St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
McMaster University, Hamilton, Ontario, Canada.
Can J Cardiol. 2022 May;38(5):560-587. doi: 10.1016/j.cjca.2022.02.029.
Patients with widespread atherosclerosis such as peripheral artery disease (PAD) have a high risk of cardiovascular and limb symptoms and complications, which affects their quality of life and longevity. Over the past 2 decades there have been substantial advances in diagnostics, pharmacotherapy, and interventions including endovascular and open surgical to aid in the management of PAD patients. To summarize the evidence regarding approaches to diagnosis, risk stratification, medical and intervention treatments for patients with PAD, guided by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework, evidence was synthesized, and assessed for quality, and recommendations provided-categorized as weak or strong for each prespecified research question. Fifty-six recommendations were made, with 27% (15/56) graded as strong recommendations with high-quality evidence, 14% (8/56) were designated as strong recommendations with moderate-quality evidence, and 20% (11/56) were strong recommendations with low quality of evidence. Conversely 39% (22/56) were classified as weak recommendations. For PAD patients, strong recommendations on the basis of high-quality evidence, include smoking cessation interventions, structured exercise programs for claudication, lipid-modifying therapy, antithrombotic therapy with a single antiplatelet agent or dual pathway inhibition with low-dose rivaroxaban and aspirin; treatment of hypertension with an angiotensin converting enzyme or angiotensin receptor blocker; and for those with diabetes, a sodium-glucose cotransporter 2 inhibitor should be considered. Furthermore, autogenous grafts are more effective than prosthetic grafts for surgical bypasses for claudication or chronic limb-threatening ischemia involving the popliteal or distal arteries. Other recommendations indicated that new endovascular techniques and hybrid procedures be considered in patients with favourable anatomy and patient factors, and finally, the evidence for perioperative risk stratification for PAD patients who undergo surgery remains weak.
患有广泛动脉粥样硬化疾病（如外周动脉疾病）的患者存在心血管和肢体症状及并发症的高风险，这会影响他们的生活质量和寿命。在过去的 20 年中，在诊断、药物治疗和干预方面取得了实质性进展，包括血管内和开放手术，以帮助管理 PAD 患者。本研究旨在根据推荐分级评估、制定与评价（GRADE）框架，总结有关 PAD 患者诊断、风险分层、药物和介入治疗方法的证据，对证据进行综合评估，并针对每个预设的研究问题提供弱或强的推荐。共提出了 56 项建议，其中 27%（15/56）为高质量证据的强推荐，14%（8/56）为中等质量证据的强推荐，20%（11/56）为低质量证据的强推荐。相反，39%（22/56）为弱推荐。对于 PAD 患者，基于高质量证据的强推荐包括戒烟干预、间歇性跛行的结构化运动方案、降脂治疗、抗血小板药物单药或低剂量利伐沙班联合阿司匹林的双联抗栓治疗；高血压患者使用血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂；对于糖尿病患者，应考虑使用钠-葡萄糖协同转运蛋白 2 抑制剂。此外，自体移植物在治疗因跛行或慢性肢体威胁性缺血而导致的股动脉或远端动脉病变的旁路手术中比人造移植物更有效。其他建议表明，对于具有有利解剖结构和患者因素的患者，可以考虑使用新的血管内技术和杂交手术。最后，对于接受手术的 PAD 患者的围手术期风险分层的证据仍然薄弱。
