Editor's Choice - European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication

Ankle Brachial Index Bare Metal Stent Coronary Artery Disease Confidence Interval Chronic Limb Threatening Ischaemia Cardiac Rehabilitation Computed Tomography Angiography Cardiovascular Dual Antiplatelet Therapy Drug Coated Balloon Drug Eluting Stent Digital Subtraction Angiography expanded PolyTetraFluoroEthylene European Society of Cardiology European Society for Vascular Surgery Guidelines Steering Committee Guideline Writing Committee Home Based Exercise Therapy Hazard Ratio Health Related Quality of Life Intermittent Claudication International Normalised Ratio Major Adverse Cardiovascular Events Major Adverse Limb Events Magnetic Resonance Angiography Odds Ratio Peripheral Arterial Disease Proprotein Convertase Subtilisin/Kexin type 9 Percutaneous Transluminal Angioplasty Patient Reported Outcome Measure Quality Adjusted Life Years Randomised Controlled Trial Risk Ratio Supervised Exercise Therapy Toe Brachial Index Toe Pressure The Active detection and Management of the Extension of atherothrombosis in high Risk coronary patients In comparison with standard of Care for coronary Atherosclerosis Bare Metal Stent Versus Paclitaxel Eluting Stent in the Setting of Primary Stenting of Intermediate Length Femoropopliteal Lesions BIOTRONIK’s First in Man study of the Passeo-18 LUX drug releasing PTA Balloon Catheter vs. the uncoated Passeo-18 PTA balloon catheter in subjects requiring revascularisation of infrapopliteal arteries CANagliflozin cardioVascular Assessment Study Clopidogrel versus vs.Aspirin in Patients at Risk of Ischaemic Events Clopidogrel and AcetylSalicylic acid in bypass surgery for Peripheral ARterial disease Cilostazol:A STudy in Long-term Effects Comparison and Evaluation of Cardiac Biomarkers in Patients with Intermittent Claudication Claudication:Exercise Vs. Endoluminal Revascularisation Covered Versus vs. Balloon Expandable Stent Trial the Danish Cardiovascular Screening trial Dapagliflozin and Prevention of Adverse outcomes in Chronic Kidney Disease trial Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction Dapagliflozin and Cardiovascular Outcomes in Type 2 Diabetes Dutch Iliac Stent trial:COVERed balloon-expandable versus vs.uncovered balloon-expandable stents in the common iliac artery Bypass Oral anticoagulants or Aspirin Trial Comparing ELUVIA Versus vs.Bare Metal Stent in Treatment of Superficial Femoral and/or Proximal Popliteal Artery Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes Empagliflozin in Heart Failure with a Preserved Ejection Fraction Ticagrelor versus vs. Clopidogrel in Symptomatic Peripheral Artery Disease Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk German Epidemiological Trial on Ankle Brachial Index Heart Outcomes Prevention Evaluation Heart Protection Study The Nord-Trøndelag Health Survey Self-Expanding Versus vs.Balloon-Expandable Stents for Iliac Artery Occlusive Disease Invasive revascularisation or not in intermittent claudication Management of peripheral arterial interventions with mono or dual antiplatelet therapy Self-Assessment Method for Statin side-effects Or Nocebo Prevalence of peripheral Arterial disease in patients with a non-high cardiovascular disease risk, with No overt vascular Diseases nOR diAbetes mellitus Prevention Of Progression of Arterial Disease And Diabetes PAD Awareness, Risk, and Treatment: NEw Resources for Survival Alirocumab and Cardiovascular Outcomes after Acute Coronary Syndrome Stents versus vs.angioplasty for the treatment of iliac artery occlusions Supervised Exercise Therapy vs. Endovascular Revascularisation for Intermittent Claudication Caused by Iliac Artery Obstruction Viborg Vascular Trial VIABAHN endoprosthesis versus vs.bare nitinol stent implantation for complex superficial femoral artery occlusive disease Viabahn endoprosthesis with PROPATEN bioactive surface versus vs.bare nitinol stent in the treatment of long lesions in superficial femoral artery occlusive disease Rivaroxaban in Peripheral Artery Disease after Revascularisation YUKON-drug-eluting Stent Below The Knee ZILVER PTX Stent versus vs.Bypass Surgery in Femoropopliteal Lesions Zilver PTX randomised trial of paclitaxel-eluting stents for femoropopliteal artery disease The European Society for Vascular Surgery (ESVS) continuously develops clinical practice guidelines for patients with vascular diseases. This is the first guideline that specifically covers the diagnosis and treatment of patients with atherosclerotic lower extremity peripheral arterial disease (PAD, see also section 2.1) falling within the following clinical stages: (1) asymptomatic lower limb PAD (Rutherford grade 0/Fontaine stage I); and (2) intermittent claudication (IC, Rutherford grade I–III/Fontaine stage IIa and IIb). Thus, the management of patients with chronic limb threatening ischaemia (CLTI) falls outside the primary purpose of this guideline, as the management of such patients is already covered by other recent guidelines from the Society.1Conte M.S. Bradbury A.W. Kolh P. White J.V. Dick F. Fitridge R. et al.Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia.Eur J Vasc Endovasc Surg. 2019; 58: S1-S109Abstract Full Text Full Text PDF PubMed Scopus (648) Google Scholar Throughout the guideline, the term lower limb PAD refers to both aforementioned patient categories, whereas the terms asymptomatic PAD and IC are used where a certain section or recommendation only applies to that particular subcategory. Within the context of this guideline, the term PAD includes atherosclerotic disease from the infrarenal aorta to the toes. The primary aim of the guideline is to assist clinicians and patients in their selection of an optimal diagnostic and therapeutic pathway for PAD during patient centred shared decision making. A secondary aim is to contribute to an aligned management and research process of the disease across European countries and globally. Both the diagnostic and the therapeutic landscapes have evolved markedly within the PAD space during recent years with the introduction of new diagnostic modalities, imaging protocols, and therapeutic options. These include increased understanding and utilisation of non-interventional treatment options such as exercise therapy and secondary preventive pharmacotherapy and continuous advancements in endovascular therapeutic options that are becoming available to an increasing number of PAD patients. The scope of this guideline is to provide comprehensive, evidence based and clear recommendations on as many as possible of the different steps and decisions that fall within the clinical PAD patient management process. The term patient as used in the guideline is all encompassing, including people of all sex identities, and in general, these guidelines apply to adults over the age of 18 years. The clinician responsible for a PAD patient’s care will also differ by country, and will among others include vascular surgeons, angiologists, cardiologists, interventional radiologists, vascular physicians, primary care physicians, and exercise rehabilitation specialists. The guidelines were therefore developed by a multidisciplinary group of specialists in the field (see Appendix B) to promote a high standard of care based on the highest quality evidence available. This guideline should not be considered as a legal standard of care. The document provides guidance and support, and the choice of therapy will ultimately depend on the individual patient and treatment setting and fall within the responsibility of the treating physician. All ESVS guidelines, including app based smartphone and tablet versions, can be downloaded free of charge from the ESVS website (https://www.esvs.org/journal/guidelines/). The AGREE reporting standards for clinical practice guidelines were used throughout the guideline process and the AGREE II checklist is included as supplementary material (Appendix A).2Brouwers M.C. Kerkvliet K. Spithoff K. AGREE Next Steps ConsortiumThe AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines.BMJ. 2016; 352: i1152Crossref PubMed Scopus (436) Google Scholar The development of these guidelines also followed the principal steps suggested for the ESVS guidelines development cycle, and was further informed by the ESVS Clinical Practice Guideline Development Scheme.3Antoniou G.A. Bastos Goncalves F. Bjorck M. Chakfe N. Coscas R. Dias N.V. et al.Editor's Choice - European Society for Vascular Surgery Clinical Practice Guideline Development Scheme: An Overview of Evidence Quality Assessment Methods, Evidence to Decision Frameworks, and Reporting Standards in Guideline Development.Eur J Vasc Endovasc Surg. 2022; 63: 791-799Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Members of the Guideline Writing Committee (GWC) were selected by the guideline chairs in collaboration with the ESVS Guideline Steering Committee (GSC) to represent an expert clinician group deeply involved in the management of PAD. This included representation from the disciplines of vascular surgery, angiology, physiotherapy, and vascular medicine (Appendix A). Members of the GWC have provided annual disclosure statements regarding relationships which might be perceived as conflicts of interest. These are available from ESVS headquarters upon request ([email protected]). Members of the GWC received no financial support from any pharmaceutical, medical device, or industry body to develop these guidelines. Videoconference software support along with travel and accommodation costs for mandatory meetings to develop the guideline were funded by the ESVS. The ESVS GSC was