What are the treatment options for broken capillaries in the legs and arteriopathy?

Management of Broken Capillaries and Arteriopathy in the Legs

The term "broken capillaries" typically refers to telangiectasias (spider veins), which are cosmetic concerns distinct from arteriopathy (peripheral artery disease/PAD); these conditions require fundamentally different treatment approaches—telangiectasias are treated with sclerotherapy or laser therapy for cosmetic improvement, while arteriopathy demands aggressive cardiovascular risk reduction and revascularization only when specific clinical criteria are met.

Distinguishing Between the Two Conditions

Telangiectasias ("Broken Capillaries")

• Telangiectasias are small dilated superficial blood vessels that appear as red or purple thread-like lines on the skin, affecting up to 41% of women and increasing with age 1
• These are not a manifestation of arteriopathy but rather a venous or capillary issue 1
• Patients may be asymptomatic or report pain, burning, or itching 1

Arteriopathy (Peripheral Artery Disease)

• PAD is an atherosclerotic condition causing arterial stenosis or occlusion, leading to reduced blood flow to the legs 2
• Symptoms include claudication (leg pain with walking), rest pain, or critical limb-threatening ischemia (CLTI) with nonhealing wounds or gangrene 3
• The ankle-brachial index (ABI) should be measured; normal is >0.9, while <0.5 indicates severely impaired circulation 3

---

Treatment of Telangiectasias (Broken Capillaries)

First-Line Treatment Options

• Sclerotherapy with any sclerosing agent is more effective than placebo for resolution or improvement of telangiectasias (SMD 3.08,95% CI 2.68 to 3.48), though it causes more adverse events including hyperpigmentation (RR 11.88) and matting (RR 4.06) 1
• Polidocanol causes less pain compared to other sclerosing agents (SMD -0.26,95% CI -0.44 to -0.08) with similar efficacy 1
• Sodium tetradecyl sulphate (STS) should be avoided as first-line therapy due to increased hyperpigmentation (RR 1.71), matting (RR 2.10), and pain 1

Alternative Treatment Options

• Laser therapy shows comparable efficacy to sclerotherapy for resolution of telangiectasias (SMD -0.09,95% CI -0.25 to 0.07) and may result in less hyperpigmentation (RR 0.57) 1
• Combined laser plus polidocanol sclerotherapy may provide superior resolution compared to polidocanol alone (SMD 5.68,95% CI 5.14 to 6.23), though with potentially more pain 1

Important Caveats

• Foam sclerotherapy may cause more matting (RR 6.12) compared to liquid sclerosants 1
• No studies have evaluated intensive pulsed light, thermocoagulation, or microphlebectomy adequately 1

---

Treatment of Arteriopathy (Peripheral Artery Disease)

Medical Therapy (Mandatory for ALL PAD Patients)

Lipid Management

• Reduce LDL-C by ≥50% from baseline to a goal of <55 mg/dL using high-intensity statin therapy 4
• Statins improve both cardiovascular outcomes and walking distance 4

Antiplatelet Therapy

• For symptomatic PAD, use low-dose rivaroxaban 2.5 mg twice daily combined with aspirin 81 mg daily to reduce major adverse cardiovascular events (MACE) and major adverse limb events (MALE) 4
• Single antiplatelet therapy (aspirin 75-325 mg daily or clopidogrel 75 mg daily) is reasonable if dual therapy is contraindicated 4
• Oral anticoagulation alone (without aspirin) is harmful and should NOT be used (Class III: Harm) 4

Blood Pressure Control

• ACE inhibitors or ARBs reduce cardiovascular ischemic events 4
• Blood pressure control reduces MI, stroke, heart failure, and cardiovascular death 4

Smoking Cessation

• Smoking cessation with pharmacotherapy (varenicline, bupropion, or nicotine replacement) is mandatory at every visit 4

Glycemic Control

• In diabetic patients, glycemic control reduces limb-related outcomes in CLTI 4

Exercise Therapy (For Claudication)

• Supervised exercise programs are Class I, Level A recommendation and should be discussed before considering revascularization for claudication 3, 4
• High-quality evidence shows exercise improves pain-free walking distance by 82 meters (95% CI 71.73 to 92.48) and maximum walking distance by 120 meters (95% CI 50.79 to 189.92) 5
• Supervised sessions should be held at least twice weekly for up to two years 5
• Unstructured advice to "walk more" is NOT efficacious 4

