What is the next step in managing a patient with moderate peripheral arterial disease (PAD) and atheromatous changes in the lower extremities?

Management of Moderate Peripheral Arterial Disease (PAD) with Atheromatous Changes

The next step in managing this patient with moderate peripheral arterial disease (PAD) should be referral to a vascular specialist for assessment, along with implementation of a comprehensive treatment plan including ankle-brachial index (ABI) testing, cardiovascular risk factor modification, and initiation of structured exercise therapy. 1

Immediate Diagnostic Steps

• Complete ABI testing with follow-up Doppler imaging as recommended in the ultrasound report to further quantify disease severity and establish a baseline for future comparison 1
• Referral to a vascular specialist for comprehensive assessment, as indicated in the ultrasound report findings showing moderate PAD with reduced perfusion in the right popliteal artery 1

Medical Management

Cardiovascular Risk Reduction

• Initiate or optimize statin therapy to achieve LDL-C target <70 mg/dL for this high-risk patient 1
• Implement antithrombotic therapy:
  • Consider combination of low-dose rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg daily) if patient has high ischemic risk and non-high bleeding risk 1
  • Alternatively, single antiplatelet therapy with aspirin (75-100 mg daily) or clopidogrel 1, 2
• Optimize blood pressure control targeting <140/90 mmHg (or <130/80 mmHg if diabetes or chronic kidney disease is present) 1
• Implement aggressive smoking cessation interventions if patient is a smoker, including counseling, pharmacotherapy, and referral to smoking cessation programs 1, 2
• Optimize diabetes management if applicable, targeting HbA1c <7% 1, 3

Exercise Therapy

• Prescribe supervised exercise therapy (SET) as a first-line treatment 1
  • Program should include:
    • Minimum 30-45 minutes per session
    • At least 3 sessions per week
    • Minimum program duration of 12 weeks
    • Walking to moderate-to-maximum claudication pain, alternating with rest periods 1
• If supervised exercise is not available, implement a structured home-based exercise program with clear guidance on frequency, intensity, and progression 1
• Consider high-intensity training (77-95% of maximal heart rate) to improve walking performance 1

Follow-up Plan

• Schedule regular follow-up visits at least annually to assess:
  • Clinical and functional status
  • Medication adherence
  • Limb symptoms
  • Cardiovascular risk factors 1
• Perform periodic ABI measurements to monitor disease progression 1
• Consider arterial duplex ultrasound surveillance, especially if the patient undergoes any revascularization procedures in the future 1

Revascularization Considerations

• Revascularization is not indicated at this stage unless:
  • The patient has significant lifestyle-limiting symptoms after 3 months of optimal medical therapy and exercise 1
  • There is evidence of critical limb ischemia (which is not present in this case) 1
• If revascularization becomes necessary in the future, the approach should be tailored to the specific anatomical lesion location and morphology 1

Important Caveats

• PAD is a marker of systemic atherosclerosis and significantly increases risk of cardiovascular events, making aggressive risk factor modification essential 3, 4
• The monophasic waveform in the right popliteal artery with reduced PSV (34.07 cm/s) confirms moderate PAD requiring attention, even if symptoms are minimal 1, 5
• Patients with PAD are often undertreated with guideline-directed medical therapy, so ensure comprehensive implementation of all recommended therapies 4
• Regular foot examinations are crucial to detect early signs of tissue compromise, especially if the patient has diabetes 1, 5