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BMJ 2003;326:584-588 ( 15 March )

Clinical review

Management of peripheral arterial disease in primary care

Paul Burns, research fellow=20 a, Stephen Gough,=20 reader b, Andrew=20 W Bradbury, professor=20 a. 

a Department of Vascular Surgery, University of Birming= ham,=20 Birmingham B9 5SS, b Department of Medicine, University of= =20 Birmingham

Correspondence to A W Bradbury, University Department of Vascular Surge= ry,=20 Lincoln House (Research Institute), Heartlands Hospital, Bordesley Green E= ast,=20 Birmingham B9 5SS

Best medical treatment for peripheral arterial disease, including ma= naging=20 hypertension and diabetes, reduces morbidity and mortality and = can=20 obviate the need for invasive intervention

One in five of the middle aged (65-75 years) population of the Uni= ted=20 Kingdom have evidence of peripheral arterial disease on clinica= l=20 examination, although only a quarter of them have symptoms. The= most=20 common symptom is muscle pain in the lower limbs on exerciseintermittent claudication.1= =20 Invasive interventions (angioplasty, stenting, surgery) undoubt= edly=20 have a role in the management of peripheral arterial disease.=20 However, in common with coronary artery disease, the morbidity = and=20 mortality associated with peripheral arterial disease can be gr= eatly=20 reduced, and the results of intervention significantly improved= , by=20 the institution of so called "best medical treatment," much of = which=20 can be implemented in primary care. <= /A>
Summary=20 points=20

Diagnosis of peripheral arterial disease is based mainly on the hi= story,=20 with examination and ankle brachial pressure index being used to c= onfirm=20 and localise the disease=20
Peripheral arterial disease is a marker for systemic atheroscleros= is;=20 the risk to the limb in claudication is low, but the risk to life = is=20 high=20
Patients with intermittent claudication should initially be treate= d with=20 "best medical treatment"; some patients may be candidates for=20 percutaneous angioplasty, but this treatment is not based on evide= nce=20
Patients should be referred to a vascular surgeon if there is doub= t=20 about the diagnosis or evidence of aortoiliac disease or if the pa= tient=20 has not responded to best medical treatment or has severe disease= =20




 =   Sources and selection=20 criteria
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Sources and selection criteria
Diagnosis and assessment
The rationale for best...
Components of best medical...
When should a patient...
Ongoing research
References

We used Medline to identify recent reviews and articles on the epidemio= logy,=20 assessment, and treatment of peripheral arterial disease and=20 intermittent claudication, by using the terms "intermittent=20 claudication," "peripheral arterial disease," and "peripheral=20 vascular disease." We also consulted standard textbooks, national=20 and local guidelines, and service frameworks.


<= /TABLE>


View larger= =20 version (125K):
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  		Fig 1.   Angiogram sho= wing=20 bilateral femoral artery occlusions in a patient with claudica= tion=20
 =   Diagnosis and assessment
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Sources and selection criteria
Diagnosis and assessment
The rationale for best...
Components of best medical...
When should a patient...
Ongoing research
References

A diagnosis of intermittent claudication can usually be made on the bas= is of=20 the history3D---the Edinburgh claudication questionnaire is=20 highly specific (91%) and sensitive (99%) for the condition (ta= ble A=20 on bmj.com).2= The=20 differential diagnosis includes both venous and neurogenic=20 claudication (table 1).=20 Examination usually reveals weak or absent pulses, and further= =20 investigations (duplex ultrasonography, angiography) are usuall= y=20 reserved for the small minority of patients in whom invasive=20 intervention is being considered (fig 1).
=
 =   The rationale for best medical=20 treatment
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Sources and selection criteria
Diagnosis and assessment
The rationale for best...
Components of best medical...
When should a patient...
Ongoing research
References

