p.65 抽出テキスト

unaffected, distinguishing them from individuals with malignancies. An abdominal examination might reveal a bruit. Lactate, lactate dehydrogenase, and/or leucocyte count are unhelpful in CMI diagnosis.840,841 Functional testing (tonometry, visible light spectroscopy) is applicable in patients with symptomatic mesenteric stenosis and single-vessel disease.842 Imaging Duplex ultrasound is valuable due to its low costs, absence of the need for contrast agents, and no radiation. However, skilled investigators in specialized centres are required for the examination. Despite suggested diagnostic criteria, consensus is lacking.843,844 Anatomical mapping for treatment planning typically involves CTA or MRA, 845,846 with DSA reserved only for therapeutic purposes (Figure 20).

8.3.3.2.2 Treatment strategy. Optimal medical treatment is the basis

of CMI management. Prophylactic revascularization is not recommended for asymptomatic CMI. In symptomatic cases, a meta-analysis favoured endovascular over open surgery due to fewer complications and a trend towards lower 30 day mortality.835 However, open surgery showed superior long-term results, with fewer symptom recurrences and higher 1 and 5 year primary patency rates in two additional meta-analyses.847,848 Despite the growing use of endovascular therapy, open surgery remains indicated after failed endovascular therapy without the option for repeat intervention, and in cases with extensive occlusions, calcifications, or technical challenges.

8.3.3.2.3 Follow-up. Following CMI revascularization, lifelong medical

treatment, including lifestyle changes and OMT for atherosclerosis, is recommended. SVS guidelines propose mesenteric DUS surveillance for recurrent stenosis. A potential follow-up schedule involves controls within 1 month post-procedure, biannually for the first 2 years, and annually thereafter.849

9 Aorta

9.1 Atheromatous disease of the aorta

9.1.1. General concepts Atheromatous disease of the aorta has an estimated incidence of 40%–51.3%, being complicated in 7.6% of cases.850–853 Earlier stages of atherosclerosis, presenting as plaque inflammation, can be present in 48% of asymptomatic individuals.850 Atherosclerotic plaque classification is based on plaque thickness and the presence of ulceration or mobile components (Table 14).159,171,854 This classification is crucial because severe or complex atherosclerotic plaques in the aortic arch or ascending aorta are strongly linked to cerebrovascular events (odds ratio [OR] 4–9.1 for plaques ≥4 mm).855–860 Additionally, the annual incidence of stroke recurrence remains high (up to 16%) despite antiplatelet or anticoagulant therapy.855,861

9.1.2 Treatment

9.1.2.1. Primary prevention Asymptomatic non-severe/non-complex aortic plaques (Table 14) should not mandate antiplatelet therapy. Nonetheless, in severe/complex plaques, statins should be indicated to decrease plaque progression or CV events,862 and SAPT with clopidogrel or low-dose aspirin should be considered after risk/benefit evaluation.493,666,861,863 However, in this scenario, anticoagulation861 or DAPT (low-dose aspirin and clopidogrel) are not indicated.666,863 Floating aortic thrombi and complex mobile plaques are rare, with limited large-scale trials on their management. Guidance relies on case reports, observational studies, and expert opinions, yet there is evidence favouring anticoagulation, particularly for symptomatic cases.864

9.1.2.2 Secondary prevention

Secondary prevention with antiplatelet therapy after an embolic event is recommended to prevent recurrences.666,865,866 While the value of DAPT vs. SAPT remains uncertain, recent studies indicate that prolonged DAPT raises bleeding risk without added antithrombotic benefits.667,863,867 Treatment duration is unclear and must strike a balance between early benefit (notably within 7 days post-emboli) and steady bleeding risk. Statins (LDL target below 1.4 mmol/L [55 mg/dL]) prove effective in preventing strokes regardless of the aetiology.862,865,868 Additionally, a healthy lifestyle is crucial for improving CV health and reducing complications.

Recommendation Table 32 — Recommendations in patients with visceral artery stenosis

Recommendations Classa Levelb

In patients with acute mesenteric ischaemia due to acute occlusion of the SMA, endovascular revascularization is recommended.829–831 I B In patients with suspected acute or chronic mesenteric ischaemia, CTA is recommended.826,827,845,846 I C In patients with acute or chronic mesenteric ischaemia, assessment by a vascular team is recommended. I C Revascularization of asymptomatic atherosclerotic visceral artery stenosis is not recommended. III C © ESC 2024

CTA, computed tomography angiography; SMA, superior mesenteric artery. aClass of recommendation. bLevel of evidence. Recommendation Table 33 — Recommendations for primary and secondary prevention in aortic atheromatous plaques

Recommendations Classa Levelb

Primary prevention In patients with severe/complex aortic atheromatous plaques, statins should be considered to decrease progression and risk of CV events.862 IIa C SAPT with clopidogrel or low-dose aspirin should be considered in severe/complex plaques.493,666,861,863 IIa C Anticoagulation861 or DAPT863 are not recommended in aortic plaques since they present no benefit and increase bleeding risk.666 III C Secondary prevention after an embolic event related to aortic atherosclerosis In patients with an embolic event and evidence of an aortic arch atheroma, intensive lipid management to an LDL-C target <1.4 mmol/L (<55 mg/dL) is recommended to prevent recurrences.242,862,865,868 I A In patients with an embolic event and evidence of an aortic arch atheroma, SAPT is recommended to prevent recurrences.666,865,866 I C © ESC 2024

CV, cardiovascular; DAPT, dual antiplatelet therapy; LDL-C, low-density lipoprotein cholesterol; SAPT, single antiplatelet therapy. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/45/36/3538/7738955 by guest on 07 October 2026