Editors: Lars Norgren and William R Hiatt

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• Editors Lars Norgren and William R Hiatt
• Associate Editors John A Dormandy and Mark R
  Nehler
• Contributing Editors Kenneth A Harris and F
  Gerry R Fowkes
• Consulting Editor Robert B Rutherford
• Journal of Vascular Surgery 2007451S-67S,
• European Journal Vascular Endovascular Surgery
  200733S1-S75

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TASC II writing and endorsing societies

• Mark A Creager American College of Cardiology
• Peter Sheehan American Diabetes Association
• Joseph M Caporusso American Podiatric Medical
  Association
• Kenneth A Harris Canadian Society for Vascular
  Surgery
• Johannes Lammer Marc Sapoval Cardiovascular
  and Interventional Radiology Society of Europe
• Denis Clement CoCaLis collaboration
• Henrik Sillesen Christos Liapis European
  Society for Vascular Surgery
• Nicholaas C Schaper International Diabetes
  Federation
• Salvatore Novo International Union of Angiology
• Kevin Bell Interventional Radiology Society of
  Australasia
• Hiroshi Shigematsu and Kimihiro Komori Japanese
  College of Angiology
• Christopher White Kenneth Rosenfield Society
  for Cardiovascular Angiography and Intervention
• John White Society for Vascular Surgery
• Mahmood Razavi Society of Interventional
  Radiology
• Michael R Jaff Society for Vascular Medicine and
  Biology
• John V Robbs Vascular Society of Southern Africa
• Isabelle Durand-Zaleski health economics advice
• Emile Mohler American College of Physicians
  (representing only)

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TASC II grading
Grade recommendation 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 B Based on
well-conducted clinical studies but no good
quality randomized clinical trials on the topic
of recommendation C Based on evidence obtained
from expert committee reports or opinions and/or
clinical experiences of respected authorities
(i.e. no applicable studies of good quality)
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TASC II PAD guidelinesSmoking cessation

• All patients who smoke should be strongly and
  repeatedly advised to stop smoking B.
• All patients who smoke should receive a program
  of physician advice, group counseling sessions,
  and nicotine replacement A.
• Cessation rates can be enhanced by the addition
  of antidepressant drug therapy (bupropion) and
  nicotine replacement A.

Norgren and Hiatt for the TASC II writing
group In press (2007) J Vasc Surg and Eur J Vasc
Endovasc Surg
5
TASC II PAD guidelinesDiabetes therapies

• Patients with diabetes and PAD should have
  aggressive control of blood glucose levels with a
  hemoglobin A1c goal of lt7.0 or as close to 6 as
  possible C.

Norgren and Hiatt for the TASC II writing
group In press (2007) J Vasc Surg and Eur J Vasc
Endovasc Surg
6
TASC II PAD guidelinesLipid-lowering therapies

• All symptomatic PAD patients should have their
  low-density lipoprotein (LDL)-cholesterol lowered
  to lt2.59 mmol/L (lt100 mg/dL) A.
• In patients with PAD and a history of vascular
  disease in other beds (eg, coronary artery
  disease) it is reasonable to lower LDL
  cholesterol levels to lt1.81 mmol/L (lt70 mg/dL)
  B.
• All asymptomatic patients with PAD and no
  other clinical evidence of cardiovascular disease
  should also have their LDL-cholesterol level
  lowered to lt2.59 mmol/L (lt100 mg/dL) C.
• In patients with elevated triglyceride levels
  where the LDL cannot be accurately calculated,
  the non-HDL cholesterol level should be lt3.36
  mmol/L (lt130 mg/dL) and in high risk patients the
  level should be lt2.59 mmol/L (lt100 mg/dL) C.

Norgren and Hiatt for the TASC II writing
group In press (2007) J Vasc Surg and Eur J Vasc
Endovasc Surg
7
TASC II PAD guidelinesLipid-lowering therapies
Dietary modification should be the initial
intervention to control abnormal lipid levels
B. In symptomatic PAD patients, statins
should be the primary agents to lower LDL
cholesterol levels to reduce the risk of
cardiovascular events A. Fibrates and/or
niacin to raise HDL-cholesterol levels and lower
triglyceride levels should be considered in
patients with PAD who have other evidence of
cardiovascular disease B.
Norgren and Hiatt for the TASC II writing
group In press (2007) J Vasc Surg and Eur J Vasc
Endovasc Surg
8
TASC II PAD guidelines Antihypertensive therapies

• All patients with hypertension should have
  blood pressure controlled to lt140/90 mm Hg or
  lt130/80 mm Hg if they also have diabetes or renal
  insufficiency A.
• JNC VII and European guidelines for the
  management of hypertension in PAD should be
  followed A.
• Thiazides and ACE inhibitors should be
  considered an initial blood-pressure lowering
  drugs in PAD to reduce the risk of cardiovascular
  events B.
• Beta-adrenergicblocking drugs are not
  contraindicated in PAD A.

