Guideline sources The following summarized guidelines for the evaluation and management of subclavian and brachiocephalic artery stenosis are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC/ESVS 2018) and the Society for Cardiovascular Angiography and Interventions (SCAI/SNIS/SVM/AANS/ASNR/CNS/AANN/SVS/AHA/ACR/SAIP/ACC/ASA/SIR 2011). 1 2 Guidelines 1. Screening and diagnosis Indications for screening: Screen for PAD of lower and upper extremities in patients undergoing TAVI or other structural interventions requiring an arterial approach. B Obtain full vascular assessment in all patients being candidates for heart transplantation or cardiac assist device implantation. B https://web.pathway.md/diseases/recLztgs0fyrL4n6Q 1/3 6/24/23, 3:13 PM Subclavian and brachiocephalic artery stenosis Pathway 2. Diagnostic investigations Diagnostic imaging: obtain CT angiography or MRA for detection of vertebral artery disease as part of the initial evaluation of patients with subclavian steal syndrome. B 3. Medical management Management of hypertension: Target controlling BP at < 140/90 mmHg in patients with PAD and hypertension. A Consider offering ACEIs or ARBs as first-line therapy in patients with PAD and hypertension. C Management of dyslipidemia: Offer statins in all patients with PADs. A Target reducing LDL cholesterol to < 1.8 mmol/L (< 70 mg/dL) or decreasing it by 50% if baseline values are 1.8-3.5 mmol/L (70-135 mg/dL). B Management of diabetes mellitus: obtain strict glycemic control in patients with diabetes mellitus and PAD. B 4. Nonpharmacologic interventions Lifestyle modifications: advise smoking cessation B , healthy diet and physical activity in all patients with PADs. B 5. Therapeutic procedures Indications for revascularization: consider performing revascularization in symptomatic patients with subclavian artery stenosis/occlusion. C Show 2 more Endovascular revascularization: consider performing percutaneous angioplasty and stenting in patients with symptomatic anterior cerebral ischemia caused by brachiocephalic artery occlusive disease. C Show 3 more 6. Surgical interventions Surgical revascularization: consider performing revascularization by direct arterial reconstruction or extra-anatomic bypass surgery in patients with symptomatic ischemia involving the anterior cerebral circulation caused by common carotid or brachiocephalic artery occlusive disease. C Show 4 more https://web.pathway.md/diseases/recLztgs0fyrL4n6Q 2/3 6/24/23, 3:13 PM Subclavian and brachiocephalic artery stenosis Pathway 7. Quality improvement Hospital requirements: healthcare centers should set up a multidisciplinary vascular team to make decisions for the management of patients with PADs. B References 1. Victor Aboyans, Jean-Baptiste Ricco, Marie-Louise E L Bartelink et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery ESVS Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization ESO The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology ESC and of the European Society for Vascular Surgery ESVS . Eur Heart J. 2018 Mar 1;39 9 763 816. Open 2. Brott TG, Halperin JL, Abbara S et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation. 2011 Jul 26;124 4 489 532. Open https://web.pathway.md/diseases/recLztgs0fyrL4n6Q 3/3