Contrary to popular belief, the risk of a person with claudication=20 progressing to critical limb ischaemia and needing amputation i= s low=20 (<1% a year). However, the risk of death, mainly from coronary and=20 cerebrovascular events, is high (5-10% a year), some three to f= our=20 times greater than that of an age and sex matched population wi= thout=20 claudication (fig 2 and fi= g A on=20 bmj.com15).=20 Initial management should consist of modification of vascular r= isk=20 factors and implementation of best medical treatment in the=20 expectation that this will extend life, reduce still further th= e risk=20 of critical limb ischaemia, and improve the patient's functiona= l=20 status. Only when best medical treatment has been instituted an= d=20 given sufficient time to take effect should endovascular or sur= gical=20 intervention be considered, as most patients' symptoms improve = with=20 best medical treatment to a point where invasive intervention i= s no=20 longer needed.3= =20 Best medical treatment is beneficial even in patients who event= ually=20 need invasive treatment, as the safety, immediate success, and= =20 durability of intervention is greatly improved in patients who = adhere=20 to best medical treatment. 4= 5= =20


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  		<= STRONG>

Table 1.  Differential diagnosis= of=20 intermittent=20 claudication



 =   Components of best medical=20 treatment
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Sources and selection criteria
Diagnosis and assessment
The rationale for best...
Components of best medical...
When should a patient...
Ongoing research
References

Table = 2=20 summarises the components of best medical treatment and their effects on=20 peripheral arterial disease, vascular events, and=20 mortality.

Smoking cessation
Complete and permanent cessat= ion of=20 smoking is by far the single most important factor determining = the=20 outcome of patients with intermittent claudication.w5=20 Unfortunately, rates of cessation after simple oral or written = advice=20 from a doctor are as low as 13% at two years.6= =20 Randomised controlled trials have shown that nicotine replaceme= nt=20 treatment approximately doubles the cessation rate in unselecte= d=20 smokers.w2 Bupropion has a similar benefit when used with inten= sive=20 support.w3 Both treatments are now available on prescription, a= nd=20 every patient with claudication should be offered nicotine=20 replacement treatment in the first instance. Not all nicotine=20 replacement preparations (patches, gum, sprays) are the same, a= nd if=20 one preparation is unsuccessful then other preparations, or=20 combinations with different delivery profiles, should be tried.= The=20 Cochrane group found smoking classes but not alternative therap= ies=20 (hypnotherapy, acupuncture, or "aversive smoking") to be=20 beneficial.7-9,w4=20


<= /TABLE>

Antiplatelet agents
The Antiplatelet Trialists'= =20 Collaboration showed that prescription of an antiplatelet agent= ,=20 usually aspirin, reduced vascular death in patients with any=20 manifestation of atherosclerotic disease by about 25% and that= =20 antiplatelet agents were equally effective in patients who pres= ent=20 with coronary artery disease and with peripheral arterial disea= se.10,w8=20 Some indirect evidence shows that some antiplatelet agents may = also=20 improve walking distance in people with claudication.w10 Clopid= ogrel=20 is at least as effective as, and possibly more effective than,= =20 aspirin in patients with peripheral arterial disease and has a = better=20 side effect profile.w9 However, it is much more expensive and i= s=20 generally reserved for the sizeable minority of patients with=20 peripheral arterial disease who cannot take aspirin or who cont= inue=20 to have events on aspirin. No data exist to support the routine= use=20 of combination treatment (aspirin and clopidogrel) in patients = with=20 peripheral arterial disease, but trials are under way.=20



View larger= =20 version (32K):
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  		Fig 2.   Outcome for p= atients=20 with intermittent claudication over five years14=20
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Table 2.  Components of best med= ical=20 treatment in peripheral arterial=20 disease

Management of diabetes mellitus
Diagnosis of ty= pe=20 2 diabetes, or its exclusion, is important in patients wit= h=20 peripheral arterial disease (box), but this is not straightforw= ard.11 A=20 threshold of fasting glucose >7.0 mmol/l, as recommended by= =20 Diabetes UK, should be supported by symptoms of diabetes and ma= y miss=20 a large number of asymptomatic patients (20-30%). The oral gluc= ose=20 tolerance test is the "gold standard" but is logistically diffi= cult.=20 In practice, random blood glucose may be the easiest measure to= =20 obtain; a random blood glucose >11.1 mmol/l (plasma glucose= =20 performed in an accredited laboratory not finger prick, capilla= ry=20 glucose) is diagnostic of type 2 diabetes, and a random bl= ood=20 glucose of 7.0-11.1 mmol/l should followed with an oral gl= ucose=20 tolerance test.
Rationale for sc= reening=20 for diabetes mellitus in intermittent claudication=20

