What workup and treatment are recommended for suspected peripheral arterial disease (PAD) and chronic venous insufficiency (CVI)?

Workup and Treatment for Suspected Peripheral Arterial Disease (PAD) and Chronic Venous Insufficiency (CVI)

For patients with suspected PAD and CVI, a comprehensive diagnostic workup including ankle-brachial index (ABI) measurement, toe-brachial index (TBI), and duplex ultrasound is recommended, followed by targeted treatment addressing both conditions with appropriate exercise therapy, pharmacologic management, and consideration of compression therapy only when arterial flow is adequate.

Diagnostic Workup

Initial Assessment

• Conduct vascular review of symptoms to assess:

  • Walking impairment and claudication
  • Ischemic rest pain
  • Presence of non-healing wounds
  • Edema, skin changes, and varicosities 1, 2

• Perform comprehensive pulse examination and foot inspection 2

• Assess for family history of abdominal aortic aneurysm in individuals over 50 years 2

Non-invasive Testing

1. Ankle-Brachial Index (ABI) - first-line test 1, 2

   • Interpret results as:
     • Normal: 1.00-1.40
     • Borderline: 0.91-0.99
     • Abnormal (PAD): ≤0.90
     • Noncompressible arteries: >1.40

2. For noncompressible arteries (ABI >1.40):

   • Perform toe-pressure/toe-brachial index (TBI) with waveforms 1
   • Normal TBI: >0.70
   • Abnormal TBI: ≤0.70

3. For normal or borderline ABI with symptoms:

   • Perform exercise treadmill ABI testing 1

4. For suspected chronic limb-threatening ischemia:

   • Measure toe pressure (target <30 mmHg indicates CLTI)
   • Measure transcutaneous oxygen pressure (TcPO₂) (target <30 mmHg indicates CLTI)
   • Measure skin perfusion pressure (SPP) 1

5. Anatomical assessment:

   • Perform segmental leg pressures with pulse volume recordings (PVR) and/or Doppler waveforms to delineate anatomic level of PAD 1
   • Perform duplex ultrasound to assess both arterial and venous systems 1, 2

Advanced Imaging

• Only if revascularization is being considered:

  • Duplex ultrasound
  • Computed tomography angiography (CTA)
  • Magnetic resonance angiography (MRA)
  • Catheter angiography 1

• Caution: Do not perform CTA, MRA, or catheter angiography solely for anatomic assessment if revascularization is not being considered 1

Treatment Approach

Risk Factor Modification

1. Lipid management:

   • Statin therapy for all PAD patients 1, 2
   • Target LDL-C reduction ≥50% from baseline and goal <55 mg/dL 2

2. Blood pressure control:

   • Target <140/90 mmHg (non-diabetics)
   • Target <130/80 mmHg (diabetics) 1, 2
   • Beta-blockers are not contraindicated in PAD 1, 2
   • Consider ACE inhibitors for patients with asymptomatic PAD 1

3. Diabetes management:

   • Tight glycemic control (HbA1c <7%) 2
   • Proper foot care including daily inspection 1

4. Smoking cessation - critical for both PAD and CVI management

Antiplatelet Therapy

• For symptomatic PAD:
  • Aspirin (75-160 mg daily) or clopidogrel (75 mg daily) 2
  • Consider rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily in high ischemic risk patients without high bleeding risk 2

Exercise Therapy

• Supervised exercise training:

  • Frequency: At least 3 times weekly
  • Duration: ≥30 minutes per session
  • Program length: ≥12 weeks 2
  • Improves walking distance and quality of life

• Home-based exercise programs when supervised programs are unavailable 2

Pharmacotherapy for Claudication

• Cilostazol: 100 mg twice daily to improve walking distance and quality of life 2
• Pentoxifylline: May be considered (400 mg three times daily) but has less evidence of benefit 2, 3
  • Improves blood flow properties by decreasing viscosity
  • Enhances tissue oxygenation
  • Not intended to replace more definitive therapy

Management of Coexisting PAD and CVI

1. For mild to moderate PAD with CVI:

   • Progressive elastic compression stockings may be used if:
     • ABI ≥0.5 4, 5
     • No decrease in toe pressure with compression application 6
   • Consider specialized compression stockings designed for combined disease:
     • Lower compression at ankle (8-10 mmHg)
     • Higher compression at calf (15-20 mmHg) 5

2. For severe PAD (ABI <0.5) with CVI:

   • Avoid compression therapy
   • Prioritize PAD treatment first 4, 5, 6

3. Monitor arterial perfusion:

   • Reassess ABI and TBI after initiating compression therapy
   • Discontinue compression if symptoms worsen 4, 5

Revascularization Considerations

• For functionally limiting claudication with inadequate response to medical therapy:

  • Endovascular-first approach for short (<5 cm) aorto-iliac lesions and short (<25 cm) femoro-popliteal lesions 1, 2
  • Bypass surgery with autologous vein for long (≥25 cm) femoro-popliteal or infra-popliteal lesions 2

• For chronic limb-threatening ischemia:

  • Urgent revascularization is indicated for limb salvage 1, 2

Follow-up and Monitoring

• Regular clinical evaluation including assessment of:

  • Limb symptoms and functional status
  • Lower extremity pulse and foot assessment
  • Progress of risk factor management 1

• For patients who underwent revascularization:

  • ABI and arterial duplex ultrasound within 1-3 months post-procedure
  • Repeat at 6 and 12 months, then annually 1, 2

• Coordinate care among clinicians to optimize management of both PAD and CVI 1

Special Considerations

• PAD is more frequent in patients with severe forms of CVI (17-18%) 7
• Patients with combined PAD and CVI have higher arterial stiffness and cardiovascular risk 8
• Always assess for PAD before initiating compression therapy for CVI 4, 6