What is the management of Peripheral Vascular Disease (PVD)?

Management of Peripheral Vascular Disease (PVD)

The management of peripheral vascular disease requires aggressive cardiovascular risk factor modification, antiplatelet therapy, supervised exercise programs, and appropriate revascularization for symptomatic patients to reduce mortality and improve quality of life.

Risk Factor Modification

Smoking Cessation

• Individuals with PVD who smoke should be advised by all clinicians to stop smoking and offered comprehensive smoking cessation interventions, including behavior modification therapy, nicotine replacement therapy, or bupropion 1
• Smoking cessation significantly reduces the risk of death, myocardial infarction, and amputation in PVD patients 1

Blood Pressure Control

• Antihypertensive therapy should be administered to achieve a goal of <140/90 mmHg in non-diabetics or <130/80 mmHg in diabetics and those with chronic renal disease 1
• Beta-blockers are effective and not contraindicated in PVD patients 1
• Angiotensin-converting enzyme (ACE) inhibitors are reasonable for symptomatic PVD patients to reduce adverse cardiovascular events 1

Lipid Management

• LDL-C reduction by ≥50% from baseline and an LDL-C goal of <1.4 mmol/L (<55 mg/dL) is recommended for patients with PVD 1
• Statin therapy improves symptoms of intermittent claudication and reduces cardiovascular events 1

Diabetes Management

• Aggressive glucose control with a target hemoglobin A1C <7% is recommended to reduce microvascular complications and potentially improve cardiovascular outcomes 1
• Proper foot care is essential for diabetic PVD patients, including appropriate footwear, daily foot inspection, skin cleansing, and prompt attention to skin lesions 1

Antithrombotic Therapy

Antiplatelet Therapy

• Antiplatelet therapy is indicated to reduce the risk of MI, stroke, or vascular death in patients with atherosclerotic PVD 1
• Aspirin (75-325 mg daily) is recommended as safe and effective antiplatelet therapy 1
• Clopidogrel (75 mg daily) is an effective alternative to aspirin 1
• In patients with high ischemic risk and non-high bleeding risk, combination therapy with rivaroxaban (2.5 mg twice daily) and aspirin (100 mg daily) should be considered 1

Anticoagulation

• Oral anticoagulation with warfarin is not indicated to reduce cardiovascular events in PVD patients 1

Exercise Therapy

Supervised Exercise Programs

• A supervised exercise program is recommended as initial treatment for patients with intermittent claudication 1
• Exercise should be performed for 30-45 minutes, at least 3 times weekly for a minimum of 12 weeks 1
• Walking to moderate-severe claudication pain may improve walking performance, though improvements are also achievable with lesser pain severities 1
• Progressive increase in exercise training load every 1-2 weeks may be considered based on patient tolerance 1

Pharmacological Treatment for Claudication

Cilostazol

• Cilostazol can improve symptoms of claudication and increase walking distance 2, 3
• It functions as an antiplatelet and antithrombotic agent 4

Pentoxifylline

• Pentoxifylline may be used for treatment of peripheral arterial disease, though its efficacy is modest compared to cilostazol 5, 3
• Caution is needed in patients on anticoagulants or with bleeding risk factors 5

Revascularization

Indications

• Revascularization is recommended for patients with symptomatic PVD and impaired quality of life after 3 months of optimal medical therapy and exercise 1
• Early revascularization is recommended for chronic limb-threatening ischemia (CLTI) 1
• Revascularization is not recommended for asymptomatic PVD or solely to prevent progression to CLTI 1

Approach

• The mode and type of revascularization should be adapted to anatomical lesion location, morphology, and patient condition 1
• For femoro-popliteal lesions, drug-eluting treatment should be considered as first-choice endovascular strategy 1
• Open surgical approach should be considered when autologous vein is available in low-risk patients 1
• In CLTI, autologous veins are the preferred conduit for infra-inguinal bypass surgery 1

Follow-up

• Regular follow-up at least once yearly is recommended to assess clinical and functional status, medication adherence, limb symptoms, and cardiovascular risk factors 1
• Duplex ultrasound assessment should be performed as needed 1

Special Considerations

Polyvascular Disease

• PVD frequently coexists with coronary artery disease and cerebrovascular disease 1
• Patients with PVD and atrial fibrillation with CHA2DS-VASc score ≥2 should receive full oral anticoagulation 1
• Screening for ilio-femoral PAD is recommended in patients undergoing transcatheter aortic valve implantation 1

Common Pitfalls and Caveats

• Beta-blockers were previously thought to worsen claudication but are now recognized as safe and effective in PVD patients 1
• Unsupervised exercise programs have less established efficacy compared to supervised programs 1
• Antihypertensive therapy may theoretically decrease limb perfusion pressure, but most patients tolerate therapy without worsening symptoms 1
• Patients with PVD are at high risk of cardiovascular events, with mortality primarily due to cardiovascular causes rather than progression of PVD itself 2
• Monitoring of anticoagulant activity is recommended when pentoxifylline is introduced or the dose is changed in patients on vitamin K antagonists 5