  • Up to 20% of patients with intermittent claudication have diab= etes;=20 in up to 50% of cases this may be undiagnosed at the time of=20 presentation=20
  • The United Kingdom prospective diabetes study has shown that=20 intensive glycaemic control reduces the microvascular complication= s of=20 type 2 diabetes and that the use of metformin reduces macrova= scular=20 complications in overweight people with diabetesw8,w9=20
  • Most studies show that diabetes is a powerful risk factor for= =20 progression to critical limb ischaemia16=20
  • Patients with diabetes should have tighter limits placed on bl= ood=20 pressure and, possibly, lipid concentrations 17=20 18=20
  • Diabetic patients are more likely to have spuriously high ankl= e=20 pressures19=20
  • Diabetic patients respond less well to surgical intervention b= ut=20 gain a greater benefit from medical treatments for cardiovascular= =20 disease than do non-diabetic patients20=20
  • Many diabetic patients have neuropathy, which, in combination = with=20 arterial insufficiency, puts them at increased risk of neuroischae= mic=20 tissue loss

Hypertension
The benefit of treating hypertensi= on in=20 terms of reducing stroke and coronary events is well accepted;= =20 data indicate a target of less than 140/85 mm Hg for non-diabet= ic=20 patients and 140/80 mm Hg for patients with type=20 2 diabetes.w13 However, in the short term a reduction in b= lood=20 pressure may worsen intermittent claudication. This is true of= =20 whatever drug treatment has been used, and no evidence exists t= hat=20 3D"beta blockers are particularly culpable.12=20 The heart outcomes prevention evaluation study has shown that=20 ramipril, an angiotensin converting enzyme inhibitor, reduces=20 cardiovascular morbidity and mortality in patients with periphe= ral=20 arterial disease by around 25%.w15,w16 Patients did not have to= be=20 hypertensive to be included in the study, and the observed risk= =20 reduction could not be accounted for by the relatively modest=20 reduction in blood pressure. The implication of the heart outco= mes=20 prevention evaluation study is that most patients with peripher= al=20 arterial disease would benefit from an angiotensin converting e= nzyme=20 inhibitor, provided that treatment is not associated with a=20 deterioration of renal function due to occult renal artery= =20 stenosis.

Exercise
A recent Cochrane review has shown tha= t=20 exercise treatment can produce a significant and clinically=20 meaningful increase in walking distance (150%) in most people w= ith=20 claudication who adhere to it.w20 Although the exact= =20 mechanisms by which exercise leads to clinical improvement have= not=20 been precisely defined, several factors that help to maximise b= enefit=20 from exercise treatment have been identified (table B on bmj.co= m).=20 The clinical effectiveness and cost effectiveness of best medic= al=20 treatment, best medical treatment plus supervised exercise, and= best=20 medical treatment plus angioplasty are currently being evaluate= d in=20 the exercise versus angioplasty in claudication trial funded by= =20 Health Technology Assessment.

Reduction in cholesterol
The heart protection s= tudy has=20 shown that lowering total cholesterol and low density lipoprote= in=20 cholesterol by 25% with a statin reduces cardiovascular mortali= ty and=20 morbidity in patients with peripheral arterial disease by aroun= d a=20 quarter, irrespective of age, sex, or baseline cholesterol=20 concentration.w6 The implication is that every patient with=20 peripheral arterial disease should be treated with a statin. Th= e=20 lipid profile should be measured before and six weeks after sta= rting=20 treatment, to ensure that a 25% reduction in cholesterol is bei= ng=20 achieved and to identify those few patients with very high=20 cholesterol concentrations or hypertriglyceridaemia who may ben= efit=20 from referral to a specialist lipid clinic.

Adjuvant treatment
Cilostazol has been shown to= =20 significantly increase (35-109%) walking distance in people wit= h=20 claudication in several large double blind placebo controlled=20 randomised trials.w21-w23 The precise role of cilostazol remain= s to=20 be defined, but a trial of the drug is probably indicated in pa= tients=20 who have unacceptable symptoms despite three to six months of=20 adherence to best medical treatment. No convincing evidence sup= ports=20 treatment with other drugs or vitamins,13=20 but trials evaluating the effect of folate and vitamin B-12 on= =20 hyperhomocysteinaemia, a putative vascular risk factor, are nea= r=20 completion.