responsible for undertaking the review process which also included several independent external experts outside of the ESVS organisation. The final version was checked and approved by all members of both the GWC and the GSC. Following the completion of the second draft of the guideline on 15 January 2022, the GWC sent out the Guideline draft for review by the Swedish Heart and Lung Association (https://www.hjart-lung.se/om-oss/about-us/); a non-profit Swedish national patient organisation formed in 1939 that strives to improve the quality of life for persons with cardiovascular and lung diseases and works to ensure that patients with heart, vascular, and lung disease receive the care they need. This organisation was invited to review and provide comments from the patient and public perspectives on the full guideline content. After reading through the guideline document the response received stated that, as the organisation does not have medically trained personnel, neither among elected representatives nor civil servants, they could not comment on the specific medical content of the guidelines. They, however, welcomed the work done by the ESVS to design a compilation of knowledge, and in the guidelines propose the best possible care and treatment, based on science and clinical experience. Overall, the guideline content received a positive opinion from the patient organisation. The GWC held an introductory meeting on 23 and 24 June 2021 by video conference, where the list of topics and author assignments was determined by consensual agreement. The GWC met monthly by videoconference to discuss the writing process and any ongoing issues. After the first draft was completed and internally reviewed, the GWC met again on 21 and 22 April 2022 to review and approve the wording and content of each recommendation. If any of the GWC members disagreed with the content of a particular recommendation during this meeting, an open vote was held (where all GWC members participated and had the same voting rights) where a simple majority decision was decisive for acceptance of the recommendation. Detailed search strategies for the different topic specific sections of the guideline are available in Supplementary material. Members of the GWC performed literature searches in Medline/PubMed, Embase, and the Cochrane Library from inception up to the date specified in the search for peer reviewed publications. Hand searching of included references was also performed. As per the ESVS guideline development process cycle, all systematic literature searches were last updated in November 2022 when the GWC worked with the first revision of the guideline draft. The last literature search was done in July 2023. Selection of studies for inclusion was based on the titles and abstracts of retrieved studies. The selection process followed the pyramid of evidence with systematic review and meta-analysis of randomised trials at the top, followed by individual randomised trials, meta-analysis of observational studies, and finally observational studies. Case reports, abstracts, and in vitro studies were excluded leaving expert opinion at the base of the pyramid. Other guideline documents were considered only if they applied a systematic approach for literature searches and or produced their own meta-analyses of existing literature. For section 3.3 where no suitable systematic review or consensus document was available, an extensive DELPHI expert consensus process on the use of patient reported outcome measures was arranged and published separately to support this part of the guideline.4Arndt H. Nordanstig J. Bertges D.J. Budtz-Lilly J. Venermo M. Espada C.L. et al.A Delphi Consensus on patient reported outcomes for registries and trials including patients with intermittent claudication: recommendations and reporting standard.Eur J Vasc Endovasc Surg. 2022; 64: 526-533Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar For section 6.4 of the guidelines where there was no appropriate systematic review and meta-analysis available, such a study was performed by members of the GWC.5Koeckerling D. Raguindin P.F. Kastrati L. Bernhard S. Barker J. Quiroga Centeno A.C. et al.Endovascular revascularization strategies for aortoiliac and femoropopliteal artery disease: a meta-analysis.Eur Heart J. 2023; 44: 935-950Google Scholar The studies that underpin each recommendation are shown directly in the individual recommendation table, and further details are given for each in more comprehensive tables of evidence Supplementary material. The European Society of Cardiology (ESC) system was used for grading the level of evidence and the accompanying class of each recommendation. For each guideline recommendation, the level of evidence was graded from A to C (Table 1) with A being the highest. The strength (class) of