How to manage peripheral artery disease?

Management of Peripheral Artery Disease

All patients with PAD require comprehensive cardiovascular risk factor modification including smoking cessation, statin therapy targeting LDL-C <55 mg/dL, antiplatelet therapy, blood pressure control, and supervised exercise therapy as first-line treatment for claudication symptoms. 1, 2

Initial Assessment and Diagnosis

Risk Assessment and Screening:

• Perform vascular symptom review assessing for walking impairment, claudication, ischemic rest pain, and nonhealing wounds in all at-risk patients 1
• Conduct comprehensive pulse examination and foot inspection 1
• Screen patients over 50 years for family history of abdominal aortic aneurysm 1
• Obtain resting ankle-brachial index (ABI) for diagnostic confirmation; if normal but symptoms persist, proceed with exercise ABI testing 3

Risk Factor Modification (Foundation of All PAD Management)

Smoking Cessation (Class I Recommendation):

• Advise cessation at every visit and assist with developing a quit plan 1
• Offer pharmacotherapy: varenicline, bupropion, or nicotine replacement therapy unless contraindicated 1
• Provide behavioral counseling and consider referral to smoking cessation programs 1

Lipid Management (Class I Recommendation):

• Initiate high-intensity statin therapy for all PAD patients 1, 2
• Target LDL-C reduction ≥50% from baseline with goal <55 mg/dL (<1.4 mmol/L) 2
• For very high-risk patients, target LDL-C <70 mg/dL 1
• Consider fibric acid derivatives for patients with low HDL, normal LDL, and elevated triglycerides 1

Blood Pressure Control (Class I Recommendation):

• Target <140/90 mmHg in non-diabetics 1, 2
• Target <130/80 mmHg in diabetics and chronic kidney disease patients 1, 2
• Beta-blockers are safe and effective; they are NOT contraindicated in PAD 1
• ACE inhibitors may reduce adverse cardiovascular events (Class IIb) 1

Diabetes Management (Class I Recommendation):

• Target hemoglobin A1C <7% to reduce microvascular complications 1, 2
• Implement proper foot care including daily inspection, appropriate footwear, chiropody/podiatry, skin cleansing, and topical moisturizers 1
• Address skin lesions and ulcerations urgently 1

Antiplatelet and Antithrombotic Therapy

Standard Antiplatelet Therapy (Class I Recommendation):

• Aspirin 75-325 mg daily for all symptomatic PAD patients to reduce MI, stroke, and vascular death 1
• Clopidogrel 75 mg daily is a safe alternative to aspirin 1

Dual Pathway Inhibition (Class IIa Recommendation):

• For symptomatic PAD without high bleeding risk: consider low-dose rivaroxaban 2.5 mg twice daily PLUS aspirin 100 mg daily 2
• This combination showed benefit in reducing cardiovascular events but increases bleeding risk 1

Exercise Therapy for Intermittent Claudication

Supervised Exercise Training (Class I Recommendation - First-Line Therapy):

• Conduct in hospital or outpatient facility with direct supervision by qualified healthcare providers 1
• Use intermittent walking exercise to moderate-to-maximum claudication alternating with rest periods 1
• Prescribe 30-45 minutes per session, minimum 3 times weekly, for minimum 12 weeks 1, 2
• Include warm-up and cool-down periods 1

Alternative Exercise Programs (Class IIa Recommendation):

• Structured community- or home-based programs with behavioral change techniques can improve walking ability 1
• Alternative modalities include upper-body ergometry, cycling, and pain-free or low-intensity walking 1

Pharmacotherapy for Claudication Symptoms

Cilostazol (Class I Recommendation):

• Prescribe 100 mg twice daily for patients with intermittent claudication WITHOUT heart failure 2, 4
• Effective for improving symptoms and increasing walking distance 2
• Contraindicated in patients with heart failure 2

Pentoxifylline:

• Less effective than cilostazol but may be considered as alternative 5
• Improves blood flow properties by decreasing viscosity 5
• Dose-related hemorrheologic effects 5

Revascularization Strategies

Indications for Revascularization in Claudication: Before offering revascularization, patients must meet ALL of the following criteria 1:

• Received information about supervised exercise therapy and pharmacotherapy 1
• Completed comprehensive risk factor modification and antiplatelet therapy 1
• Have significant disability (unable to perform normal work or serious impairment of important activities) 1
• Failed 3 months of optimal medical therapy and exercise 2, 4
• Have favorable lesion anatomy with low procedural risk and high probability of success 1

Revascularization Approach:

• Endovascular intervention is first-line for TASC type A iliac and femoropopliteal lesions 4
• Bypass surgery is reasonable for limb-threatening ischemia in patients with life expectancy >2 years and available autogenous vein conduit 4
• Tailor revascularization mode to anatomic location, lesion morphology, and patient status 6

Critical Limb-Threatening Ischemia (CLTI) Management

Urgent Interventions (Class I Recommendations):

• Expedite evaluation and treatment of amputation risk factors 1
• Assess cardiovascular risk before open surgical repair 1
• Initiate systemic antibiotics promptly for skin ulcerations with infection 1
• Refer to specialized wound care providers for skin breakdown 1
• Evaluate for aneurysmal disease if atheroembolization features present 1
• Early revascularization is indicated 2, 4

High-Risk Patient Monitoring:

• Regular foot inspection for patients at risk (ABI <0.4 with diabetes, or any diabetic with known PAD) 1
• Direct foot examination with shoes and socks removed at regular intervals after successful CLTI treatment 1

Follow-Up and Monitoring

Routine Follow-Up:

• Evaluate at least annually (or twice annually for CLTI history) to assess clinical status, medication adherence, symptoms, and cardiovascular risk factors 2, 4
• Perform duplex ultrasound as needed 2
• Patients with prior CLTI require evaluation at least twice annually by vascular specialist due to high recurrence risk 1

Post-Revascularization Care:

• Continue antiplatelet therapy indefinitely unless contraindicated 4
• Maintain all cardiovascular risk factor modifications 1

Common Pitfalls to Avoid

• Do not withhold beta-blockers - they are safe and effective antihypertensives in PAD 1
• Do not prescribe cilostazol to patients with heart failure - it is contraindicated 2
• Do not proceed to revascularization without first attempting 3 months of supervised exercise and optimal medical therapy for claudication patients 2, 4
• Do not use aspirin plus clopidogrel routinely - dual antiplatelet therapy is not standard; consider rivaroxaban plus aspirin instead for appropriate candidates 2
• Do not delay treatment in CLTI - these patients require expedited evaluation and intervention 1