 =   When should a patient be referred to a vascula= r=20 surgeon?
Top
Sources and selection criteria
Diagnosis and assessment
The rationale for best...
Components of best medical...
When should a patient...
Ongoing research
References

Local circumstances vary considerably, but referral is appropriate if <= /P>

  • The primary care team is not confident of making the diagnosis, lack= s the=20 resources necessary to institute and monitor best medical=20 treatment, or is concerned that the symptoms may have an unus= ual=20 cause=20
  • The patient has unacceptable symptoms despite a reasonable trial of,= and=20 adherence to, best medical treatment=20
  • The patient has weak or absent femoral pulse(s) (see belo= w).=20

Patient with critical limb ischaemia (rest pain, gangrene, or ulceratio= n)=20 should be referred urgently (preferably by telephone) to the ne= xt=20 vascular surgical clinic. The patient should also be referred=20 urgently if an abdominal aortic aneurysm is suspected on abdomi= nal=20 examination or if the history suggests a carotid territory tran= sient=20 ischaemia attack or amaurosis fugax.

Vascular and endovascular surgery
No convincing= =20 evidence supports the use of percutaneous balloon angioplasty o= r=20 stenting in patients with intermittent claudication.14=20 Two randomised controlled trials have shown that although succe= ssful=20 percutaneous balloon angioplasty may lead to a short term (six= =20 months) improvement in walking distance, in the longer term (tw= o=20 years) best medical treatment is better than percutaneous ballo= on=20 angioplasty in terms of walking distance and quality of life=20 measures.4= The=20 exercise versus angioplasty in claudication trial is further=20 evaluating the role of percutaneous balloon angioplasty.5= In=20 the United Kingdom bypass surgery is performed only infrequentl= y for=20 intermittent claudication because

  • The risks of surgery are generally believed to outweigh the benefits= in=20 most patients who improve on best medical treatment=20
  • Even though symptoms are frequently unilateral, most people with=20 claudication have bilateral disease; revascularising one leg = often=20 simply serves to unmask hitherto asymptomatic contralateral=20 disease.

In general, the threshold for percutaneous balloon angioplasty, stentin= g, and=20 surgery is lower in patients who have predominantly aortoiliac= =20 (suprainguinal) disease because

  • In terms of walking distance, such patients seem to benefit less fro= m best=20 medical treatment, although they gain just as much in terms o= f=20 protecting life and limb; this may be because the body is les= s able=20 to collateralise around an aortoiliac block=20
  • Percutaneous balloon angioplasty and stenting in the aorta or iliac= =20 arteries is more durable than that below the inguinal ligamen= t,=20 presumably because larger calibre, high flow arteries are inv= olved=20
  • Aortoiliac reconstruction deals with both legs at the same=20 time.

This greater readiness to intervene in patients with absent or diminish= ed=20 femoral pulses in no way undermines the key role of best medica= l=20 treatment. Furthermore, aortoiliac reconstruction in a patient = who=20 also has severe infrainguinal disease is unlikely to lead to a= =20 clinically significant reduction in symptoms. See bmj.com for m= ore=20 details on endovascular techniques. 4= 5= 14=20 21=20 22=20




 =   Ongoing research
Top
Sources and selection criteria
Diagnosis and assessment
The rationale for best...
Components of best medical...
When should a patient...
Ongoing research
References

Several recent landmark trials have confirmed the clinical effectivenes= s and=20 cost effectiveness of best medical treatment for peripheral art= erial=20 disease, and further trials are under way. The exercise versus= =20 angioplasty in claudication trial will help to define the role = of=20 adjuvant treatments such as percutaneous balloon angioplasty an= d=20 supervised exercise (see bmj.com). The main challenge facing pe= ople=20 caring for patients with peripheral arterial disease is applyin= g what=20 we know already. Primary care teams are best placed to deliver = this=20 highly effective and evidence based care, possibly through the= =20 establishment of community based, nurse led, protocol driven va= scular=20 clinics to which general practitioners can refer any "vascular"= =20 patient who needs best medical treatment. Interested general=20 practitioners or secondary care specialists in vascular medicin= e or=20 surgery could oversee such clinics, which would have clear and = widely=20 agreed policies for further investigations and referral to seco= ndary=20 care. Such clinics would need additional funding in the short t= erm=20 but would be likely to be cost neutral, or even beneficial, in = the=20 medium and long term through the prevention of expensive vascul= ar=20 events such as stroke and amputation.
<= /TR>
Additional educa= tional=20 resources=20

