As a novel addition, it is recommended to adopt a comprehensive approach that addresses the entire arterial circulation. This includes an objective assessment using specific questionnaires or tests to evaluate functional capacity and depressive disorders.

The guidelines review the various imaging modalities available for assessing the thoracic and abdominal aorta. Detailed discussions on how to perform measurements using different techniques are provided without altering the recommendations (table 1).

Screening for PAD is not systematically recommended, except in patients older than 65 years with risk factors (IIaC). It is also proposed that diabetic patients or those with chronic kidney disease who have a normal ankle-brachial index (ABI) at rest should undergo a toe-brachial index test.

Multisite artery disease (MAD) is defined as the presence of atherosclerosis in 2 or more vascular beds. While it is not proposed to be actively identified, MAD is recognized as having added value for the risk reclassification of patients with intermediate to high risk. This allows the identification of patients who may benefit from more intensive preventive treatments or strategies that combine antiplatelet therapy with low-dose anticoagulation (COMPASS strategy).

For abdominal aortic aneurysm screening, duplex ultrasound (DUS) (IA) is recommended for men older than 65 years who smoke and for first-degree relatives older than 50 years (IC). Opportunistic abdominal aortic aneurysm screening is also considered in patients with PAD who undergo DUS. Interestingly, cardiologists may also consider screening men older than 65 years and women older than 75 years who undergo echocardiography, even in the absence of risk factors (IIaB).

Optimal management of PAAD involves a synergistic approach that combines pharmacological therapy with lifestyle modifications. Key lifestyle changes include: a) adhering to a Mediterranean diet, b) engaging in regular physical activity to improve functional capacity, and c) quitting smoking to reduce disease progression. Patient education and structured support programs also play a critical role in promoting self-care and improving treatment adherence, which further enhances clinical outcomes.

The pharmacological management of PAAD focuses on addressing the underlying pathophysiology, reducing cardiovascular (CV) risk, and slowing the progression of the disease. Pharmacological therapy includes the following:

Given the complexity and scarcity of testing, the guidelines recommend that individuals with suspected genetic aortic disease be evaluated in specialized centers with expertise in assessing patients and their first-degree relatives for genetic testing. The guidelines also provide a specific screening algorithm for thoracic aortic disease. A comprehensive evaluation of the entire aorta and other vascular regions is recommended in patients with hereditary thoracic aortic disease. Both genetic testing and imaging—mainly through transthoracic echocardiography, cardiovascular magnetic resonance, or cardiovascular computed tomography if the aortic root/ascending aorta is not well visualized—are essential for diagnosing hereditary thoracic aortic disease in patients and family members. In patients with a strong suspicion of an underlying genetic defect but no identified genetic cause, a genetic reassessment in 3 to 5 years should be considered.

As a novelty, specific recommendations are provided for evaluating imaging or surgery in patients with Turner syndrome, Ehlers-Danlos syndrome, and Loeys-Dietz syndrome. For Marfan syndrome, the main recommendations focus on imaging follow-up, medical treatment (beta-blockers or angiotensin receptor blockers at maximum tolerated doses), exercise prescription, and pregnancy care.

The recommendation to adopt a new international consensus nomenclature and classification for patients with bicuspid aortic valve and aortopathy, replacing various competing nomenclatures, is a positive development. Surgery for bicuspid aortopathy continues to be recommended when the maximum aortic diameter is ≥ 55mm. As a new recommendation, surgery for the root phenotype (IB) of bicuspid aortopathy is advised when the maximum aortic diameter is ≥ 50mm.

Patients with dilatation of the tubular ascending aorta, tricuspid aortic valve, and low predicted surgical risk should be considered for ascending aortic replacement when the maximum diameter exceeds 52mm (IIaB), while surgery is recommended for diameters of ≥ 55mm (IB). In patients undergoing surgery for tricuspid aortic valve disease who also have concomitant dilatation of the aortic root or ascending tubular aorta and low predicted surgical risk, ascending aorta or root replacement should be considered when the maximum diameter is at least 45mm; otherwise, the threshold is 50mm. Preoperative evaluation and initial follow-up of patients are shown in table 2.

For the treatment of aortic arch, open repair remains the gold standard for symptomatic patients with aortic arch aneurysms (IC) or asymptomatic patients with low operative risk and an arch diameter≥ 55mm (IIaB). Hybrid or endovascular treatment is reserved for patients who meet the criteria for intervention but are at high surgical risk (IIbC).

Endovascular treatment is preferred over open repair in patients without hereditary thoracic aortic disease who have unruptured descending thoracic aorta aneurysms when elective repair is indicated (diameter >55mm) and anatomy is suitable (IB). Additionally, in patients with degenerative thoracoabdominal aortic aneurysms measuring≥ 60mm and with suitable anatomy, endovascular repair using fenestrated and/or branched endografts should be considered in experienced centers (IIaB).

