PAAD

Question 1

Patients with chronic symptomatic PAD after endovascular revascularization :

Answer 1

1. Long-term anticoagulation required : YES

High bleeding risk : OAC

No High bleeding risk : SAPT 1–3 months and OAC - then OAC

2. Long-term anticoagulation required : No

High bleeding risk : DAPT 1–3 months then SAPT

No High bleeding risk : ASA and 2.5 mg rivaroxaban b.i.d. +/- clopidogrel

for 1 month then ASA + 2.5 mg rivaroxaban b.i.d.

Question 2

Anti thrombotic therapy in patients with chronic symptomatic PAD

Answer 2

1. Patients requiring long-term anticoagulation : Single OAC monotherapy
2. High-risk limb presentation or high-risk comorbiditiesa without high bleeding risk : ASA and 2.5 mg rivaroxaban b.i.d.
3. Non high-risk limb presentation or high-risk comorbidities : Single antiplatelet therapy (ASA or clopidogrel)

High-risk limb presentation : previous amputation, chronic limb-threatening ischaemia, previous revascularization

high-risk comorbidities : heart failure, diabetes, vascular disease in two or more vascular beds, moderate kidney dysfunction; eGFR <60 mL/min/1.73 m2

Question 3

Chronic limb-threatening ischaemia :

Answer 3

Ischaemic rest pain or gangrene or non-healing chronic wound and critical limb perfusion (AP <50 mmHg, TP <30 mmHg or TcPO2 <30 mmHg)

Question 4

PAD classifications

Answer 4

Rutherford
Fontaine

Question 5

Acute limb ischemia

Answer 5

Urgent revascularization and anticoagulation

Question 6

PAD diagnosis

Answer 6

ABI < 0.9 confirms
If >1.4 or CVRFs : echo

Question 7

When to revascularize carotid artery stenosis ?

Answer 7

Asymptomatic patient if 60–99% carotid stenosis (if high risk features)
Symptomatic patient if 50-99% carotid stenosis

High-risk features associated with increased
risk of stroke in patients with asymptomatic internal carotid artery stenosis on optimal medical treatment

1. Clinical Contralateral TIA/stroke
2. Cerebral imaging Ipsilateral silent infarction
3. Ultrasound/CT imaging
   - Stenosis progression (>20%)
   - Spontaneous embolization on transcranial Doppler
   (HITS)
   - Impaired cerebral vascular reserve
   - Large plaques
   - Echolucent plaques
   - Increased juxta-luminal black (hypoechogenic)
   area
4. MRA Intraplaque haemorrhage
   Lipid-rich necrotic

Question 8

DAPT in carotid artery stenosis

Answer 8

Une double anti-agrégation plaquettaire par aspirine faible dose et clopidogrel (75 mg) est
recommandée pour un délai minimal de 21 jours dans l’attente d’un geste de revascularisation
carotidienne si le risque hémorragique le permet (grade IA). Cette bithérapie est à poursuivre
pour une durée de 1 mois en cas de revascularisation par angioplastie (grade IA).
Au long cours, la prescription d’une simple anti-agrégation plaquettaire est recommandée chez
les patients ayant bénéficié d’un geste et de revascularisation. Cette recommandation s’étend,
en prévention primaire, en cas de sté

Question 9

Subclavian artery stenosis indications

Answer 9

In symptomatic patients with atherosclerotic
subclavian artery disease (TIA/stroke, coronary
subclavian steal syndrome, ipsilateral haemodialysis
access dysfunction, severe ischaemia), both
revascularization options (endovascular ± stenting
or surgery) should be considered and discussed case
by case by a vascular team

Should be considered in cases of proximal stenosis in
patients undergoing CABG using the ipsilateral
internal mammary artery.

Should be considered in cases of proximal stenosis in
patients who already have the ipsilateral internal
mammary artery grafted to coronary arteries with
evidence of myocardial ischaemia.

Should be considered in cases of ipsilateral
haemodialysis arteriovenous access

Question 10

RAS revascularization ?

Answer 10

RAS (>70%) + Kidney viable + Presence of high-risk features:
Rapidly progressive, treatment-resistant arterial hypertension; rapidly declining renal function; flash pulmonary oedema; solitary kidney