Norgren and Hiatt for the TASC II writing
group In press (2007) J Vasc Surg and Eur J Vasc
Endovasc Surg
9
TASC II PAD guidelines Antiplatelet therapy

• All symptomatic patients with or without a
  history of other cardiovascular disease should be
  prescribed an antiplatelet drug long term to
  reduce the risk of cardiovascular morbidity and
  mortality A.
• Aspirin/ASA is effective in patients with PAD
  who also have clinical evidence of other forms of
  cardiovascular disease (coronary or carotid) A.
• The use of aspirin/ASA in patients with PAD who
  do not have clinical evidence of other forms of
  cardiovascular disease can be considered C.
• Clopidogrel is effective in reducing
  cardiovascular events in a subgroup of patients
  with symptomatic PAD, with or without other
  clinical evidence of cardiovascular disease B

Norgren and Hiatt for the TASC II writing
group In press (2007) J Vasc Surg and Eur J Vasc
Endovasc Surg
10
TASC II PAD management guidelines Exercise
therapy

• A program of supervised exercise therapy should
  always be considered as part of the initial
  treatment for patients with claudication and PAD
  A
• The most effective programs employ treadmill or
  track walking that is of sufficient intensity to
  bring on claudication, followed by rest, over the
  course of a 30-60 minute session. Exercise
  sessions are typically conducted three times a
  week for three months A.

Norgren and Hiatt for the TASC II writing
group In press (2007) J Vasc Surg and Eur J Vasc
Endovasc Surg
11
TASC II PAD guidelines Revascularization for
claudication

• Patients with intermittent claudication who
  continue to experience limitations to their
  quality of life after appropriate medical therapy
  (exercise rehabilitation and/or pharmacotherapy)
  or patients with critical limb ischemia, may be
  considered candidates for revascularization if
  they meet the following additional criteria

• A suitable lesion for revascularization is
  identified
• The patient does not have any systemic
  contraindications for the procedure and
• The patient desires additional therapy B.

Norgren and Hiatt for the TASC II writing
group In press (2007) J Vasc Surg and Eur J Vasc
Endovasc Surg
12
TASC II aorto-iliac

• Type A lesions
• Unilateral or bilateral stenoses of CIA
• Unilateral or bilateral single short (3 cm)
  stenosis of EIA
• Type B lesions
• Short ( 3 cm) stenosis of infrarenal aorta
• Unilateral CIA occlusion
• Single or multiple stenosis totalling 310 cm
  involving the EIA, not extending into the CFA
• Unilateral EIA occlusion not involving the
  origins of internal iliac or CFA

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TASC II aorto-iliac lesionsType A and Type B
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TASC II aorto-iliac

• Type C lesions
• Bilateral CIA occlusions
• Bilateral EIA stenoses 310 cm long, not
  extending into CFA
• Unilateral EIA stenosis extending into the CFA
• Unilateral EIA occlusion that involves the
  origins of internal iliac and/or CFA
• Heavily calcified unilateral EIA occlusion with
  or without involvement of origins of internal
  iliac and CFA
• Type D lesions
• Infra-renal aortoiliac occlusion
• Diffuse disease involving the aorta and both
  iliac arteries
• Diffuse multiple stenoses involving the CIA, EIA,
  and CFA
• Unilateral occlusions of both CIA and EIA
• Bilateral occlusions of EIA
• Iliac stenoses in patients with AAA

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TASC II aorto-iliac lesionsType C and Type D
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TASC II femoral popliteal lesions

• Type A lesions
• Single stenosis 10 cm in length
• Single occlusion 5 cm in length
• Type B lesions
• Multiple lesions (stenoses or occlusions), each
  5 cm
• Single stenosis or occlusion 15 cm not involving
  the infra geniculate popliteal artery
• Single or multiple lesions in the absence of
  continuous tibial vessels to improve inflow for a
  distal bypass
• Heavily calcified occlusion 5 cm in length
• Single popliteal stenosis

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TASC II femoral popliteal lesions Type A and
Type B
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TASC II femoral popliteal lesions Type C and
Type D
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TASC II femoral popliteal lesions

• Type C lesions
• Multiple stenoses or occlusions totalling gt15 cm
  with or without heavy calcification
• Recurrent stenoses or occlusions that need
  treatment after two endovascular interventions
• Type D lesions
• Chronic total occlusions of CFA or SFA (gt20 cm),
  involving the popliteal artery)
• Chronic total occlusion of popliteal artery and
  proximal trifurcation vessels

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TASC II PAD guidelinesPharmacotherapy of
claudication

• A 3- to 6-month course to determine efficacy of
  cilostazol should be first-line pharmacotherapy
  for the relief of claudication symptoms, as
  evidence shows both an improvement in treadmill
  exercise performance and in quality of life A

Cilostazol should be avoided in patients with
congestive heart failure
Norgren and Hiatt for the TASC II writing
group In press (2007) J Vasc Surg and Eur J Vasc
Endovasc Surg
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Claudication treatment options

• Treatment Mechanism TASC II
• Exercise Metabolic,
• Walking efficiency A
• Endothelial
• Angioplasty Hemodynamic A
• Cilostazol Metabolic,
• Hemodynamic A
• Vascular smooth muscle

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Claudication treatment options

• Treatment Benefit QOL Limitation
• Exercise 100 ?? Not available
• Angioplasty 50-100 ? Distal lesions
• Surgery 150 ?? 2-5 risk
• Cilostazol 50 ? Not in CHF