What are the treatment options for peripheral arterial disease?

Treatment Options for Peripheral Arterial Disease

The cornerstone of peripheral arterial disease (PAD) management includes supervised exercise therapy, antiplatelet therapy, risk factor modification, and revascularization for symptomatic patients who fail conservative management after 3 months. 1

Risk Factor Modification

• Smoking cessation is essential for all PAD patients, using comprehensive interventions including behavioral therapy, nicotine replacement, or medications like bupropion 2, 3
• Aggressive lipid management with high-intensity statins aiming for LDL-C reduction by ≥50% from baseline is recommended for all PAD patients 1, 2
• Blood pressure control with a target of <140/90 mmHg in non-diabetics or <130/80 mmHg in diabetics and those with chronic kidney disease 2, 4
• Diabetes management with target hemoglobin A1C <7% to reduce microvascular complications 2, 5

Exercise Therapy

• Supervised exercise training (SET) is recommended as first-line therapy for patients with intermittent claudication 1, 6
• SET should be conducted at least three times per week, for at least 30 minutes per session, for a minimum of 12 weeks 1, 2
• Walking should be considered the first-line training modality, performed at high intensity (77%–95% of maximal heart rate) 1
• When SET is not available, a structured and monitored home-based exercise program should be considered 1
• Alternative exercise modes (strength training, arm cranking, cycling) should be considered when walking exercise is not an option 1

Pharmacological Management

Antiplatelet Therapy

• For patients with symptomatic PAD and high ischemic risk but non-high bleeding risk, combination of low-dose rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg daily) should be considered 1, 2
• For secondary prevention in patients with symptomatic PAD, long-term aspirin (75-100 mg/day) or clopidogrel (75 mg/day) is recommended 1, 7
• Single antiplatelet therapy is preferred over dual antiplatelet therapy for patients undergoing peripheral artery percutaneous transluminal angioplasty with stenting 1

Symptom Relief Medications

• Cilostazol (100 mg twice daily) is effective for improving symptoms and increasing walking distance in patients with intermittent claudication without heart failure 2, 3
• Pentoxifylline may be considered for treatment of intermittent claudication when cilostazol is contraindicated or not tolerated 8
• For patients with critical limb ischemia and rest pain unable to undergo revascularization, prostanoids may be considered 1

Revascularization

• Revascularization should be considered for patients with symptomatic PAD who have inadequate response to optimal medical therapy and exercise after 3 months 1, 2
• Early revascularization is indicated for chronic limb-threatening ischemia (CLTI) 1, 2
• The mode and type of revascularization should be adapted to anatomical lesion location, lesion morphology, and general patient condition 1
• In femoro-popliteal lesions, drug-eluting treatment should be considered as the first-choice endovascular strategy 1
• Open surgical approach should be considered when an autologous vein is available in patients with low surgical risk 1
• For acute limb ischemia due to acute thrombosis or embolism, surgery is recommended over peripheral arterial thrombolysis 1

Follow-up and Monitoring

• Regular follow-up at least once a year is recommended to assess clinical status, medication adherence, symptoms, and cardiovascular risk factors 1, 2
• Duplex ultrasound assessment should be performed as needed 1
• Patients with a prior history of critical limb ischemia should be evaluated at least twice annually by a vascular specialist 1
• Direct examination of the feet with shoes and socks removed should be performed at regular intervals, especially in patients with diabetes 1

Special Considerations

• Patients with PAD and skin breakdown should be referred to healthcare providers with specialized expertise in wound care 1
• Systemic antibiotics should be initiated promptly in patients with critical limb ischemia, skin ulcerations, and evidence of limb infection 1
• Patients with critical limb ischemia should be managed by a multidisciplinary vascular team 1