each recommendation was graded from I to III with I as the strongest (Table 2). The class II subcategory was also further subcategorised into IIa and IIb based on an overall assessment of the strength and robustness of available evidence alongside concurrent clinical experience and expert consensus opinion within the GWC.Table 1Levels of evidence adapted from the European Society of Cardiology evidence grading system.Level of Evidence AData derived from multiple randomised trials or meta-analyses of randomised trialsLevel of Evidence BData derived from a single randomised trial or large non-randomised studiesLevel of Evidence CConsensus opinion of experts and or small studies, retrospective studies, registries Open table in a new tab Table 2Class of recommendations from the European Society of Cardiology evidence grading system.ClassDefinitionWordingIEvidence and or general agreement that a given treatment or procedure is beneficial, useful, effectiveis recommendedIIaConflicting evidence and or divergence of opinion about the usefulness or efficacy of the given treatment or procedure: weight of evidence or opinion is in favour of usefulness or efficacyshould be consideredIIbConflicting evidence and or divergence of opinion about the usefulness or efficacy of the given treatment or procedure: usefulness or efficacy is less well established by evidence or opinionmay be consideredIIIEvidence or general agreement that a given treatment or procedure is not useful or effective and in some cases may be harmfulis not recommended, should not be done Open table in a new tab This is the first ESVS guideline focusing on asymptomatic PAD and IC. However, the ESC/ESVS 2017 Guidelines on the Diagnosis and Treatment of PAD included several relevant sections and recommendations that potentially overlap with this guideline.6Aboyans V. Ricco J.B. Bartelink M.E.L. Bjorck M. Brodmann M. Cohnert T. et al.Editor's Choice - 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 305-368Abstract Full Text Full Text PDF PubMed Scopus (608) Google Scholar Furthermore, this guideline does not cover acute lower limb PAD presentations, as these are already covered by the ESVS 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia.7Bjorck M. Earnshaw J.J. Acosta S. Bastos Goncalves F. Cochennec F. Debus E.S. et al.Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia.Eur J Vasc Endovasc Surg. 2020; 59: 173-218Abstract Full Text Full Text PDF PubMed Scopus (214) Google Scholar The ESVS 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases contains comprehensive recommendations on antithrombotic therapies for both asymptomatic PAD and IC patients, and the recommendations from that guideline are aligned with this as far as possible; however, an updated literature search was done on this topic to account for potential new evidence that may have emerged following the publication of the antithrombotic guideline. When this guideline changes or updates a previous recommendation from any of these previous guidelines, it is discussed in the relevant section, and all changed or updated recommendations are also briefly summarised below (Table 3).Table 3Brief overview of differences between previous cardiovascular guideline recommendations and this guideline.GuidelineYear of printed publicationRecommendation in previous guidelinesESVS lower limb PAD and intermittent claudication guideline recommendationReasons for differencesCanadian Cardiovascular Society 2022 Guidelines for Peripheral Arterial Disease2022We suggest against routine PAD testing for inferring global cardiovascular risk, in patients without symptoms of PAD, who have clinically symptomatic atherosclerosis in another vascular territory (Weak Recommendation;Moderate quality evidence).Recommendation 4:For clinically asymptomatic individuals at increased risk of lower limb peripheral arterial disease, focused screening for peripheral arterial disease with ankle brachial index measurements based on the lowest recorded ankle pressure may be considered, to support secondary prevention strategies. (IIb, B)They suggest against screening in patients who already manifested atherosclerotic symptoms from other vascular territories than the legs (and thus are already considered having a high cardiovascular risk).European Society for Vascular Medicine (ESVM) Guideline on Peripheral Arterial Disease2019It is recommended that patients with diabetes should be screened for PAD (Class I Level B)Recommendation 4:For clinically asymptomatic individuals at increased risk of lower limb peripheral arterial disease, focused screening for peripheral arterial disease with ankle brachial index measurements based on the lowest recorded ankle pressure may be considered, to support secondary prevention strategies. (IIb, B)They recommend PAD screening only for