ABC of arterial and venous disease. BMJ 2000;320. Review=20 articles on

  • Non-invasive methods of arterial and venous assessment: p 698-= 701=20
  • Acute limb ischaemia: p 764-7=20
  • Chronic limb ischaemia: p 854-7=20
  • Secondary prevention of arterial disease: p 1262-5

Cochrane review of exercise therapy in peripheral arterial diseas= eLeng GC, Fowler B, Ernst E. Exercise for intermitten= t=20 claudication. Cochrane Database Syst Rev 2000;(2):CD000990

Consensus document on peripheral arterial disease3D---=20TASC=20 Working Group. Management of peripheral arterial disease: transatlan= tic=20 intersociety consensus (TASC). Eur J Vasc Endovasc Surg=20 2000;19(suppl A):S1-244. (250 page evidenced based document pro= duced=20 by international expert panel, covering all aspects of peripheral ar= terial=20 disease (also available at http://www.tasc-pad.org/))

Information for patients

The Vascular Surgical Society of Great Britain and Ireland produc= es=20 patient information sheets on intermittent claudication, arteriogram= s,=20 percutaneous balloon angioplasty, and amputations3D---=20available from http://www.vssgbi.org/



 =   Footnotes

Competing interests: None declared.=20

Extra references, tables, figure, and = information=20 are on bmj.com
 =   References
Top
Sources and selection criteria
Diagnosis and assessment
The rationale for best...
Components of best medical...
When should a patient...
Ongoing research
References
<= BR clear=3Dall>
1.=20 Fowkes FGR, Housley E, Cawood EHH, MacIntyre CAA, Ruc= kley=20 CV, Prescott RJ. Edinburgh artery study: prevalence of asymptomatic = and=20 symptomatic peripheral arterial disease in the general population. <= I>Int=20 J Epidemiol 1991; 20: 384-391[Abstract].=20
2.=20 Leng GC, Fowkes FGR. The Edinburgh claudication=20 questionnaire: an improved version of the WHO/Rose questionnaire for= use=20 in epidemiological surveys. J Clin Epidemiol 1992; 45: 1101-1= 109[ISI][Medline].=20
3.=20 Leng GC, Lee AJ, Fowkes FGR, Whiteman M, Dunbar J, Ho= usley=20 E, et al. Incidence, natural history and cardiovascular events in=20 symptomatic and asymptomatic peripheral arterial disease in the gene= ral=20 population. Int J Epidemiol 1996; 25: 1172-1181[Abstract].=20
4.=20 Whyman MR, Fowkes FG, Kerracher EM, Gillespie IN, Lee= AJ,=20 Housley E, et al. Is intermittent claudication improved by percutane= ous=20 transluminal angioplasty? A randomised controlled trial. J Vasc=20 Surg 1997; 26: 551-557[ISI][Medline].=20
5.=20 Perkins JM, Collin J, Creasy TS, Fletcher EW, Morris = PJ.=20 Exercise training versus angioplasty for stable claudication: long a= nd=20 medium term results of a prospective randomised trial. Eur J Vasc= =20 Endovasc Surg 1996; 11: 409-413[ISI][Medline].=20
6.=20 Hirsch AT, Treat-Jacobson D, Lando HA, Hatsukami DK. = The=20 role of tobacco cessation, antiplatelet and lipid-lowering therapies= in=20 the treatment of peripheral arterial disease. Vasc Med 1997; = 2:=20 243-251[Medline].=20
7.=20 Abbot NC, Stead L, White A, Barnes J, Ernst=20 E. Hypnotherapy for smoking cessation. Cochrane Database Sys= t=20 Rev 2000;(2):CD001008.
8.=20 Hajek P, Stead LF. Aversive smoking for smoking cessa= tion.=20 Cochrane Database Syst Rev 2000;(2):CD000546.
9.=20 White AR, Rampes H, Ernst E. Acupuncture for smo= king=20 cessation. Cochrane Database Syst Rev 2000;(2):CD000009.
