This document discusses the TASC (TransAtlantic Inter-Society Consensus) process and documents for classifying and making treatment recommendations for peripheral artery disease (PAD). It notes that while the TASC classification is useful, the revascularization recommendations are often ignored in practice due to changes in technology. Additionally, the TASC process is subject to political influence from vascular societies that can prevent publication of documents not aligned with their views, hindering progress. Overall, the classification aspect of TASC remains important, but the process could be improved by reducing political influences from professional societies.

1. TASC Process & Documents:
Needed or a Waste of Time?
Mahmood Razavi, MD, FSIR
Director
Center for Clinical Trials
St Joseph Heart & Vascular Institute

2. Disclosures
♦ Scientific Advisory Board
• 480 Biomedical, Abbott Vascular, Bard, Boston
Scientific, Covidien, EmboMedix, Javlin, Mercator,
Neuravi, Reflow Medical, Trivascular, Veneti, Walk
Vascular
♦ Consultant
• Cordis
♦ Grants
• NIH, WL Gore

3. TASC Disclosure
♦ TASC Writing Group & Steering
Committee

4. TASC Classification
&Recommendations
♦ Does TASC matter?
♦ Does anyone care?
♦ Why is it important to have such a
process and document?

5. Background
♦ There are multiple treatment options
for pts with PAD
♦ Approaches are sometimes
complementary but often competitive
and occasionally mutually exclusive
♦ Robust comparative data often not
available

6. So how should a patient be best
treated?
Expert panelsExpert panels
AHA & TASCAHA & TASC

7. Determinants of Therapy
♦ Patients’ condition
♦ Anatomic severity of disease
♦ Comorbid conditions
♦ Patients’ wishes
Disease classification is neededDisease classification is needed

8. Basis of TASC Classification
♦ Clinical presentation (considering all
relevant clinical variables)
♦ Lesion characteristics:
• Location
• Length
• Morphology

9. TASC-I & II Process
♦ Representatives from 16 international
Societies & health economics experts
participated
♦ After extensive review of existing
literature a draft document prepared
♦ All participating Societies reviewed
and commented

10. Grading of Recommendations
ecommendations and selected statements are rated according to guidance issued
rmer US Agency for Health Care Policy and Research (6), now renamed the Age
ealthcare Research and Quality:
Grade Recommendation
A Based on the criterion of at least one randomized, controlled
clinical trial as part of the body of literature of overall good quality
and consistency addressing the specific recommendation
B Based on well-conducted clinical studies but no good quality
randomized clinical trials on the topic of recommendation
C Based on evidence obtained from expert committee reports or
opinions and/or clinical experiences of respected authorities (i.e.
applicable studies of good quality)

11. Anatomic Classification Generated

12. Does TASC Classification Predict Outcome?
TASC-ATASC-A
TASC-BTASC-B
TASC-DTASC-D
TASC-CTASC-C
patencypatency
TASC classificationTASC classification

13. Who Needs TASC?
♦ The TASC documents are the second
highest referenced papers in the history
of surgical literature
♦ TASC documents are clearly important
♦ Is it the classification or the
recommendations?

14. TASC Recommendations for
Treatment of PAD
♦ Risk factor modification
• Optimal management of DM & HTN,
smoking cessation, wt. reduction,
exercise, etc
♦ Anti-lipids, antiplatelets
♦ Cilostezol & exercise for IC
♦ Revascularization when needed
Common to all international guidelinesCommon to all international guidelines

15. TASC Controversy
♦ Method of revascularization

16. TASC-II Recommendations for
Aortoiliac & Fempop Lesions
♦ TASC A: Endovascular approach is the tx
of choice
♦ TASC B: Endo preferred
♦ TASC C: Surgery preferred
♦ TASC D: Surgery is the tx of choice

17. TASC-II classification is useful but the
revascularization recommendations are
mostly irrelevant today
In the real world endo first is the majority
practice in all morphologies
Recommendations commonly ignored byRecommendations commonly ignored by
vascular surgeons who are endo-trainedvascular surgeons who are endo-trained
Recommendations commonly ignored byRecommendations commonly ignored by
vascular surgeons who are endo-trainedvascular surgeons who are endo-trained

18. TASC-IIb Recommendations
♦ TASC A & B: Endovascular approach is the
tx of choice
♦ TASC C: Endo preferred if local expertise
exist
♦ TASC D: Surgery is tx of choice, endo if
local expertise exist & patient’s anatomy
allows

19. TASC-IIb illuminated the
weaknesses of TASC process
TASC process is subject to political infighting between professionalTASC process is subject to political infighting between professional
Societies and recommendations are based as much on politicalSocieties and recommendations are based as much on political
considerations as on clinical evidence and practice patternsconsiderations as on clinical evidence and practice patterns
After an exhaustive 3 year review process by all SocietiesAfter an exhaustive 3 year review process by all Societies
and initial acceptance of TASC IIb recommendations,and initial acceptance of TASC IIb recommendations,
including by the SVS & ESVS, SVS threatenedincluding by the SVS & ESVS, SVS threatened
to pull out of TASC if TASC-IIb was publishedto pull out of TASC if TASC-IIb was published

20. The TASC IIb document was
hence withdrawn from
publication !!

21. TASC III
♦ SVS & ESVS were active participants
initially but withdrew when they could
not get their way
♦ Among their demands:
• >50% surgical representation on all
aspects of TASC because …

22. “Setting standards across the
world for optimal care of this
group of patients resides
principally with vascular
surgeons.”
SVS & ESVSSVS & ESVS

23. Ideal Situation
Unmet needsUnmet needs
in practicein practice
HypothesisHypothesis
and R&Dand R&D
Clinical trialsClinical trials
& evidence& evidence
SocietalSocietal
GuidelineGuideline
PracticePractice
patternspatterns
Practice is ahead of dataPractice is ahead of data
Data is ahead of GuidelinesData is ahead of Guidelines
Practice politics is ahead of everythingPractice politics is ahead of everything

24. Conclusions
♦ Classification of disease is needed to be
able to compare outcomes across studies
and judge best therapies
♦ Standardization of reporting and treatment
critical in advancing tx of PAD
♦ TASC process critically needed but
disabled by politics of $$ and power