What are the recommendations for Peripheral Artery Disease (PAD)?

Recommendations for Peripheral Artery Disease (PAD) Management

The management of peripheral artery disease requires aggressive cardiovascular risk factor modification, antiplatelet therapy, supervised exercise training, and consideration of revascularization for symptomatic patients with impaired quality of life despite optimal medical therapy.

Diagnosis and Screening

• Diagnostic Testing:

  • Ankle-brachial index (ABI) is the first-line diagnostic test for PAD (≤0.90 confirms diagnosis) 1
  • For noncompressible arteries (ABI >1.40), use toe-brachial index (TBI <0.70 is abnormal) 1
  • Duplex ultrasound is the first-line imaging test for anatomical assessment 1

• Screening Recommendations:

  • Consider screening for asymptomatic carotid stenosis in patients with multiple cardiovascular risk factors 2
  • Consider opportunistic AAA screening with duplex ultrasound in PAD patients 2
  • Consider femoro-popliteal aneurysm screening with duplex ultrasound in patients with AAA 2

Risk Factor Modification

• Smoking Cessation:

  • Ask about tobacco use at every visit 2
  • Offer behavioral and pharmacological treatment including varenicline, bupropion, and nicotine replacement therapy 2
  • E-cigarettes may be considered as a quitting aid, but limit use due to unknown long-term effects 2

• Lipid Management:

  • Statin therapy is recommended for all patients with atherosclerotic PAD 2
  • Target LDL-C goal <1.4 mmol/L (55 mg/dL) and >50% reduction from baseline 2
  • If target not achieved with maximally tolerated statins, add ezetimibe 2
  • If target still not achieved, add PCSK9 inhibitor 2
  • For statin-intolerant patients, use bempedoic acid alone or with PCSK9 inhibitor 2

• Blood Pressure Control:

  • Target <140/90 mmHg for patients without diabetes 2
  • Target <130/80 mmHg for patients with diabetes or chronic kidney disease 2
  • Beta-blockers are not contraindicated in PAD 2

• Diabetes Management:

  • Target HbA1c <7% to reduce microvascular complications 2, 1
  • Proper foot care is essential for diabetic patients with PAD 2

Exercise and Rehabilitation

• Supervised Exercise Training (SET):

  • Recommended as initial treatment for intermittent claudication 2
  • Also recommended as adjuvant therapy after endovascular revascularization 2
  • Program specifications:
    • Minimum 30-45 minutes per session 2
    • At least 3 times per week 2
    • Minimum 12-week duration 2
    • High-intensity training (77-95% of maximal heart rate) improves walking performance 2

• Home-Based Exercise Training (HBET):

  • Consider when SET is not available or feasible 2
  • Should be structured and monitored (calls, logbooks, connected devices) 2

Pharmacological Therapy

• Antiplatelet Therapy:

  • Aspirin (75-325 mg daily) is recommended for symptomatic PAD 2
  • Clopidogrel (75 mg daily) is an effective alternative to aspirin 2, 3
  • Consider combination of rivaroxaban (2.5 mg twice daily) and aspirin (100 mg daily) for high ischemic risk patients with non-high bleeding risk 2
  • Antiplatelet therapy can be useful for asymptomatic individuals with ABI ≤0.90 2

• Cilostazol:

  • Recommended (100 mg twice daily) to improve symptoms and walking distance in patients with intermittent claudication without heart failure 2

Revascularization

• Indications:

  • Consider after 3-month period of optimal medical therapy and exercise with impaired PAD-related quality of life 2
  • Not recommended for asymptomatic PAD or solely to prevent progression to chronic limb-threatening ischemia (CLTI) 2

• Approach:

  • Adapt revascularization options based on anatomical lesion location, morphology, and patient condition 2
  • For femoro-popliteal lesions, drug-eluting treatment should be considered as first-choice strategy 2
  • Consider open surgical approach when autologous vein is available in low-risk patients 2

Chronic Limb-Threatening Ischemia (CLTI)

• Early recognition and referral to vascular team is essential for limb salvage 2
• Patients with CLTI should be managed by a multidisciplinary vascular team 2
• For patients with ulcers, offloading mechanical tissue stress is indicated to allow wound healing 2

Follow-up

• Regular follow-up at least once yearly is recommended 2
• Assess clinical and functional status, medication adherence, limb symptoms, and cardiovascular risk factors 2
• Perform duplex ultrasound assessment as needed 2

Common Pitfalls to Avoid

• Failing to screen high-risk patients for PAD 1
• Attributing leg symptoms solely to arthritis or neuropathy 1
• Relying on pulse palpation alone for diagnosis 1
• Overlooking the need for definitive treatment of underlying lesions after successful thrombolysis 1
• Delaying treatment for acute limb ischemia 1
• Attributing poor healing solely to "small vessel disease" without proper vascular assessment 1

By following these evidence-based recommendations, clinicians can effectively manage PAD, reduce cardiovascular morbidity and mortality, improve quality of life, and prevent limb-threatening complications.