10.=20 Antiplatelet Trialists' Collaboration. Collaborative= =20 overview of randomised trials of antiplatelet therapy3D---=I:=20 prevention of death, myocardial infarction, and stroke by prolonged= =20 antiplatelet therapy in various categories of patients. BMJ 1= 994;=20 308: 81-106[Abstract/Free Full Text].=20
11.=20 Diabetes UK. Diabetes UK position statement=20 2002. Early identification of people with type 2 diabetes.= http://www.diabetes.org.uk/= =20 (accessed Nov 2002).
12.=20 Heintzen MP, Strauer BE. Peripheral vascular effects = of=20 beta-blockers. Eur Heart J 1994; 15(suppl C): 2-7[ISI][Medline].=20
13.=20 Kleijnen J, Mackerras D. Vitamin E for intermitt= ent=20 claudication. Cochrane Database Syst Rev 2000;(2):CD000987. <= !-- HIGHWIRE ID=3D"326:7389:584:13" -->
14.=20 TASC Working Group. Management of peripheral arterial= =20 disease: transatlantic intersociety consensus (TASC). Eur J Vasc= =20 Endovasc Surg 2000; 19(suppl A): S1-244[ISI].=20
15.=20 Dormandy J, Heeck L, Vig S. Lower-extremity atheroscl= erosis=20 as a reflection of a systemic process: implications for concomitant= =20 coronary and carotid disease. Semin Vasc Surg 1999; 12: 118-1= 22[Medline].=20
16.=20 Dormandy J, Heeck L, Vig S. The natural history of=20 claudication: risk to life and limb. Semin Vasc Surg 1999; 12= :=20 123-137[Medline].=20
17.=20 Py=F6r=E4la K, Pedersen TR, Kjekshus J, Faergeman O, = Olsson AG,=20 Thorgeirsson G. Cholesterol lowering with simvastatin improves progn= osis=20 of diabetic patients with coronary heart disease. Diabetes Care=20 1997; 20: 614-620[Abstract].=20
18.=20 UK Prospective Diabetes Study Group. Tight blood pres= sure=20 control and risk of macrovascular and microvascular complications in= type=20 2 diabetes: UKPDS 38 [correction appears in BMJ=20 1999;318:29]. BMJ 1998; 317: 703-713[Abstract/Free Full Text].=20
19.=20 Orchard TJ, Strandness DE. Assessment of peripheral=20 vascular disease in diabetes: report and recommendations of an=20 international workshop sponsored by the American Diabetes Associatio= n and=20 the American Heart Association. Circulation 1993; 88: 819-828= [ISI][Medline].=20
20.=20 Gutteridge W, Torrie EPH, Galland RB. Cumulative risk= of=20 bypass, amputation or death following percutaneous transluminal=20 angioplasty. Eur J Vasc Endovasc Surg 1997; 14: 134-139[ISI][Medline].=20
21.=20 London NJ, Srinivasan R, Naylor AR, Hartshorne T, Rat= liff=20 DA, Bell PR, et al. Subintimal angioplasty of femoropopliteal artery= =20 occlusions: the long-term results. Eur J Vasc Endovasc Surg 1= 994;=20 8: 148-155= .
22.=20 McCarthy RJ, Neary W, Rowbottom C, Tottle A, Ashley A= .=20 Short term results of femoropopliteal sub-intimal angioplasty. Br= J=20 Surg 2000; 87: 1361-1365= [CrossRef][ISI][Medline].=20

=A9 2003 B= MJ=20 Publishing Group Ltd

Rapid responses:

Read all Rapid responses=20

Bed-Side Biophysical-Semeiotic Diagnosis of Peripheral Arter= ial=20 Disease, even in early phase.=20
Sergio Stagnaro=20
bmj.com, 14 Mar 2003 [Fu= ll=20 text]


3D""=20PDF of this=20 article
3D""=20extra: Extr= a=20 material
3D""=20 Email=20 this article to a friend
3D""=20Respon= d to=20 this article
3D""=20Read=20 responses to this article
3D""=20See related This wee= k in=20 BMJ item
3D""=20PubMed=20 citation
3D""=20Related=20 articles in PubMed
3D""=20Down= load to=20 Citation Manager
3D""=20Search Medline for articles by: Burns,=20 P. || Bradbury,=20 A. W
3D""=20Alert me when:
New articles cite this=20 article
3D""=20Collections under which this article appears:
= Other=20 Cardiovascular Medicine
D= rugs:=20 cardiovascular system
=3D""=20Ischa= emic=20 heart disease
3D""=20Vascular Sur= gery=20