patients with diabetes whereas the ESVS guideline suggest focused screening in a broader high risk population (see section 3.1.1.2).2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)2018In patients with coronary artery disease, screening for lower extremity atherosclerotic disease (LEAD) by ABI measurement may be considered for risk stratification. (IIb, B)Screening for LEAD may be considered in patients with heart failure. (IIb, C)Recommendation 4:For clinically asymptomatic individuals at increased risk of lower limb peripheral arterial disease, focused screening for peripheral arterial disease with ankle brachial index measurements based on the lowest recorded ankle pressure may be considered, to support secondary prevention strategies. (IIb, B)They recommend PAD screening only for patients with manifest coronary artery disease or heart failure whereas this guideline suggests focused screening in a broader high risk population (see section 3.1.1.2).2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)2018Measurement of the ABI is indicated as a first line non-invasive test for screening and diagnosis of lower extremity atherosclerotic disease (LEAD). (Class 1 Level C)Recommendation 5:The ankle brachial index is recommended as the appropriate test to establish the diagnosis of lower limb peripheral arterial disease.(I, B)Current evidence level supports upgrading from level C to B, based on two review studies, one systematic Cochrane review, one meta-analysis, and one clinical trial (see section 3.1.3.1)Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication2015Recommendation 2.1We recommend using the ABI as the first line non-invasive test to establish a diagnosis of PAD in individuals with symptoms or signs suggestive of disease. When the ABI is borderline or normal (> 0.9) and symptoms of claudication are suggestive, we recommend an exercise ABI. (Grade 1 Level A)Recommendation 5:The ankle brachial index is recommended as the appropriate test to establish the diagnosis of lower limb peripheral arterial disease.(I, B)Current evidence level supports a downgrading from level A to B. (see section 3.1.3.1)European Society for Vascular Medicine (ESVM) Guideline on Peripheral Arterial Disease2019Measurement of the ABI by non-invasive measurements using Doppler occlusion pressure is indicated as an appropriate test to verify PAD. (Class 1 Level C)Recommendation 5:The ankle brachial index is recommended as the appropriate test to establish the diagnosis of lower limb peripheral arterial disease.(I, B)Current evidence level supports upgrading from level C to B, based on two review studies, one systematic Cochrane review, one meta-analysis and one clinical trial (see section 3.1.3.1)European Society for Vascular Medicine (ESVM) Guideline on Peripheral Arterial Disease2019It is recommended that ABI values ≤ 0.9 are evidence of significant PAD. (Class I Level B)Recommendation 6:It is recommended that an ankle brachial index cutoff value at ≤ 0.9 is used for lower limb peripheral arterial disease diagnosis, and that a value ≥ 1.4 be considered inconclusive.(I, C)A cutoff value has been added for incompressible ankle arteries (ABI ≥ 1.4) which led to an overall downgrading of evidence to level C. No references are provided in support of the level B evidence level in the ESVM guideline.European Society for Vascular Medicine (ESVM) Guideline on Peripheral Arterial Disease2019It is recommended that the ABI score with the highest ankle artery pressure value is to be used for the calculation of ABI. (Class I Level C)Recommendation 7:When the ankle brachial index is used to estimate the severity of lower limb peripheral arterial disease in symptomatic patients or is being used during follow up after revascularisation, it is recommended to be calculated by dividing the highest systolic pressure at the ankle level by the highest systolic arm pressure. (I, B)The recommendation has been upgraded to level B based on two observational studies and one review. The level C evidence statement suggested by ESVM refers to the scientific statement from the American Heart Association. (Aboyans et al. Circulation 2012) that in turn suggested a Grade I Level A recommendation.Canadian Cardiovascular Society 2022 Guidelines for Peripheral Arterial Disease2022We recommend smoking cessation interventions ranging from intensive counselling, nicotine replacement therapy, bupropion, varenicline, and sometimes nicotine e-cigarettes (Strong Recommendation; High quality Evidence).Recommendation 22:For patients with lower limb peripheral arterial disease who smoke, councelling as part of intensive smoking cessation intervention is recommended. (I, B)Recommendation 23:For patients with lower limb periperal arterial disease who smoke, varenicline, either alone or in combination with nicotine