Treatment Approaches for PAD, CLI, and ALI
Peripheral Artery Disease (PAD)
For stable PAD, prioritize medical management and supervised exercise over revascularization—revascularization is not indicated for asymptomatic PAD or solely to prevent progression to critical limb ischemia. 1
Medical Management (All PAD Patients)
Antiplatelet therapy: Single agent therapy with either aspirin 75-100 mg daily OR clopidogrel 75 mg daily is strongly recommended for cardiovascular event reduction 2, 3. Clopidogrel is preferred based on superior outcomes in the CAPRIE trial 4.
Statin therapy: Mandatory for all PAD patients regardless of baseline cholesterol, targeting LDL-C <70 mg/dL for very high-risk patients 2, 4.
Blood pressure control: Target <140/90 mmHg (or <130/80 mmHg if diabetes or chronic kidney disease present) to reduce MI, stroke, heart failure, and cardiovascular death 2, 4.
Smoking cessation: Essential intervention for all patients who smoke 4.
Avoid dual antiplatelet therapy: Does not provide additional benefit over single therapy and increases major bleeding risk 2.
Do not combine antiplatelet agents with warfarin: This combination is contraindicated in symptomatic PAD 2.
Symptom Management for Claudication
Supervised exercise training: First-line treatment—at least 3 times weekly for minimum 30 minutes per session over 12+ weeks, with walking as the primary modality 4.
Cilostazol 100 mg twice daily: Add to baseline antiplatelet therapy when claudication persists despite exercise therapy and smoking cessation 2.
When Revascularization is NOT Indicated
- Asymptomatic PAD: Revascularization is not recommended 1.
- Solely to prevent progression to CLTI: This is not an indication for intervention 1.
- Severe ABI reduction without symptoms: Surgical and endovascular intervention is not indicated in patients with ABI <0.4 in the absence of clinical CLI symptoms 1.
Follow-Up Protocol
- Annual minimum: Assess clinical and functional status, medication adherence, limb symptoms, cardiovascular risk factors, with duplex ultrasound as needed 1.
Critical Limb Ischemia (CLI) / Chronic Limb-Threatening Ischemia (CLTI)
For limb salvage in CLTI, revascularization is mandatory and should be performed as soon as possible—early recognition and immediate referral to a vascular team are critical. 1
Immediate Actions
Early vascular team referral: Prompt recognition and referral are essential for limb salvage 1.
Urgent revascularization: Perform as soon as possible after diagnosis 1.
Multidisciplinary risk assessment: Individual evaluation weighing procedural risks of endovascular versus surgical revascularization 1.
Diagnostic Thresholds
- Absolute systolic pressure ≤50 mmHg at ankle or ≤30 mmHg at toe: Suggests amputation may be required without successful revascularization 1.
Revascularization Strategy
For combined inflow and outflow disease:
- Address inflow lesions first (Class I recommendation) 1.
- If CLI or infection persists after inflow revascularization: Perform outflow revascularization 1.
Choice of revascularization approach (based on BASIL trial):
Life expectancy ≤2 years OR no autogenous vein available: Balloon angioplasty is reasonable as initial procedure when possible 1.
Life expectancy >2 years AND autogenous vein available: Bypass surgery is reasonable as initial treatment, as it provides 7.3 months longer overall survival (95% CI: 1.2-13.4 months) for patients surviving ≥2 years 1.
Autologous veins are the preferred conduit for infrainguinal bypass surgery 1.
Prosthetic bypass outcomes are extremely poor: Balloon angioplasty may be preferable to prosthetic bypass even in patients with life expectancy >2 years 1.
Multilevel Disease
- Eliminate inflow obstructions when treating downstream lesions 1.
Primary Amputation Indications
Consider primary amputation for patients with 1:
- Significant necrosis of weight-bearing foot portions (in ambulatory patients)
- Uncorrectable flexion contracture
- Extremity paresis
- Refractory ischemic rest pain
- Sepsis
- Very limited life expectancy due to comorbidities
Post-Revascularization Management
Regular follow-up: Assess clinical, hemodynamic and functional status, limb symptoms, treatment adherence, and cardiovascular risk factors 1.
Continue medical management: All cardiovascular risk reduction therapies (antiplatelet, statin, antihypertensive) remain essential 5.
Acute Limb Ischemia (ALI)
ALI is a vascular emergency requiring urgent evaluation by an experienced vascular clinician within hours—in cases of neurological deficit, urgent revascularization is mandatory. 1
Immediate Assessment (The Five "Ps")
Look for 1:
- Pain
- Pulselessness
- Pallor
- Paresthesias
- Paralysis
Initial Management
Immediate systemic anticoagulation: Unfractionated heparin is recommended over no anticoagulation 2.
Urgent vascular clinician evaluation: Must have sufficient experience to assess limb viability and implement appropriate therapy 1.
Analgesics as soon as possible: For pain control 1.
Revascularization Timing
With neurological deficit (Rutherford IIb):
- Urgent revascularization is mandatory 1.
- Diagnostic imaging should guide treatment but must not delay intervention if neurological deficit present 1.
- If need for primary amputation is obvious, proceed without imaging 1.
Without severe neurological deficit (Rutherford I and IIa):
- Revascularization within hours of initial imaging in case-by-case decision 1.
Revascularization Approach
Surgery is preferred over intraarterial thrombolysis for definitive management 2.
Catheter-based thrombolysis: Effective for acute limb ischemia (Rutherford categories I and IIa) of <14 days' duration 1.
Mechanical thrombectomy devices: Can be used as adjunctive therapy 1.
For ALI >14 days' duration (Rutherford IIb): Catheter-based thrombolysis or thrombectomy may be considered 1.
Post-Revascularization Monitoring
Monitor for compartment syndrome: Treat with fasciotomy if develops 1.
Assess clinical and hemodynamic success following revascularization 1.
Determine Underlying Cause
- Comprehensive medical history: Determine cause of thrombosis and/or embolization 1.
- Evaluate for proximal aneurysmal disease (abdominal aortic, popliteal, or common femoral aneurysms) if atheroembolization suspected 1.
Post-Procedure Antiplatelet Therapy
- Long-term single antiplatelet therapy: Continue aspirin 75-100 mg daily OR clopidogrel 75 mg daily after any revascularization procedure 2.