What is the recommended workup and treatment for peripheral vascular disease (PVD)?

Peripheral Vascular Disease Workup and Treatment

The recommended workup for peripheral vascular disease (PVD) should begin with ankle-brachial index (ABI) measurement as the first-line non-invasive test, followed by duplex ultrasound (DUS) for anatomical characterization of lesions, with treatment focusing on aggressive risk factor modification, supervised exercise therapy, and selective revascularization based on symptom severity and lesion characteristics. 1

Diagnostic Workup

Initial Assessment

• History and Physical Examination
  • Assess for walking impairment, claudication, ischemic rest pain, and non-healing wounds 1
  • Comprehensive pulse examination and foot inspection 1
  • Evaluate family history of abdominal aortic aneurysm in individuals over 50 years 1

First-Line Diagnostic Tests

• Ankle-Brachial Index (ABI)
  • Indicated as first-line screening and diagnostic test 1
  • ABI <0.9 indicates PAD
  • For incompressible arteries or ABI >1.40, use alternative methods:
    • Toe-brachial index (TBI)
    • Doppler waveform analysis
    • Pulse volume recording 1, 2

Advanced Imaging

• Duplex Ultrasound (DUS)

  • Recommended as first-line imaging to confirm PAD lesions 1
  • Non-invasive, cost-effective, and does not require contrast 2

• Additional Imaging (for complex cases)

  • CT Angiography (CTA) or MR Angiography (MRA) for:
    • Anatomical characterization to guide revascularization strategy 1
    • Aorto-iliac or multisegmental/complex disease 1
  • Contrast angiography reserved for definitive localization before intervention 3

Important Diagnostic Considerations

• Normal resting ABI does not rule out PAD in symptomatic patients
  • Up to 31% of patients with normal resting ABI may have abnormal post-exercise ABI 4
• Exercise testing recommended when resting ABI is normal but symptoms suggest PAD 4
• In patients with diabetes or renal failure, measuring toe pressure (TP) or toe-brachial index (TBI) is recommended if resting ABI is normal 1

Treatment Approach

Risk Factor Modification

1. Smoking Cessation

   • Critical intervention for symptom improvement and reducing cardiovascular events 5
   • Utilize physician advice, nicotine replacement therapy, and bupropion 5

2. Lipid Management

   • Statin therapy indicated for all PAD patients 1
   • Target LDL-C reduction by ≥50% from baseline and goal <1.4 mmol/L (<55 mg/dL) 1
   • Statins improve walking distance in claudication 1

3. Blood Pressure Control

   • Antihypertensive therapy to achieve goal <140/90 mmHg (non-diabetics) or <130/80 mmHg (diabetics) 1
   • Beta-blockers are not contraindicated in PAD 1
   • ACE inhibitors/ARBs recommended for hypertension management 1

4. Diabetes Management

   • Tight glycemic control (HbA1c <7%) to reduce microvascular complications 1
   • Prioritize glucose-lowering agents with proven CV benefits (SGLT2i, GLP-1RAs) 1
   • Proper foot care essential in diabetic PAD patients 1

Medical Therapy

1. Antiplatelet Therapy

   • Recommended for symptomatic PAD: aspirin (75-160 mg daily) or clopidogrel (75 mg daily) 1
   • Consider rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily in high ischemic risk patients with non-high bleeding risk 1
   • Not routinely recommended for asymptomatic PAD without clinically relevant atherosclerotic cardiovascular disease 1

2. Exercise Therapy

   • Supervised exercise training (SET) strongly recommended for claudication 1
   • Improves walking distance and quality of life 5
   • Non-supervised exercise training recommended when supervised programs unavailable 1
   • Training frequency: at least 3 times weekly for ≥30 minutes per session for ≥12 weeks 1

3. Pharmacotherapy for Claudication

   • Cilostazol can improve walking distance and quality of life 5
   • Pentoxifylline may be considered but has less evidence of benefit 6
     • Monitor for potential side effects including angina, hypotension, and arrhythmia
     • Use cautiously with anticoagulants due to increased bleeding risk

Revascularization

Indications for Revascularization

• Significant disability affecting work or important activities 1
• Failure of conservative therapy (3-month trial of optimal medical therapy and exercise) 1
• Chronic limb-threatening ischemia (CLTI) 1
• Acute limb ischemia with neurological deficit (urgent revascularization) 1

Revascularization Strategy by Anatomical Location

1. Aorto-iliac Occlusive Lesions

   • Endovascular-first strategy for short (<5 cm) lesions 1

2. Femoro-popliteal Occlusive Lesions

   • Endovascular-first for short (<25 cm) lesions 1
   • Bypass surgery for long (≥25 cm) lesions when autologous vein available and life expectancy >2 years 1
   • Autologous saphenous vein is the conduit of choice 1

3. Infra-popliteal Occlusive Lesions

   • Revascularization indicated for limb salvage in CLTI 1
   • Bypass using great saphenous vein is preferred 1

Follow-up and Monitoring

• Regular follow-up at least annually for all PAD patients 1

• Assessment should include:

  • Clinical and functional status
  • Medication adherence
  • Limb symptoms
  • Cardiovascular risk factors 1
  • DUS assessment as needed 1

• For patients with revascularization:

  • ABI and arterial duplex ultrasound within 1-3 months post-procedure
  • Repeat at 6 and 12 months, then annually 1
  • More frequent monitoring for autogenous vein bypass grafts 1

Special Considerations

• Critical Limb Ischemia (CLTI)

  • Early recognition and referral to vascular team is mandatory 1
  • Assessment of amputation risk indicated 1
  • Revascularization should be performed as soon as possible 1
  • Stem cell/gene therapy is not indicated 1

• Acute Limb Ischemia

  • Urgent revascularization for neurological deficit 1
  • Heparin and analgesics as soon as possible 1
  • Evaluate for cardiovascular causes of thromboembolism 1

By following this structured approach to diagnosis and treatment of peripheral vascular disease, clinicians can effectively manage patients to improve symptoms, quality of life, and reduce the risk of limb loss and cardiovascular events.