replacement therapy, is recommended as the first line pharmacological smoking cessation treatment due to its higher effectiveness as compared to other pharmacological alternatives. (I, B)We considered the current evidence base differently, especially for bupropion. We also considered the potential harm of e-cigarettes (see chapter 4.1.1.1)Canadian Cardiovascular Society 2022 Guidelines for Peripheral Arterial Disease2022Statin add on therapies (ezetimibe and or PCSK-9 inhibitors) if receiving maximally tolerated dose of statin therapy and the low density lipoprotein cholesterol is ≥ 1.8 mmol/L, non-high density lipoprotein cholesterol ≥ 2.4 mmol/L or apolipoprotein B 100 ≥ 0.7 mg/dL.Recommendation 32:For patients with lower limb peripheral arterial disease, it is recommended to reduce the low density lipoprotein cholesterol concentrations to < 1.4 mmol/L (< 55 mg/dL) and decrease it by ≥ 50% if baseline values are within 55–110 mg/dL. (I, B)We recommended a slightly lower low density lipoprotein cholesterol threshold, although we recognise that the current evidence for a lower threshold is mainly based on heterogeneous cohorts and was mainly driven by positive data from recent trials on PCSK-9 inhibitors.2021 ESC Guidelines on cardiovascular disease prevention in clinical practice2021Considered to be at high risk:Documented atherosclerotic cardiovascular disease (ASCVD), clinical or unequivocal on imaging. Documented clinical ASCVD includes previous AMI, ACS, coronary revascularisation and other arterial revascularisation procedures, stroke and TIA, aortic aneurysm and PAD.Symptomatic or asymptomatic lower extremity atherosclerotic disease (LEAD) (ABI < 0.90) is associated with a doubling of the 10 year rate of coronary events, CV mortality, and total mortality.Recommendation 44For patients with lower limb peripheral arterial disease, even if asymptomatic, it is recommended to consider an ankle brachial index ≤ 0.9 or ≥ 1.4 a risk enhancing factor for a cardiovascular event and for an increased all cause mortality. (I, A)The ESC document classifies PAD as a documented ASCVD, and further emphasises the high cardiovascular risk associated with PAD.In our document we have suggested a diagnostic method for PAD which is not given in the ESC guideline.European Society for Vascular Medicine (ESVM) Guideline on Peripheral Arterial Disease2019It is recommended that recognition be given that patients with PAD have a high risk of vascular events in other vascular beds, and as such these patients should always be considered very high risk for further events. (Class I Level A)andIt is recommended that ABI values ≤ 0.9 are evidence of significant PAD (Class I Level B)Recommendation 44:For patients with lower limb peripheral arterial disease, even if asymptomatic, it is recommended to consider an ankle brachial index ≤ 0.9 or ≥ 1.4 a risk enhancing factor for a cardiovascular event and for an increased all cause mortality. (I, A)The two quoted recommendations from ESVM together provide a similar message to recommendation 43 in this guideline.Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication2015Recommendation 5.5We recommend the selective use of BMS or covered stents for aorto-iliac angioplasty for common iliac artery or external iliac artery occlusive disease, or both, due to improved technical success and patency. (Grade 1 Level B)Recommendation 55:For patients with disabling intermittent claudication undergoing revascularisation, primary bare metal stenting is recommended over primary balloon angioplasty for iliac artery occlusions due to the lower risk of distal embolisation. (I, B)We have also considered the risk of distal embolisation when performing balloon angioplasty on iliac artery occlusions why we did not recommend selective use of stents for iliac artery occlusions. We also considered the results from the recently published DISCOVER trial that did not show any benefit of covered vs. uncovered stents in the common iliac artery (see chapter 6.4).Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: Management of asymptomatic disease and claudication2015Recommendation 5.6We recommend the use of covered stents for treatment of AIOD in the presence of severe calcification or aneurysmal changes where the risk of rupture may be increased after unprotected dilation. (Grade 1 Level C)Recommendation 57:For patients with disabling intermittent claudication undergoing revascularisation who have Trans-Atlantic Inter-Society Consensus Document II C/D iliac lesions, covered stent placement may be considered over bare metal stents due to higher patency rates. (IIb, B)Our recommendation more precisely targets complex (i.e., TASC II C and D) aorto-iliac lesions, where the risk of vessel rupture is substantially higher. We also considered the results of the recently published