2024 ESC Guidelines for the Management of Peripheral Arterial and Aortic Diseases

Authors, Journal, Affiliations, Type, DOI

• Authors: Lucia Mazzolai (Chairperson, Switzerland), Gisela Teixido-Tura and Stefano Lanzi (Task Force Co-ordinators), with a multidisciplinary task force of cardiologists, vascular surgeons, angiologists, radiologists and internists
• Journal: European Heart Journal. 2024;45:3538–3700
• Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), European Reference Network on Rare Multisystemic Vascular Diseases (VASCERN), European Society of Vascular Medicine (ESVM)
• Type: ESC clinical practice guideline — the first ESC guideline to combine peripheral arterial and aortic disease in one document, and a deliberate replacement for the separate treating-specialty model
• DOI: https://doi.org/10.1093/eurheartj/ehae179

Overview

The ESC's central move is terminological and organisational: peripheral arterial and aortic diseases are one entity — PAAD — with one systemic atherosclerotic driver and one prevention strategy. The guideline calls for "a comprehensive approach that addresses the entirety of the arterial circulation" as a Class I, Level B recommendation, and treats the presence of disease in one territory as a mandate to look for it in another.

Two changes go beyond prior ESC positions. On treatment, PAD is managed as a high-risk coronary equivalent: LDL-C target <1.4 mmol/L with a >50% reduction (I/A), SGLT2 inhibitors and GLP-1 receptor agonists with proven CV benefit in type 2 diabetes with PAAD (I/A), and blood pressure toward 120–129 mmHg (I/A) — targets stricter than the 2018 ESC PAD guideline. On antiplatelet therapy, aspirin loses its automatic primacy: aspirin 75–160 mg or clopidogrel alone is recommended (I/A), with clopidogrel preferred as a possibility (IIb/B), long-term dual antiplatelet therapy actively discouraged (III/A), and low-dose rivaroxaban 2.5 mg twice daily plus aspirin recommended for high ischaemic, non-high-bleeding-risk patients (IIa/A).

On the aortic side it keeps the ESC's preferred vocabulary of significant aortic dilatation rather than "aneurysm", and sets an ascending aortic replacement threshold of ≥55 mm (I/B) with a >52 mm trigger in low-risk patients (IIa/B) — a lower, risk-stratified band than the numerical cut-offs alone imply.

Keywords

Peripheral arterial disease · aortic disease · PAAD · chronic limb-threatening ischaemia · CLTI · acute limb ischaemia · intermittent claudication · ankle-brachial index · supervised exercise therapy · antithrombotic therapy · low-dose rivaroxaban · lipid lowering · LDL-C · diabetes · thoracic aortic aneurysm · abdominal aortic aneurysm · acute aortic syndrome · aortic dissection · intramural haematoma · penetrating aortic ulcer · heritable thoracic aortic disease · Marfan syndrome · Loeys-Dietz syndrome · bicuspid aortic valve · coarctation · carotid stenosis · renal artery stenosis · TEVAR · EVAR

Key Takeaways

Definition, screening and diagnosis of PAD

• ABI ≤0.90 is the diagnostic criterion for lower-limb PAD, and ABI is the first-line non-invasive test (I/B). Non-compressible arteries or ABI >1.40 require toe pressure, toe-brachial index or Doppler waveform analysis (I/B).
• Screen with ABI or TBI in patients ≥65 with cardiovascular risk factors (IIa/C), in diabetes or CKD with a normal resting ABI by TBI (IIa/B), and opportunistically in patients ≥65 without risk factors (IIb/C).
• AAA screening with ultrasound in men ≥65 with a smoking history (I/A); first-degree relatives of AAA patients from age 50 (I/C); men ≥75 irrespective of smoking, or women ≥75 who smoke or are hypertensive (IIb/C).

PAD clinical syndromes

• Three presentations: asymptomatic PAD (pathological ABI without symptoms), symptomatic effort-related PAD (claudication or atypical effort symptoms), and CLTI.
• CLTI is defined haemodynamically, not descriptively: ankle pressure <50 mmHg, toe pressure <30 mmHg or TcPO₂ <30 mmHg, together with ischaemic rest pain, a non-healing ulcer >2 weeks, or gangrene.
• Five-year cumulative incidence of deterioration: 7% from asymptomatic to claudication, 21% from claudication to CLTI. CLTI raises all-cause mortality (RR 2.26) and MACE (RR 1.73) relative to symptomatic PAD.
• Use the WIfI classification to estimate amputation risk when there are wounds.

