What is the treatment for Peripheral Artery Disease (PAD) or Peripheral Vascular Disease (PVD)?

Treatment of Peripheral Artery Disease (PAD)

All patients with PAD require comprehensive optimal medical therapy including supervised exercise training, antiplatelet therapy, high-intensity statin therapy, and aggressive cardiovascular risk factor modification to reduce major adverse cardiovascular events (MACE), major adverse limb events (MALE), and improve quality of life. 1

Lifestyle Modifications and Exercise Therapy

Smoking Cessation

• Smoking cessation is mandatory for all PAD patients who smoke, using counseling combined with pharmacotherapy (nicotine replacement, bupropion, or varenicline). 2, 3
• This is the single most important modifiable risk factor for PAD progression. 4

Supervised Exercise Training (SET)

• SET is the first-line treatment for symptomatic PAD, with demonstrated improvements in pain-free walking distance, maximum walking distance, and quality of life. 1, 5
• Prescribe at least 3 sessions per week, 30-60 minutes per session, for minimum 12 weeks. 1, 2, 5
• Patients should exercise to moderate-to-severe claudication pain for optimal benefit, though a flexible approach considering patient tolerance is reasonable. 1, 3
• When SET is unavailable, structured home-based exercise training with monitoring should be implemented, though it is less effective. 1, 5

Dietary Modifications

• Recommend a diet rich in legumes, dietary fiber, nuts, fruits, vegetables, and high flavonoid intake for cardiovascular prevention. 2

Pharmacological Management

Antiplatelet/Antithrombotic Therapy

• For symptomatic PAD without high bleeding risk: Combination therapy with rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily is recommended to reduce both MACE and MALE. 1, 3
• For patients with contraindications to dual therapy or high bleeding risk: Single antiplatelet therapy with clopidogrel 75 mg daily (preferred) or aspirin 75-100 mg daily. 1, 2, 3
• Antiplatelet therapy is reasonable even for asymptomatic PAD to reduce cardiovascular events. 5

Lipid-Lowering Therapy

• All PAD patients require statin therapy regardless of baseline LDL-C levels. 1, 2, 3
• Target LDL-C <70 mg/dL for all PAD patients (considered very high cardiovascular risk). 1, 5, 3
• Consider fibric acid derivatives for patients with low HDL, normal LDL, and elevated triglycerides. 1

Antihypertensive Therapy

• Treat hypertension to target <140/90 mmHg (non-diabetic) or <130/80 mmHg (diabetic or chronic kidney disease). 1, 5, 3
• ACE inhibitors are preferred as they provide additional cardiovascular protection beyond blood pressure reduction. 1, 4
• Beta-blockers are safe and effective in PAD and should be used when coronary artery disease coexists. 1

Diabetes Management

• Target HbA1c <7% to reduce microvascular complications and potentially improve cardiovascular outcomes. 1
• Implement proper foot care including appropriate footwear, daily inspection, and urgent treatment of any skin lesions. 1

Claudication-Specific Pharmacotherapy

• Cilostazol (phosphodiesterase III inhibitor) improves maximal walking distance and can be added for symptomatic relief in patients with claudication. 5, 4
• Pentoxifylline has limited evidence and is generally not recommended as first-line therapy. 6

Revascularization Considerations

• Consider revascularization only after 3 months of optimal medical therapy and supervised exercise training in patients with lifestyle-limiting claudication and inadequate response. 2, 5
• Immediate revascularization is indicated for chronic limb-threatening ischemia (CLTI) to prevent limb loss. 1, 3
• Revascularization is NOT indicated for asymptomatic PAD or solely to prevent progression to CLTI. 5
• Tailor revascularization approach (endovascular, surgical, or hybrid) to lesion location, morphology, and patient comorbidities in a multidisciplinary vascular team setting. 1, 2

Surveillance and Follow-Up

• Monitor patients at least annually with assessment of cardiovascular risk factors, limb symptoms, functional status, and medication adherence. 2, 3
• Measure ankle-brachial index (ABI) or toe-brachial index (TBI) for patients with diabetes or renal failure if resting ABI is normal. 1
• Screen all symptomatic PAD patients for abdominal aortic aneurysm with duplex ultrasound. 5, 3

Special Populations and Comorbidities

PAD with Atrial Fibrillation

• PAD patients with AF have 40% higher all-cause mortality and >70% higher MACE risk compared to AF without PAD. 1
• Anticoagulation decisions should balance stroke prevention (CHA2DS2-VASc score includes PAD) with bleeding risk. 1

PAD with Heart Failure

• Concomitant HF increases MACE risk by 30% and mortality by 40%. 1
• Optimize HF therapy and intensify risk factor modification in these high-risk patients. 1

PAD with Diabetes or Renal Failure

• Use toe pressure or toe-brachial index when ABI is falsely elevated due to arterial calcification. 1
• For patients with chronic wounds, apply the WIfI (Wound, Ischemia, foot Infection) classification to estimate amputation risk. 1

Critical Pitfalls to Avoid

• Do not withhold beta-blockers in PAD patients—they are safe and effective, particularly when CAD coexists. 1
• Monitor prothrombin time more frequently when combining antiplatelet agents with warfarin or when starting pentoxifylline in anticoagulated patients. 6
• PAD patients are frequently undertreated compared to those with coronary disease—ensure all secondary prevention measures are implemented. 1, 5
• Women may respond less favorably to exercise therapy, though evidence is inconsistent—monitor response and adjust accordingly. 5
• Avoid chelation therapy—it has no proven benefit. 7