What is the initial management for severe peripheral vascular disease?

Management of Severe Peripheral Vascular Disease

For severe peripheral vascular disease (chronic limb-threatening ischemia), immediate revascularization is the cornerstone of management to achieve limb salvage, and this must be performed as soon as possible following urgent evaluation by an experienced vascular team. 1

Immediate Recognition and Referral

• Early recognition of chronic limb-threatening ischemia (CLTI) and prompt referral to a multidisciplinary vascular team are mandatory for limb salvage. 1
• Urgent evaluation by a vascular clinician with sufficient experience to assess limb viability and implement appropriate therapy is required. 1
• In cases with neurological deficit, urgent revascularization is recommended; diagnostic imaging should guide treatment but must not delay intervention if limb viability is threatened. 1

Revascularization Strategy

Timing and Approach

• Revascularization should be performed as soon as possible in CLTI patients. 1
• Individual risk assessment weighing procedural risk of endovascular versus surgical revascularization by a multidisciplinary vascular team is essential. 1

Multilevel Disease Management

• For combined inflow and outflow disease with CLTI, inflow lesions must be addressed first. 1
• If symptoms of CLTI or infection persist after inflow revascularization, an outflow revascularization procedure should be performed. 1
• If uncertainty exists about hemodynamically significant inflow disease, intra-arterial pressure measurements across suprainguinal lesions should be obtained before and after vasodilator administration. 1

Surgical Revascularization

• Autologous veins are the preferred conduit for infra-inguinal bypass surgery in CLTI. 1
• For patients with limb-threatening ischemia and estimated life expectancy >2 years, bypass surgery with autogenous vein conduit is the preferred initial treatment when available. 1
• Bypasses to the above-knee and below-knee popliteal artery should be constructed with autogenous saphenous vein when possible. 1
• Femoral-tibial artery bypasses should use autogenous vein, including ipsilateral greater saphenous vein or, if unavailable, other sources from leg or arm. 1
• The most distal artery with continuous flow from above and without stenosis >20% should be the point of origin for distal bypass. 1

Endovascular Revascularization

• For patients with limb-threatening ischemia and estimated life expectancy ≤2 years in whom autogenous vein conduit is unavailable, balloon angioplasty is reasonable as the initial procedure when possible. 1

Acute Limb Ischemia Management

• Catheter-based thrombolysis is indicated for patients with acute limb ischemia (Rutherford categories I and IIa) of <14 days' duration. 1
• Mechanical thrombectomy devices can be used as adjunctive therapy for acute limb ischemia due to peripheral arterial occlusion. 1
• Treatment with analgesics should be initiated as soon as possible for pain control. 1
• Monitor for compartment syndrome after revascularization and treat with fasciotomy when indicated. 1

Medical Management Adjuncts

Antiplatelet Therapy

• Antiplatelet therapy is recommended to reduce cardiovascular risk, with clopidogrel (75 mg daily) as the preferred agent. 2, 3, 4
• Aspirin (75-325 mg daily) is an effective alternative for reducing cardiovascular events. 2, 5

Cardiovascular Risk Factor Modification

• Statin therapy should target LDL-C <100 mg/dL (or <70 mg/dL for highest-risk patients). 2, 5, 3
• Antihypertensive therapy targeting blood pressure <140/90 mmHg (or <130/80 mmHg with diabetes or chronic kidney disease) is essential. 2, 5
• Angiotensin-converting enzyme inhibitors are particularly effective in reducing cardiovascular events. 5, 3
• Smoking cessation must be addressed at every visit with comprehensive counseling and pharmacotherapy (varenicline, bupropion, nicotine replacement). 5, 3

Primary Amputation Considerations

• Primary amputation should be evaluated for patients with significant necrosis of weight-bearing portions of the foot (in ambulatory patients), uncorrectable flexion contracture, paresis of the extremity, refractory ischemic rest pain, sepsis, or very limited life expectancy due to comorbid conditions. 1

Post-Revascularization Follow-Up

• Regular follow-up is mandatory following revascularization in CLTI patients. 1
• At follow-up, assess clinical, hemodynamic and functional status, limb symptoms, treatment adherence, and cardiovascular risk factors. 1
• Clinical and haemodynamic success should be assessed following revascularization. 1

Critical Pitfalls to Avoid

• Do not delay revascularization in CLTI—time is tissue. The 2024 ESC guidelines emphasize performing revascularization "as soon as possible" in CLTI patients. 1
• Do not perform surgical or endovascular intervention in patients with severe decrements in limb perfusion (e.g., ABI <0.4) in the absence of clinical symptoms of CLTI, as intervention is not indicated. 1
• Do not use prosthetic conduits when autogenous vein is available for infra-inguinal bypass—outcomes are significantly inferior. 1