{"markup":"\u003C?xml version=\u00221.0\u0022 encoding=\u0022UTF-8\u0022 ?\u003E\n    \u003Chtml version=\u0022HTML+RDFa+MathML 1.1\u0022\n    xmlns:content=\u0022http:\/\/purl.org\/rss\/1.0\/modules\/content\/\u0022\n    xmlns:dc=\u0022http:\/\/purl.org\/dc\/terms\/\u0022\n    xmlns:foaf=\u0022http:\/\/xmlns.com\/foaf\/0.1\/\u0022\n    xmlns:og=\u0022http:\/\/ogp.me\/ns#\u0022\n    xmlns:rdfs=\u0022http:\/\/www.w3.org\/2000\/01\/rdf-schema#\u0022\n    xmlns:sioc=\u0022http:\/\/rdfs.org\/sioc\/ns#\u0022\n    xmlns:sioct=\u0022http:\/\/rdfs.org\/sioc\/types#\u0022\n    xmlns:skos=\u0022http:\/\/www.w3.org\/2004\/02\/skos\/core#\u0022\n    xmlns:xsd=\u0022http:\/\/www.w3.org\/2001\/XMLSchema#\u0022\n    xmlns:mml=\u0022http:\/\/www.w3.org\/1998\/Math\/MathML\u0022\u003E\n  \u003Chead\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_itu2PgFdrjV-docKmLK8Jn5oXe_05RgvQh73eOhI_mE.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_at_symbol.js?nzmk6p\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_article_reference_popup.js?nzmk6p\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/js\/js_I8yX6RYPZb7AtMcDUA3QKDZqVkvEn35ED11_1i7vVpc.js\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\n(function(i,s,o,g,r,a,m){i[\u0022GoogleAnalyticsObject\u0022]=r;i[r]=i[r]||function(){(i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o),m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m)})(window,document,\u0022script\u0022,\u0022\/\/www.google-analytics.com\/analytics.js\u0022,\u0022ga\u0022);ga(\u0022create\u0022, \u0022UA-15605596-27\u0022, {\u0022cookieDomain\u0022:\u0022auto\u0022});ga(\u0022set\u0022, \u0022page\u0022, location.pathname + location.search + location.hash);ga(\u0022send\u0022, \u0022pageview\u0022);ga(\u0027create\u0027, \u0027UA-189672-26\u0027, \u0027auto\u0027, {\u0027name\u0027: \u0027hwTracker\u0027});\r\nga(\u0027hwTracker.send\u0027, \u0027pageview\u0027);\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022\u003E\n\u003C!--\/\/--\u003E\u003C![CDATA[\/\/\u003E\u003C!--\njQuery.extend(Drupal.settings, {\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;9\\\/2\\\/6\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;9\\\/2\\\/6\u0022}],\u0022ac\u0022:{\u0022spmdc;9\\\/2\\\/6\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;9\\\/2\\\/6\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003ERecently, options for the endovascular treatment of peripheral vascular disease\u2014including carotid artery disease, renal artery disease, and peripheral artery disease of the legs\u2014have expanded dramatically. In general, physicians tend to use endovascular techniques for first-line therapy and reserve surgery for more complex cases. This article discusses the benefits and drawbacks of optimal medical therapy compared with endovascular or surgical approaches to vascular disease.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHypertensive Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERenal Artery Obstruction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERenal Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003ERecently, options for the endovascular treatment of peripheral vascular disease\u2014including carotid artery disease, renal artery disease, and peripheral artery disease of the legs\u2014 have expanded dramatically. In general, physicians tend to use endovascular techniques for first-line therapy and reserve surgery for more complex cases. In this presentation, Michael R. Jaff, DO, Massachusetts General Hospital, Boston, MA, discussed the benefits and drawbacks of optimal medical therapy compared with endovascular or surgical approaches to vascular disease.\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECarotid Artery Disease\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003ECurrently, there is no consensus regarding the optimal treatment for carotid stenosis. In a 2008 poll of \u003Cem\u003ENew England Journal of Medicine\u003C\/em\u003E readers worldwide, approximately 49% said that they favored aggressive medical management as first-line treatment. Remaining respondents favored either carotid endarterectomy (31%) or stenting (20%) (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). When surgery or stenting is chosen, survey respondents commented that the selection of an experienced surgeon or interventionalist who has a history of low complication rates is critical to achieving the best possible outcome [Klein A et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2008].\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/2\/6\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Worldwide Preferences for the Management of Carotid Artery Disease.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1930953153\u0022 data-figure-caption=\u0022Worldwide Preferences for the Management of Carotid Artery Disease.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/2\/6\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/2\/6\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/9\/2\/6\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11550\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003EWorldwide Preferences for the Management of Carotid Artery Disease.\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ECopyright \u00a9 Massachusetts Medical Society 2008. All rights reserved.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EOngoing trials may help to determine the optimal treatment approach in select patient subgroups, Dr. Jaff said. The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), which is expected to report preliminary results by early 2010, may help clarify the best approach for standard-risk symptomatic or asymptomatic patients. The Asymptomatic Carotid Trial (ACT 1) and Asymptomatic Carotid Surgery Trial 2 (ACST 2) will also compare carotid artery stenting with carotid endarterectomy in standard-risk, asymptomatic patients.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ERenal artery disease\u003C\/h2\u003E\n         \u003Cp id=\u0022p-6\u0022\u003ETo date, the optimal intervention for patients with atherosclerotic renal artery stenosis has not been determined. In 2006, a systematic review of clinical trial data, commissioned by the Agency for Healthcare Research and Quality (AHRQ), concluded that the available evidence does not clearly support renal artery revascularization over medical treatment for the treatment of renal artery stenosis [Balk E et al. \u003Cem\u003EAnn Intern Med\u003C\/em\u003E 2006].