Pharmacotherapy for Claudication

• Pentoxifylline is FDA-approved for intermittent claudication but is not intended to replace definitive therapy 6
• Cilostazol should be exhausted before considering intervention 4

When to Consider Revascularization

For Claudication (Lifestyle-Limiting Symptoms)

• Revascularization is reasonable ONLY for lifestyle-limiting claudication with inadequate response to guideline-directed medical therapy (GDMT), acceptable perioperative risk, and favorable anatomy 3
• Endovascular procedures are effective for hemodynamically significant aortoiliac occlusive disease (Class I, Level A) 3
• Endovascular procedures are reasonable for hemodynamically significant femoropopliteal disease (Class IIa, Level B-R) 3
• The usefulness of endovascular procedures for isolated infrapopliteal claudication is unknown (Class IIb, Level C-LD) 3

Critical Pitfall to Avoid

• NEVER perform prophylactic revascularization for asymptomatic PAD or claudication to prevent progression to CLTI—procedural risks exceed benefits (Class III: Harm) 3, 4
• Progression to critical limb ischemia occurs in only 10-15% over 5 years 4

For Critical Limb-Threatening Ischemia (CLTI)

• In patients with CLTI, revascularization should be performed when possible to minimize tissue loss (Class I, Level B-NR) 3
• An interdisciplinary care team should evaluate revascularization options before amputation (Class I, Level C-EO) 3
• Endovascular procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene 3

Revascularization Strategy for Multilevel Disease

• In patients with combined inflow and outflow disease, inflow lesions should be addressed first (Class I, Level B) 3, 7
• If symptoms of CLTI or infection persist after inflow revascularization, perform outflow revascularization 3, 7
• A staged approach to endovascular procedures is reasonable in patients with ischemic rest pain 3, 7

Surgical Revascularization

For Claudication

• Surgical procedures are reasonable when GDMT fails, perioperative risk is acceptable, and technical factors suggest advantages over endovascular procedures 3
• When surgery is performed, bypass to the popliteal artery with autogenous vein is recommended over prosthetic graft (Class I, Level A) 3
• Femoral-tibial artery bypasses with prosthetic graft should NOT be used for claudication (Class III: Harm) 3

For CLTI

• When surgery is performed for CLTI, bypass to the popliteal or infrapopliteal arteries should be constructed with suitable autogenous vein (Class I, Level A) 3
• Ipsilateral greater saphenous vein is the first choice for femoral-tibial bypass 4
• If endovascular revascularization has failed and autogenous vein is unavailable, prosthetic material can be effective for bypass to the below-knee popliteal and tibial arteries (Class IIa, Level B-NR) 3

Endovascular Techniques

• Primary stent placement is NOT recommended in femoral, popliteal, or tibial arteries (Class III) 3
• Stents may be used as salvage therapy for suboptimal balloon dilation results (persistent translesional gradient, residual stenosis >50%, or flow-limiting dissection) 3, 4
• Drug-eluting stents are superior to bare-metal stents for infrapopliteal intervention 4
• Atherectomy has niche indications in severely calcified lesions but carries risk of distal embolization 4

Post-Revascularization Management

• Antiplatelet therapy should be initiated immediately and continued indefinitely (Class I, Level A) 4
• Wound care after revascularization should be performed with the goal of complete wound healing 3
• An interdisciplinary care team should provide comprehensive care for patients with CLTI and tissue loss (Class I, Level B-NR) 3

---

Special Populations: Dialysis Patients with PAD

• ABI may be falsely elevated due to vascular calcification; toe-brachial index (TBI) is more accurate 4
• Outcomes after revascularization are inferior: high perioperative mortality, decreased wound healing, and limb loss despite patent grafts 4
• However, selected ambulatory patients can achieve 2-year limb salvage rates of 52%—revascularization should not be automatically dismissed 4

---

Key Clinical Pitfalls to Avoid

• Do not confuse cosmetic telangiectasias with arteriopathy—they require completely different treatments 1, 2
• Do not rely solely on revascularization without addressing cardiovascular risk factors—mortality is primarily from cardiovascular events, not limb complications 4
• Do not perform revascularization for asymptomatic PAD or non-limiting claudication 3, 4
• Do not use bare-metal stents in infrapopliteal arteries due to high restenosis rates 4
• Do not use chelation therapy (EDTA)—it is not indicated and may have harmful adverse effects 3, 4