Medical therapy

• Smoking cessation and abstinence from all tobacco, including e-cigarettes as a long-term habit (I/A).
• Blood pressure: target SBP 120–129 mmHg if tolerated (I/A); ACE-I or ARB as first-line (IIa/B); a more lenient goal (e.g. <140/90) in those ≥85, in residential care (IIa/C) or with severe frailty or life expectancy <3 years (IIb/C).
• Lipids: statin in all PAD (I/A); LDL-C <1.4 mmol/L and >50% reduction (I/A); ezetimibe then PCSK9 inhibitor then bempedoic acid to reach target (I/A–I/B); fibrates not recommended for cholesterol lowering (III/B).
• Diabetes: HbA1c <53 mmol/mol (7%) (I/A); SGLT2 inhibitors and GLP-1 receptor agonists with proven CV benefit are both Class I/A in type 2 diabetes with PAAD, independent of HbA1c.
• Statins for aneurysm growth: IIa/B in AAA, IIb/B in TAA.

Exercise and revascularisation

• Supervised exercise therapy is Class I/A in symptomatic PAD, and I/A as an adjunct after endovascular revascularisation. Walking is first-line; high-intensity protocols (77–95% of maximum heart rate, 14–17 on the Borg scale), ≥3 sessions/week, ≥30 minutes, ≥12 weeks.
• Revascularisation for claudication is IIb/B and only after a 3-month trial of optimal medical therapy and exercise with impaired PAD-related quality of life; not recommended in asymptomatic PAD (III/C) and not recommended solely to prevent progression to CLTI (III/B).
• Femoropopliteal: drug-eluting treatment as first choice (IIa/A). Iliac: balloon angioplasty ± stenting in external iliac, primary stenting in common iliac (IIa/B).

CLTI and acute limb ischaemia

• Revascularisation for limb salvage is I/B, "as soon as possible" (I/B), with autologous vein as the preferred conduit for infra-inguinal bypass (I/B). Patients should be managed by a vascular team (I/C), with offloading of ulcers (I/C) and antibiotics for infection (I/C).
• Lower-limb exercise training is not recommended in CLTI with wounds (III/C) — the direct opposite of the claudication recommendation.
• Acute limb ischaemia: urgent vascular assessment (I/C); immediate revascularisation with neurological deficit (I/C); watch for compartment syndrome and perform fasciotomy (I/C); after revascularisation, DAPT or rivaroxaban 2.5 mg twice daily plus aspirin should be considered (IIa/C).

Thoracic and abdominal aortic aneurysm

• Dilated/significant aortic dilatation: >40 mm in men and >36 mm in women is the practical suspicion threshold; ASI >22 mm/m². The guideline prefers "significant aortic dilatation" with the diameter stated over the word "aneurysm".
• Surveillance: TTE at diagnosis and annually; CCT/CMR for the distal ascending aorta, arch, descending and thoracoabdominal aorta (TTE explicitly not recommended there, III/C). AAA: ultrasound every 3 years at 30–39 mm, annually at 40–49 mm (men) / 40–44 mm (women), every 6 months at 50–55 mm (men) / 45–50 mm (women).
• Repair thresholds: ascending ≥55 mm (I/B), >52 mm in low-risk patients (IIa/B), ≥45 mm at concomitant tricuspid aortic valve surgery (IIa/B); arch ≥55 mm (IIa/B); descending ≥55 mm (I/B); thoracoabdominal ≥60 mm (I/B); AAA ≥55 mm in men or ≥50 mm in women (I/A). Saccular AAA ≥45 mm may be considered for repair (IIb/C).
• TEVAR over open repair for descending TAA without HTAD and suitable anatomy (I/B); EVAR over open repair for ruptured AAA with suitable anatomy (I/B); EVAR preferred for unruptured AAA with suitable anatomy and life expectancy >2 years (IIa/B).
• Left subclavian revascularisation before TEVAR with planned coverage to reduce spinal cord ischaemia and stroke (I/B).
• Endoleak management: re-intervene for type I (I/B) and type III (I/B) endoleaks; consider intervention for type II/V with sac expansion ≥10 mm (IIa/C).

Acute aortic syndromes

• ECG-gated CT from neck to pelvis is first-line imaging (I/C), with the ADD-RS as part of a multiparametric rule-in/rule-out algorithm (I/B); focused TTE during initial evaluation (I/C); TOE to guide peri-operative management (I/C).
• Anti-impulse targets: SBP <120 mmHg and heart rate ≤60 bpm (I/B), with higher mean arterial pressure maintained in spinal ischaemia or concomitant brain injury. IV beta-blockers (labetalol or esmolol) first-line (I/B); IV vasodilators added only if needed (I/B); non-dihydropyridine calcium blocker if beta-blocked is contraindicated (IIa/B); ICU and three-lead ECG (I/B).
• Type A dissection: emergency surgery (I/B); root replacement with a valved conduit where the root is destroyed or there is a known genetic disorder (I/B); aortic valve resuspension where leaflets are intact (I/B); open distal anastomosis (I/B); hemiarch over total arch absent an arch tear (I/B); frozen elephant trunk where there is a secondary arch or proximal descending tear (IIb).
• Type B dissection: medical therapy in all (I/B); TEVAR first-line for complicated (I/B); TEVAR in the subacute phase (14–90 days) in selected high-risk uncomplicated cases (IIa/B). Chronic type B: intervene at ≥60 mm (I/B) or ≥55 mm in low procedural risk (IIa/C).
• IMH and PAU: type A → surgery (I/C); type B → medical therapy with surveillance (I/C); complicated type B → TEVAR. A "wait-and-see" strategy may be considered in selected high-risk patients with uncomplicated type A IMH or PAU without high-risk features (IIb/C).
• Acute type A IMH is unusual in being Class I/C for surgery in both guidelines while the conservative option sits at IIb — the weakest-evidence corner of a very confident document.

