Management of Peripheral Artery Disease with Lower Leg Wounds in an Elderly Patient
The next best step is urgent vascular assessment to determine if this patient has chronic limb-threatening ischemia (CLTI) requiring revascularization, while simultaneously optimizing her medical therapy with consideration for adding rivaroxaban 2.5 mg twice daily to her existing aspirin regimen (if not already on antiplatelet therapy) and ensuring she is on high-intensity statin therapy with an LDL-C goal of <55 mg/dL. 1
Immediate Clinical Assessment Required
This patient's presentation of lower leg wounds with intermittent leg pain and cramping strongly suggests CLTI rather than simple claudication. 1 The presence of non-healing wounds is a defining feature of CLTI, which manifests as ischemic rest pain, non-healing wounds/ulcers, or gangrene with symptoms present for >2 weeks. 1 CLTI carries a historically estimated 1-year mortality rate of 25-35% and 1-year amputation rate up to 30%, making urgent evaluation critical. 1
Key Diagnostic Steps:
- Perform ankle-brachial index (ABI) measurement immediately to quantify the severity of arterial insufficiency 1
- Comprehensive vascular examination and inspection of legs and feet to assess wound characteristics, presence of pulses, and signs of critical ischemia 1
- Assess for signs of infection in the wounds, as the WIfI (wound, ischemia, and foot infection) classification helps estimate amputation risk 1
Optimization of Medical Therapy
Antiplatelet/Antithrombotic Strategy
Given her existing PAD with wounds and atrial fibrillation on apixaban, consider adding low-dose rivaroxaban 2.5 mg twice daily to aspirin 81 mg daily (if she is not already on antiplatelet therapy alongside her apixaban). 1 The 2024 ACC/AHA guidelines specifically state that rivaroxaban 2.5 mg twice daily combined with low-dose aspirin is effective to prevent major adverse cardiovascular events and major adverse limb events in patients with PAD who are not at increased risk of bleeding. 1
Important caveat: Her apixaban should be continued for atrial fibrillation stroke prevention, as the 2024 ESC guidelines recommend full oral anticoagulation in patients with PAD and newly diagnosed AF with CHA2DS2-VASc score ≥2. 1 However, the combination of full-dose anticoagulation with dual antiplatelet therapy significantly increases bleeding risk and requires careful assessment.
A more conservative approach would be to ensure she is on at least single antiplatelet therapy (aspirin 75-325 mg daily OR clopidogrel 75 mg daily) in addition to her apixaban. 1 Antiplatelet therapy is recommended (Class I, Level A) to reduce MI, stroke, and vascular death in patients with symptomatic PAD. 1
Lipid Management
Ensure she is on high-intensity statin therapy with an LDL-C reduction by ≥50% from baseline and an LDL-C goal of <1.4 mmol/L (<55 mg/dL). 1 Treatment with a statin medication is indicated for all patients with PAD (Class I, Level A evidence). 1 If she is not achieving this target on her current statin, consider intensifying therapy or adding a PCSK9 inhibitor. 1
Blood Pressure Management
Continue her ramipril (ACE inhibitor), as this is appropriate therapy. 1 The use of ACE inhibitors or ARBs can be effective to reduce the risk of cardiovascular ischemic events in patients with PAD (Class IIa, Level A). 1 Antihypertensive therapy should be administered to patients with hypertension and PAD to reduce the risk of MI, stroke, heart failure, and cardiovascular death. 1
Wound Care and Infection Management
Coordinate immediate wound care with a multispecialty team including podiatry or wound care specialists. 1 Care for patients with PAD, especially those with CLTI, is optimized when delivered by a multispecialty care team. 1 Foot care is crucial and ranges from preventive care to advanced care in the setting of CLTI. 1
- Assess for infection requiring antibiotics
- Implement appropriate wound dressings and offloading strategies
- Ensure adequate glycemic control if diabetic, as glycemic control can be beneficial for patients with CLTI to reduce limb-related outcomes (Class IIa, Level B-NR) 1
Revascularization Consideration
If CLTI is confirmed, urgent vascular surgery or interventional radiology consultation is needed to determine if the patient is a candidate for revascularization (endovascular or surgical). 1 The goal is limb salvage and wound healing, which often cannot be achieved with medical therapy alone in CLTI.
Critical Pitfalls to Avoid
- Do not delay vascular assessment in the presence of wounds, as this may represent CLTI requiring urgent intervention to prevent amputation 1
- Do not discontinue apixaban without alternative anticoagulation, as this increases stroke risk in atrial fibrillation 2
- Do not assume wounds will heal with medical therapy alone if significant arterial insufficiency is present 1
- Avoid triple therapy (full-dose anticoagulation plus dual antiplatelet therapy) unless absolutely necessary due to prohibitive bleeding risk, though this may be considered in select high-risk patients after revascularization 1
Longitudinal Follow-Up
Establish routine clinical evaluation including assessment of limb symptoms, functional status, lower extremity pulse and foot assessment, and progress of risk factor management. 1 Coordination of care among clinicians to improve management of PAD and comorbid conditions is recommended (Class I, Level C-EO). 1