\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EBased on current data, renal intervention should be offered as a treatment option only after a reasonable trial of optimal antihypertensive therapy fails to normalize blood pressure. In addition, patient history must demonstrate that blood pressure cannot be controlled with pharmacological therapy alone and that chronic kidney disease is due to renal ischemia rather than another cause. Ideally, treatment of renal artery disease should help normalize blood pressure, maintain renal function, and reduce the long-term risk of cardiovascular events and mortality.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003ERenal artery revascularization is not likely to gain widespread support without rigorous head-to-head comparison with optimal medical treatment, Dr. Jaff said. The Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial is designed to determine whether best medical therapy that is combined with stenting of hemodynamically significant renal artery stenosis in patients with systolic hypertension can reduce the incidence of adverse cardiovascular and renal events compared with best medical therapy alone. Findings from CORAL may determine the future of revascularization for patients with renal artery stenosis.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPeripheral Artery Disease\u003C\/h2\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EPeripheral artery disease (PAD) is associated with an increase in the risk of coronary artery and cerebrovascular disease, suggesting that the effective management of PAD has broad implications for overall cardiovascular health. Peripheral endovascular revascularization has been shown in certain series to lead to significant and sustained improvements in symptoms, physical function, and quality of life in patients with symptomatic disease [Safley DM et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2007].\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003ETechnological advances have expanded revascularizaton options for patients with PAD. Stent implantation for disease of the superficial femoral artery has been associated with high rates of late clinical failure. Therefore, percutaneous transluminal angioplasty has been the preferred technique for endovascular treatment, particularly in short (\u0026lt;7 cm) lesions, with stent deployment recommended only in the event of suboptimal technical results. However, recent data have shown that primary implantation of a self-expanding nitinol stent is more effective than primary balloon angioplasty in preventing restenosis at 6 months and improving treadmill testing outcomes at 6 and 12 months [Schillinger M et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2006].\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003ERecent data also suggest that drug-coated balloons provide a promising option for the treatment of PAD. In a pilot trial of 87 patients with PAD, paclitaxel-coated balloon catheters reduced restenosis compared with standard balloons and caused no obvious adverse events in patients who were undergoing angioplasty of the femoropopliteal arteries [Werk M et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2008].\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EIn conclusion, Dr. Jaff cautioned that technically successful procedures do not always translate into clinically important improvements. Future trials should incorporate clinically meaningful endpoints, such as walking distance, ulcer healing, and prevention of limb loss, to demonstrate the true clinical benefits of revascularization.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EState-of-the-Art Revascularization Therapy: Multivessel and Left Main Disease\u003C\/h2\u003E\n         \u003Cp id=\u0022p-13\u0022\u003ECoronary artery bypass grafting (CABG) remains the standard of care for patients with left main or multivessel coronary artery disease. However, for a subset of patients, percutaneous coronary intervention (PCI) is as safe and effective as CABG. In this presentation, Marie-Claude Morice, MD, Institut Hospitalier, Massy, France, compared CABG and PCI for patients with left main or multivessel coronary artery disease.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EImprovements in PCI, especially the advent of drug-eluting stents (DES), have led to an increase in the use of PCI in patients who are candidates for either PCI or CABG. The most recent trial to compare these procedures, the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) study, provides important lessons regarding revascularization in the patient population, Professor Morice said.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EIn the international SYNTAX trial, 1800 patients with 3-vessel or left main coronary artery disease were randomly assigned to either revascularization with CABG (n=897) or PCI (n=903) that involved DES. Patients enrolled in the SYNTAX trial had complex disease, including bifurcation in 72% of patients, medically treated diabetes in approximately 25% of patients, and more than 4 lesions on average. The primary endpoint was any major adverse cardiac or cerebrovascular event (MACCE), including death from any cause, stroke, MI, or repeat revascularization.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EAfter 1 year, the risk of MACCE was significantly higher in the PCI group than in the CABG group (17.8% vs 12.4%; p=0.002), due primarily to an increase in the rate of repeat revascularization (13.5% vs 5.9%; p\u0026lt;0.001). Conversely, the risk of stroke was significantly higher in the CABG group than in the PCI group (2.2% vs 0.6%; p=0.003). However, the noninferiority criteria were not met for the SYNTAX trial, because the primary endpoint of MAACE was significantly higher for PCI [Serruys PW et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EFindings from SYNTAX suggest that CABG should remain the standard of care for patients with left main or multivessel coronary artery disease. However, PCI is an excellent alternative to CABG in some patients, Professor Morice said. Future trials will seek to identify which patients are most likely to benefit from PCI.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2009 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/9\/2\/6.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmk6p\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmk6p\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}