What is the initial treatment for small vessel peripheral artery disease of below the knee vessels?

From the Guidelines

The initial treatment for small vessel peripheral artery disease of below-the-knee vessels should focus on risk factor modification and medical therapy, including antiplatelet therapy, statins, blood pressure control, diabetes management, and smoking cessation, as recommended by the 2024 lower extremity peripheral artery disease guideline-at-a-glance 1. The goal of treatment is to prevent major adverse cardiovascular events and major adverse limb events, while improving quality of life and functional status.

• Key components of medical therapy include:
  • Antiplatelet therapy with aspirin (75-325 mg daily) or clopidogrel (75 mg daily) to reduce thrombotic events
  • Statins, regardless of cholesterol levels, with high-intensity options like atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily
  • Blood pressure control targeting levels below 140/90 mmHg using medications like ACE inhibitors or ARBs
  • Diabetes management aiming for HbA1c below 7%
  • Smoking cessation with pharmacotherapy options including nicotine replacement, varenicline, or bupropion
• A supervised exercise program of 30-45 minutes, 3-5 times weekly is highly effective for symptom improvement, as is cilostazol 100 mg twice daily (if no heart failure) to reduce claudication symptoms. Revascularization procedures, such as endovascular therapy or open surgical approach, may be considered for patients who fail conservative management or have critical limb ischemia, as outlined in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.

From the Research

Initial Treatment for Small Vessel Peripheral Artery Disease

The initial treatment for small vessel peripheral artery disease of below the knee vessels involves a combination of lifestyle modifications and medical therapies.

• Lifestyle modifications:
  • Smoking cessation 2
  • Structured exercise program 2
• Medical therapies:
  • Statin drugs to lower blood pressure and reduce the risk of major coronary and cerebrovascular events 2, 3
  • Antiplatelet therapy with aspirin or clopidogrel to reduce the risk of major coronary and cerebrovascular events 2, 4, 5, 6
  • Cilostazol for patients with disabling intermittent claudication who do not respond to conservative measures and are not candidates for surgical or catheter-based intervention 4
  • Angiotensin-converting enzyme inhibitors to lower blood pressure and reduce the risk of major coronary and cerebrovascular events 2

Antithrombotic Therapy

Antithrombotic therapy is also an important aspect of treatment for small vessel peripheral artery disease.

• Aspirin or clopidogrel is recommended for patients with symptomatic PAD 4, 5, 6
• Dual antiplatelet therapy with clopidogrel and aspirin may be considered for patients with prior myocardial infarction 5
• Rivaroxaban plus aspirin may be considered for secondary prevention of symptomatic PAD patients 5

Statin Usage

Statin usage is also crucial in the management of peripheral artery disease.

• High-intensity statin therapy is recommended for patients with PAD, especially those with involvement of multiple vascular beds 3
• Statins should be used in combination with other medical therapies, such as antiplatelet agents and angiotensin-converting enzyme inhibitors, to reduce the risk of major coronary and cerebrovascular events 2, 3