What can be done for a leg swollen due to atherosclerosis of an artery?

Management of Leg Swelling Due to Arterial Atherosclerosis

For a leg swollen due to atherosclerosis of an artery, a comprehensive approach including medical management, exercise therapy, and revascularization is recommended based on the severity of the condition and its impact on quality of life.

Assessment and Diagnosis

• Initial evaluation should include a comprehensive vascular examination and inspection of the legs and feet to assess the severity of the condition 1
• Ankle-brachial index (ABI) testing is indicated as a first-line non-invasive test for diagnosis of lower extremity arterial disease (LEAD) 1
• If ankle arteries are incompressible or ABI >1.40, alternative methods such as toe-brachial index, Doppler waveform analysis, or pulse volume recording should be used 1
• Duplex ultrasound (DUS) is indicated as a first-line imaging method to confirm arterial lesions 1
• Further anatomical characterization with DUS, CT angiography (CTA), or MR angiography (MRA) is indicated to guide optimal revascularization strategy 1

Medical Management

• Statins are indicated to improve walking distance in patients with intermittent claudication 1
• Antiplatelet therapy is recommended for secondary prevention 2, 3
• ACE inhibitors or angiotensin receptor blockers are recommended for blood pressure management 1, 3
• Optimal glycemic control is recommended for patients with diabetes 1
• Smoking cessation is essential for patients who smoke 2, 3

Exercise Therapy

• Supervised exercise training is strongly recommended for patients with intermittent claudication 1
• When supervised exercise is not feasible, non-supervised exercise training is recommended 1
• Exercise therapy improves maximal walking distance by almost 5 minutes compared to usual care and increases pain-free and maximal walking distance by 82 and 109 meters respectively 1
• Exercise programs should last at least 3 months, with a minimum of 3 hours per week, involving walking to maximal or submaximal distance 1

Revascularization Options

When to Consider Revascularization

• Revascularization should be considered when daily life activities are compromised despite exercise therapy 1
• For limb salvage in chronic limb-threatening ischemia (CLTI), revascularization is indicated whenever feasible 1
• In acute limb ischemia with neurological deficit, urgent revascularization is indicated 1

Revascularization Approach Based on Lesion Location

1. Aorto-iliac occlusive lesions:

   • An endovascular-first strategy is recommended for short (<5 cm) occlusive lesions 1
   • In patients fit for surgery with aorto-iliac occlusions, aorto-(bi)femoral bypass should be considered 1

2. Femoro-popliteal lesions:

   • An endovascular-first strategy is recommended for short (<25 cm) lesions 1
   • For long (≥25 cm) superficial femoral artery lesions, bypass surgery using autologous saphenous vein is indicated when the vein is available and life expectancy is >2 years 1
   • Drug-eluting treatment should be considered as first-choice strategy for femoro-popliteal lesions 1

3. Infra-popliteal lesions:

   • For revascularization of infra-popliteal arteries, bypass using the great saphenous vein is indicated 1
   • In CLTI patients with below-the-knee lesions, angiography including foot runoff should be considered prior to revascularization 1

Special Considerations

• Early recognition of tissue loss and/or infection with referral to a vascular team is mandatory to improve limb salvage 1
• In acute limb ischemia, heparin and analgesics should be administered as soon as possible 1
• Post-revascularization, monitor for compartment syndrome and treat with fasciotomy if needed 1
• Regular follow-up is essential to ensure perfusion improvement, address cardiovascular risk factors, and evaluate functional capacity 1

Important Pitfalls to Avoid

• Stem cell/gene therapy is not indicated for patients with CLTI 1
• Routine revascularization is not recommended solely to prevent progression to CLTI 1
• Revascularization is not recommended in asymptomatic patients 1
• Do not delay treatment in acute limb ischemia with neurological deficit; urgent intervention is required 1
• Avoid missing concurrent atherosclerotic disease in other vascular beds, as multisite artery disease is common in patients with atherosclerosis 1