What is the best management approach for an elderly male patient with mild diffuse lower extremity atherosclerotic plaques, 50% bilateral iliofemoral stenoses, and normal toe pressures, but no symptoms of arterial insufficiency?

Management of Asymptomatic Bilateral Iliofemoral Stenosis in an Elderly Male

For this elderly male patient with 50% bilateral iliofemoral stenoses but normal toe pressures and no symptoms of arterial insufficiency, revascularization is not indicated—aggressive medical management with cardiovascular risk factor modification, antiplatelet therapy, and statin therapy is the appropriate treatment strategy. 1

Key Clinical Context

The arterial doppler findings reveal:

• Mild diffuse atherosclerotic plaques
• Approximately 50% bilateral iliofemoral stenoses
• Normal toe pressures and pulse volume recordings bilaterally
• No evidence of arterial insufficiency

This represents asymptomatic peripheral artery disease (PAD) without functional limitation or critical limb-threatening ischemia (CLTI). 1

Why Revascularization is NOT Indicated

Anatomic imaging and revascularization should not be performed for asymptomatic PAD. 1 The 2017 AHA/ACC guidelines explicitly state that invasive and noninvasive angiography (CTA, MRA) should not be performed for anatomic assessment of patients with asymptomatic PAD (Class III: Harm recommendation). 1

• For asymptomatic lower extremity PAD, there is currently no evidence that additional vascular laboratory diagnostic tests or limb arterial revascularization improves outcomes or limb function. 1
• Revascularization is not recommended for asymptomatic PAD or solely to prevent progression to CLI. 2
• The primary value of advanced imaging (CTA, MRA, catheter angiography) is to plan revascularization when clinically indicated for CLTI or functionally limiting claudication despite guideline-directed medical therapy (GDMT). 1

Recommended Management Strategy

1. Comprehensive Cardiovascular Risk Factor Modification

All patients with PAD, regardless of symptom status, should be treated as high cardiovascular risk and receive intensive atherosclerosis risk factor modification. 1

• Smoking cessation is mandatory if the patient smokes—smoking is associated with increased risk of major adverse cardiovascular events (MACE) and major adverse limb events (MALE). 1
• Lipid management: Target LDL-C <1.4 mmol/L (<55 mg/dL) or at least 50% reduction from baseline with high-intensity statin therapy. 1
• Blood pressure control: Optimize antihypertensive therapy, as uncontrolled hypertension is associated with MACE, CKD, and polyvascular disease. 1
• Diabetes management (if present): Optimize glycemic control, as diabetes amplifies risk of MACE and MALE including CLTI and amputation. 1

2. Antiplatelet Therapy

Antiplatelet therapy is recommended for all patients with PAD to reduce cardiovascular ischemic events. 1

• Standard therapy is aspirin 75-100 mg daily or clopidogrel 75 mg daily. 1
• For patients with PAD at high ischemic risk but without high bleeding risk, consider combination therapy with low-dose rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily. 1, 2 This combination has been shown to reduce MACE and MALE in patients with PAD. 1

3. Supervised Exercise Therapy

Supervised exercise therapy (SET) should be initiated in all patients with nonlimb-threatening PAD to improve maximum walking distance and functional capacity. 1, 2

• Training frequency: at least 3 times per week 2
• Session duration: at least 30 minutes 2
• Program duration: at least 12 weeks 2

4. Assessment for PAD-Related Risk Amplifiers

Clinicians should assess for and incorporate PAD-related risk amplifiers when developing treatment recommendations. 1

Key risk amplifiers to evaluate include:

• Diabetes mellitus 1
• Chronic kidney disease (CKD) or end-stage kidney disease 1
• Polyvascular disease (atherosclerosis in ≥2 vascular beds) 1
• Depression (using GDS or PHQ-9 screening tools) 1
• Ongoing smoking 1

5. Surveillance and Follow-up

Patients with PAD should be followed at least annually to assess clinical and functional status, medication adherence, limb symptoms, and cardiovascular risk factors. 2

• Perform comprehensive pulse examination and foot inspection at each visit. 2
• Conduct vascular review of symptoms to assess for development of walking impairment, claudication, ischemic rest pain, or nonhealing wounds. 2
• Repeat ABI measurement if symptoms develop or change. 1, 2

When to Reconsider Revascularization

Revascularization would only become appropriate if the patient develops:

1. Lifestyle-limiting claudication with significant functional impairment despite 3-6 months of optimal medical therapy and supervised exercise 1, 2
2. Critical limb-threatening ischemia (rest pain, nonhealing wounds, gangrene) 1, 2

Common Pitfalls to Avoid

• Do not pursue anatomic imaging (CTA, MRA, angiography) in asymptomatic patients—this represents inappropriate resource utilization and may lead to unnecessary interventions. 1
• Do not assume that anatomic stenosis severity alone warrants intervention—functional assessment and symptom status drive treatment decisions in chronic PAD. 1
• Do not neglect cardiovascular risk factor modification—patients with asymptomatic PAD have comparable cardiovascular risk to those with symptomatic disease and require aggressive secondary prevention. 1, 3
• Recognize that falsely elevated ABIs due to tibial vessel calcification (as noted in this patient) make toe pressures and pulse volume recordings the more reliable hemodynamic assessment—fortunately, these are normal in this case. 1