TASC addresses variations in medical care
At the recent Olbert Workshop in Vienna, Austria, Professor Johannes Lammer, University of Vienna, presented the 2006 TransAtlantic Inter-Society Consensus (TASC) recommendations. TASC is an organisation that strives to promote a uniformly high level of atherosclerotic disease management across different countries.
According to TASC, there is currently a huge variation in medical care, not only from country to country but also among states and hospitals. By formulating a consensus of expert opinion from key professional societies (such as the European Society for Vascular Surgery, the American College of Cardiology, the Society for Vascular Surgery and the Cardiovascular and Interventional Radiology Society of Europe, Society of Interventional Radiology, among many others), TASC has developed a consensus document that aims to optimise and maintain international medical standards, reflecting the latest developments in technology and techniques.
To achieve an in-depth consideration of the topic, the latest transatlantic inter-society document recommendations concern the management of peripheral arterial occlusive disease (PAOD) as a result of atherosclerosis affecting the lower limbs only and seeks to aid the physicians when selecting suitable treatment.
Lammer told Interventional News, "These are very good guidelines for vascular physicians in how they should treat their patients, as the documents highlight the prevalence and co-morbidities of vascular diseases and review the results of conservative and invasive treatment."
TASC recommendations
He began by discussing the non-invasive localisation of lesions in the document (Recommendation 38), stating that if a physician wishes to localise and gauge the severity of occlusive arterial lesions to assist in planning an intervention, then Duplex ultrasound, magnetic resonance angiography, and, more recently, computed tomography can be used as a preliminary, non-invasive examination before angiography. He stressed that anatomic localisation must only be considered in patients deemed suitable candidates for revascularisation, either via surgical or endovascular means.
Lammer said that in a situation where endovascular revascularisation and open repair of a specific lesion causing symptoms of PAD give equivalent short-term and long-term improvement, the technique with the least morbidity and mortality must be used first (Recommendation 29).
Unless otherwise indicated, Lammer said the preferred treatment of type A and B lesions is generally endovascular, whereas the treatment of type C lesions can be endovascular or surgical: the risks, benefits, durability and therapeutic goals must be considered for the individual patient. Concerning type D lesions, he said the treatment is generally surgical, although endovascular repair may be considered in certain cases.
The next recommendation (Recommendation 30) concerns the morphologic stratification of aorto-iliac lesions. TASC type A iliac lesions are defined as: single short stenoses of the common iliac artery or external iliac artery (unilateral/bilateral). In addition, TASC type B iliac lesions were defined as: single long stenoses involving the common iliac artery and/or external iliac artery not extending into the common femoral artery; bilateral long stenoses involving the common iliac artery and/or external iliac artery not extending into the common femoral artery; and single occlusion of the common iliac artery or external iliac artery not extending into the common femoral artery.
Furthermore, Lammer said that morphologic stratification of TASC type C aorto-iliac lesions were defined as: bilateral occlusion of the common iliac artery or external iliac artery not extending into the common femoral artery; and iliac stenoses in a patient with an abdominal aortic aneurysm. For TASC type D lesions, the definitions were: unilateral or bilateral external iliac artery stenoses extending into the common femoral artery; unilateral occlusion involving both the common iliac artery and external iliac artery; diffuse stenotic disease involving the aorta and both iliac arteries in a young, normal risk patient; and infrarenal aorto-iliac occlusions.
Morphologic stratification of femoropopliteal lesions (Recommendation 31) for TASC type A were defined as single stenoses/occlusion <10cm (unilateral/bilateral) not involving the trifurcation. In addition, TASC type B femoropopliteal lesions were defined as: multiple stenoses or occlusions <5cm each not involving the trifurcation; single stenoses or occlusion <15cm not involving the trifurcation; and single or multiple lesions in the absence of continuous tibial run-off to improve inflow for distal surgical bypass. TASC type C femoropopliteal lesions were defined as: heavily calcified common femoral artery stenoses; heavily calcified stenoses or occlusions >15cm in length; and recurrent stenoses or occlusions after one redo. Finally, TASC type D femoropopliteal lesions were defined as: complete common femoral artery occlusion; complete SFA occlusion in excess of 20cm; and complete popliteal artery and proximal trifurcation occlusion.
Lammer then revealed recommendations related to antiplatelet drugs as adjuvant pharmacotherapy (Recommendation 35). After revascularisation antiplatelet therapy should be started preoperatively and continued as adjuvant pharmacotherapy after an endovascular or surgical procedure.
Unless subsequently contraindicated, this should be continued indefinitely.
In addition, he commented that surveillance may be beneficial in order to identify a lesion on which to intervene on restenosis to prevent secondary occlusion (Recommendation 36).
When asked which recommendation he believed was the most significant, Lammer commented, "I think the most important recommendation is that we should opt to choose the least invasive techniques. In addition, and this is different to previous guidelines, the recommendations take into account the wishes of the patient. It is very important that the patient is involved in the decision-making process."
Future recommendations
"I think what we are waiting for is recommendations regarding the use of stents. A randomised study we carried out in Vienna (ABSOLUTE Study), which compared PTA and stenting in the femoropopliteal arteries, showed that at the mid-term the patency rates for patients who received stents were significantly better than those who did not."
Lammer stressed that these are "only recommendations and that minor changes may be added. Then they must be finally approved by all societies. We expect to publish the guidelines in the summer."
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