Regarding new developments in acute aortic syndrome, in patients with complicated type B aortic dissection, the level of indication (IA) is raised both for emergency intervention and for the choice of endovascular repair as first-line therapy.

The ESC 2024 Guidelines represent a significant development in the care of patients with PAD, emphasizing a holistic and personalized approach. A key aspect of these guidelines is patient education and psychosocial support, which aim to promote lifestyle changes such as smoking cessation, a healthy diet, and regular physical activity. These elements are essential for improving long-term outcomes and preventing disease progression.5 The education outlined in this guideline is tailored to the individual needs of each patient, taking into account their health literacy and possible cultural barriers. This enhances treatment adherence and empowers both patients and caregivers6 (IA).

One of the major innovations in the guidelines is the incorporation of digital technologies, such as mobile applications and personalized risk calculators (IIaB). These tools facilitate secondary prevention and remote monitoring, optimizing adherence to treatment by enabling more efficient and accessible patient management. The guidelines highlight that these digital tools show promise in improving patient outcomes, but the level of evidence indicates they are still relatively new in terms of widespread clinical application.

Additionally, active patient participation in shared decision-making has gained prominence, as it fosters patient self-efficacy and reduces the risk of hospitalization. This patient-centered approach also improves quality of life. The guidelines introduce PREMs and PROMs as essential tools for evaluating both the patient's treatment experience and their functional, mental, and social status (IIaB).

The guidelines continue to recommend assessing the risk of CV disease by evaluating traditional risk factors, such as SCORE2 and SCORE OP in Europe and ASCVD in the United States. While these scales are referenced, along with the risk of PAD associated with various traditional and nontraditional risk factors, the section lacks sufficient detail, which is crucial for disease prevention. Additionally, there is no mention of the QR4 scale, which incorporates 7 new risk factors: chronic obstructive pulmonary disease, learning disabilities, Down syndrome, and cancers of the blood, lung, mouth, and brain. This highlights the impact of other significant diseases on heart health. The QR4 scale also identifies specific factors in women's health that predict future CV risk, such as complications from high blood pressure during pregnancy and postpartum depression. Overall, the QR4 scale offers a more accurate estimate of CV disease risk than ASCVD or SCORE.

ABI measurement is recommended as the first-line noninvasive test for screening and diagnosing PAD. In patients with exertional limb pain relieved by rest and a resting ABI >0.90, exercise testing with postexercise ABI measurements may be an alternative, but no specific recommendation is made, unlike in the American guidelines, where it is a type I recommendation.7

Toe-brachial index, toe pressure, and transcutaneous oxygen pressure measurements play a significant role, especially in patients with noncompressible ankle arteries or an ABI> 1.40. However, sensitivity and specificity vary widely, and situations that may affect their value are common. Therefore, this recommendation should be applied with caution, particularly in doubtful cases.

A multidisciplinary approach is fundamental in the treatment of PAD, with nursing playing a prominent role in coordinating care and providing continuous follow-up (IA). However, the guidelines do not address the role of advanced practice nurses, whose involvement could significantly enhance the effectiveness of interventions in patients with complex chronic diseases like PAD.8 These nurses are capable of performing advanced assessments, managing long-term follow-ups, and actively participating in clinical decision-making, thereby optimizing clinical outcomes.

The guidelines also omit care coordination and the important role of general practitioners. Additionally, the recommendations regarding the urgency of referrals to surgery are not explained.9 The guidelines include as a recommendation that e-cigarettes may be considered.

The 2024 ESC clinical practice guidelines cover PAD and aortic diseases, highlighting their greater prevalence in women, even in the central illustration. As a novelty, the guidelines recommend addressing the entire arterial circulation and include specific questionnaires or tests for functional capacity and depressive disorders. Optimal management involves risk factor control, pharmacological therapy, lifestyle modifications, patient education, and exercise as a key component. In patients with symptomatic PAD, SET is recommended. Additionally, there are new surgical recommendations for abdominal and thoracic aortic aneurysms and for screening.

Care coordination is not included, nor is the important role of general practitioners. Equally, advanced practice nurses are not mentioned. Recommendations on the urgency of referrals for surgery are not explained. These guidelines suggest that e-cigarettes may aid in smoking cessation (IIb, C); however, it is advisable to limit their use and avoid simultaneous use with conventional cigarettes due to unknown long-term effects. Given that their use has been clearly associated with adverse effects on CV, respiratory, immunological, and periodontal health compared with nonuse, we find this controversial guideline recommendation to be striking.