-off to the ankle/foot should be
lesions requiring further treatment [C]. used for outflow regardless of location, provided there is
adequate length of suitable vein [C].
Recommendation 33.
Treatment of choice for compartment syndrome Recommendation 40.
• In case of clinical suspicion of compartment syndrome, Femoral below-knee popliteal and distal bypass
the treatment of choice is a fourcompartment fasciotomy • An adequate long (greater) saphenous vein is the optimal
[C]. conduit in femoral below-knee popliteal and distal bypass
[C]. In its absence, another good-quality vein should be
Recommendation 34. used [C].
Intra-arterial pressure measurements for assessment of
Recommendation 41.
stenosis
Antiplatelet drugs as adjuvant pharmacotherapy after
• If there is doubt about the hemodynamic significance of
revascularization
partially occlusive aortoiliac disease, it should be assessed
by intra-arterial pressure measurements across the stenosis • Antiplatelet therapy should be started preoperatively and
at rest and with induced hyperemia [C]. continued as adjuvant pharmacotherapy after an endovascu-
lar or surgical procedure [A]. Unless subsequently contrain-
dicated, this should be continued indefinitely [A].
Recommendation 35.
Choosing between techniques with equivalent short- Recommendation 42.
and long-term clinical outcomes Clinical surveillance program for bypass grafts
• In a situation where endovascular revascularization and • Patients undergoing bypass graft placement in the lower
open repair/bypass of a specific lesion causing symptoms of extremity for the treatment of claudication or limb-threaten-
peripheral arterial disease give equivalent short-term and ing ischemia should be entered into a clinical surveillance
long-term symptomatic improvement, endovascular tech- program.
niques should be used first [B]. This program should consist of:
• Interval history (new symptoms)
Recommendation 36. • Vascular examination of the leg with palpation of proximal,
Treatment of aortoiliac lesions graft and outflow vessel pulses
• TASC A and D lesions: Endovascular therapy is the treat- • Periodic measurement of resting and, if possible, post-exer-
ment of choice for type A lesions and surgery is the treat- cise ankle-brachial indices
ment of choice for type D lesions [C]. • Clinical surveillance programs should be performed in the
• TASC B and C lesions: Endovascular treatment is the pre- immediate postoperative period and at regular intervals
ferred treatment for type B lesions and surgery is the pre- (usually every 6 months) for at least 2 years [C].
ferred treatment for good-risk patients with type C lesions.
The patient’s co-morbidities, fully informed patient prefer- Recommendation 43.
ence and the local operator’s long-term success rates must Indications and methods to localize arterial lesions
be considered when making treatment recommendations for • Patients with intermittent claudication who continue to
type B and type C lesions [C]. experience limitations to their quality of life after appro-

14 Z GEFÄSSMED 2007; 4 (1)


TASC II – spät, aber doch

priate medical therapy (exercise rehabilitation and/or phar- • When anatomic localization of arterial occlusive lesions is
macotherapy) or patients with critical limb ischemia, may necessary for decision making, the following imaging tech-
be considered candidates for revascularization if they meet niques are recommended:
the following additional criteria: – duplex ultrasonography
(a) a suitable lesion for revascularization is identified; – magnetic resonance angiography and
(b) the patient does not have any systemic contraindica- – computed tomography angiography (depending on local
tions for the procedure; and availability, experience, and cost) [B].
(c) the patient desires additional therapy [B].
Literatur:
• Initial disease localization can be obtained with hemo- 1. Norgren L, Hiatt WR, Dormandy JA, Nehler 2. Norgren L, Hiatt WR, Dormandy JA, Nehler
MR, Harris KA, Fowkes FG; on behalf of the MR, Harris KA, Fowkes FG; on behalf of the
dynamic measures including segmental limb pressures TASC II Working Group. Inter-Society TASC II Working Group. Inter-Society
or pulse volume recording [B]. Consensus for the Management of Peripheral Consensus for the Management of Peripheral
Arterial Disease (TASC II). J Vasc Surg 2007; Arterial Disease (TASC II). Eur J Vasc
45 (Suppl 1): S5–S67. Endovasc Surg 2007; 33 (Suppl 1): S1–S75.

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