What is the treatment for peripheral arterial disease (PAD)?

Treatment of Peripheral Arterial Disease

The treatment of peripheral arterial disease (PAD) requires a comprehensive approach including risk factor modification, exercise therapy, pharmacological interventions, and revascularization for selected patients with lifestyle-limiting symptoms or critical limb-threatening ischemia (CLTI). 1

Risk Factor Modification

Smoking Cessation

• All patients with PAD who smoke should be strongly advised to quit smoking and offered comprehensive cessation interventions 1
• Interventions should include:
  • Behavioral modification therapy
  • Nicotine replacement therapy
  • Bupropion

Blood Pressure Control

• Target blood pressure:
  • <140/90 mmHg for non-diabetics
  • <130/80 mmHg for diabetics and those with chronic renal disease 1
• Antihypertensive medications:
  • ACE inhibitors are recommended for symptomatic PAD patients to reduce cardiovascular events 1
  • Beta-blockers are not contraindicated in PAD 1

Lipid Management

• High-intensity statin therapy is recommended regardless of baseline LDL levels 2
• Consider adding PCSK9 inhibitors for high-risk patients with inadequate LDL response 2
• Consider icosapent ethyl 2g twice daily for high-risk patients with triglycerides >1.5 mmol/L despite statin therapy 2

Diabetes Management

• Individualize HbA1c targets according to comorbidities, diabetes duration, and life expectancy 1
• Avoid hypoglycemia in patients with PAD 1
• Prioritize glucose-lowering agents with proven cardiovascular benefits 1
• Proper foot care is essential for diabetic patients with PAD, including:
  • Appropriate footwear
  • Daily foot inspection
  • Skin cleansing
  • Topical moisturizing creams 1

Exercise Therapy

Supervised Exercise Training (SET)

• Supervised exercise training is strongly recommended as first-line treatment for symptomatic PAD 1, 2
• Program specifications:
  • Frequency: At least 3 times per week
  • Duration: Minimum 30 minutes per session
  • Program length: At least 12 weeks 1, 2
  • Walking should be the first-line training modality
  • High-intensity training (77%-95% of maximal heart rate) improves walking performance 2

Home-Based Exercise

• When supervised exercise is not available, structured and monitored home-based exercise programs should be considered 1
• Though less effective than supervised programs, home-based exercise is better than no exercise 2

Pharmacological Therapy

Antiplatelet Therapy

• For symptomatic PAD patients:
  • Aspirin (75-100 mg daily) or clopidogrel (75 mg daily) is recommended 1, 3
  • Consider combination of rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg daily) for high ischemic risk patients with non-high bleeding risk 1, 2
• For asymptomatic PAD:
  • Aspirin 75-100 mg daily may be considered in patients with diabetes 1
  • Routine antiplatelet therapy is not recommended for asymptomatic PAD without clinically relevant atherosclerotic cardiovascular disease 1

Claudication-Specific Medications

• Cilostazol 100 mg twice daily is recommended for patients with lifestyle-limiting claudication refractory to exercise therapy and smoking cessation 1, 2
  • Contraindicated in heart failure
• Pentoxifylline 400 mg three times daily can be considered as second-line therapy, though clinical effectiveness is marginal 2, 4

Anticoagulation

• Oral anticoagulant monotherapy is not recommended for PAD unless there is another indication 1
• Long-term dual antiplatelet therapy (DAPT) is not recommended in PAD patients 1

Revascularization

Indications for Revascularization

• Revascularization is indicated after:
  • 3-month period of optimal medical therapy and exercise with persistent lifestyle-limiting symptoms 1, 2
  • For limb salvage in patients with CLTI 1

Revascularization Approaches

• The mode and type of revascularization should be adapted to:
  • Anatomical lesion location
  • Lesion morphology
  • Patient's general condition 1

Endovascular Therapy

• Drug-eluting treatment should be considered as first-choice strategy for femoro-popliteal lesions 1
• For iliac lesions, consider balloon angioplasty with or without stenting in external iliac arteries, or primary stenting in common iliac arteries 1

Surgical Revascularization

• Consider surgical approach when an autologous vein (e.g., great saphenous vein) is available in patients with low surgical risk 1
• For CLTI, autologous veins are the preferred conduit for infra-inguinal bypass surgery 1
• In multilevel disease, inflow obstructions should be eliminated when treating downstream lesions 1

Follow-up and Monitoring

• Regular follow-up at least once yearly is recommended to assess:
  • Clinical and functional status
  • Medication adherence
  • Limb symptoms
  • Cardiovascular risk factors 1
• Duplex ultrasound assessment should be performed as needed 1
• For CLTI patients after revascularization, regular follow-up is essential 1

Important Considerations and Pitfalls

• Revascularization is not recommended for:
  • Asymptomatic PAD 1
  • Solely to prevent progression to CLTI 1
• Early recognition of CLTI and prompt referral to a vascular team are critical for limb salvage 1
• Multidisciplinary vascular team approach is recommended for complex cases, especially for CLTI 1, 5
• Underutilization of exercise therapy and inadequate medical therapy are common pitfalls 2

By following this comprehensive treatment approach, the goals of reducing cardiovascular events, improving functional status, and preventing limb loss in patients with PAD can be achieved.