Heritable disease and bicuspid aortic valve

• Genetic testing where there is a family history or syndromic features (I/B); cascade testing of relatives irrespective of age (I/C); guided management informed by the specific gene/variant (IIa/B).
• Marfan: beta-blocker or ARB at maximal tolerated dose (I/A), both considered (IIa/A); root surgery at ≥50 mm (I/B), ≥45 mm with additional risk factors (IIa/C); valve-sparing root replacement where anatomy allows (I/B).
• Loeys-Dietz: TTE every 6–12 months and head-to-pelvis imaging every 1–3 years (I/C); surgery when the root exceeds 45 mm (IIa/C), adjusted by gene (IIb/C).
• Bicuspid aortopathy: surgery at ≥55 mm (I/B), ≥50 mm for the root phenotype (I/B), >52 mm for the ascending phenotype in low surgical risk (IIa/B), ≥45 mm at concomitant aortic valve surgery (IIa/C). First-degree relative screening by TTE (IIa/B).
• Coarctation: lifelong follow-up with CCT/CMR every 3–5 years (I/B); repair for hypertension with invasive peak-to-peak gradient >20 mmHg (I/C, stenting preferred).

Other arterial territories

• Carotid: NASCET method for stenosis grading (I/B), ECST explicitly not recommended (III/C); carotid endarterectomy for symptomatic 70–99% stenosis with a documented 30-day death/stroke rate <6% (I/A) and within 14 days (I/B); revascularisation not recommended below 50% (III/A).
• Subclavian, renal and mesenteric: routine revascularisation of atherosclerotic subclavian stenosis (III/C), unilateral renal artery stenosis (III/A) and asymptomatic visceral stenosis (III/C) is not recommended — the guideline is consistently conservative outside symptom-driven indications.

Limitations of the document

• The combined PAAD framing is an editorial act, not an evidence synthesis. The cardiovascular prevention recommendations are largely extrapolated from coronary and polyvascular trial populations, with few PAD-specific outcome trials behind them.
• Class I recommendations frequently rest on Level C evidence — including the entire acute aortic syndrome imaging and surgical strategy section, where the ESC and ACC/AHA agree on the recommendation but not on its evidentiary basis.
• The blood pressure target of 120–129 mmHg in PAD is extrapolated from the broader hypertension literature; there is no PAD-specific randomised trial at that target, and the guideline does not say so.
• The guideline declines to set a single ascending aortic threshold, offering 55 mm, 52 mm, 50 mm and 45 mm depending on risk and context. This is defensible clinically but makes it hard to answer the question "when do I operate?".
• Hong Kong availability is not addressed, particularly for endovascular devices, and the document is written for European health systems.

Key Concepts Mentioned

entities/Peripheral-Artery-Disease · concepts/CLTI · concepts/Acute-Limb-Ischemia · concepts/Ankle-Brachial-Index · concepts/PAD-Medical-Therapy · concepts/PAD-Exercise-Therapy · concepts/Acute-Aortic-Syndrome · concepts/Thoracic-Aortic-Aneurysm · concepts/Abdominal-Aortic-Aneurysm · concepts/Acute-Aortic-Syndrome · concepts/Heritable-Thoracic-Aortic-Disease · entities/Bicuspid-Aortic-Valve · entities/Marfan-Syndrome

Key Entities Mentioned

European Society of Cardiology · European Association for Cardio-Thoracic Surgery · VASCERN · ESVM · VOYAGER-PAD · COMPASS · CLEVER · ERASE · Marfan syndrome · Loeys-Dietz syndrome · vascular Ehlers-Danlos syndrome · Takayasu arteritis · giant cell arteritis

Wiki Pages Updated

• concepts/Acute-Aortic-Syndrome — created
• concepts/Thoracic-Aortic-Aneurysm — created
• concepts/Abdominal-Aortic-Aneurysm — created
• concepts/Heritable-Thoracic-Aortic-Disease — created
• concepts/Acute-Aortic-Syndrome — updated
• entities/Peripheral-Artery-Disease — updated
• concepts/CLTI — updated
• concepts/Acute-Limb-Ischemia — updated
• concepts/PAD-Medical-Therapy — updated
• concepts/PAD-Exercise-Therapy — updated
• concepts/Ankle-Brachial-Index — updated
• entities/Bicuspid-Aortic-Valve — updated
• entities/Marfan-Syndrome — updated
• index — hub entries added