What is the management for Peripheral Arterial Occlusive Disease (PAOD)?

From the Guidelines

Management of peripheral arterial occlusive disease (PAOD) should prioritize a comprehensive approach focusing on risk factor modification, medical therapy, and in some cases, interventional procedures to reduce morbidity, mortality, and improve quality of life. The cornerstone of management includes smoking cessation, regular exercise, and optimal control of diabetes, hypertension, and hyperlipidemia, as emphasized in the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease 1. Key aspects of management include:

• Aggressive risk factor management to slow the progression of PAOD and prevent major adverse cardiovascular events (MACE) and major adverse limb events (MALE) 1
• Antiplatelet therapy with aspirin (75-325 mg daily) or clopidogrel (75 mg daily) to reduce cardiovascular events, with rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin (81 mg daily) being an effective option for preventing MACE and MALE 1
• Statins, regardless of baseline cholesterol levels, with high-intensity statins like atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily recommended, to reduce cardiovascular risk 1
• A structured exercise program involving 30-45 minutes of walking 3-5 times weekly, pushing to moderate claudication pain, to improve functional capacity
• Regular foot care and inspection, especially in diabetic patients, to prevent ulceration and infection
• Blood pressure control to <140/90 mmHg, with ACE inhibitors or ARBs preferred, to reduce cardiovascular risk. A multispecialty care team approach is recommended to promote collaboration and avoid potential duplication of care, ensuring optimal outcomes for patients with PAOD 1.

From the FDA Drug Label

1. 2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease In patients with established peripheral arterial disease or with a history of recent myocardial infarction (MI) or recent stroke clopidogrel tablets are indicated to reduce the rate of MI and stroke.
2. 2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease 75 mg once daily orally without a loading dose

The management for Peripheral Arterial Occlusive Disease (PAOD) with clopidogrel involves a daily dose of 75 mg orally without a loading dose, as it is indicated to reduce the rate of myocardial infarction (MI) and stroke in patients with established peripheral arterial disease. 2

From the Research

Management of Peripheral Arterial Occlusive Disease (PAOD)

The management of PAOD involves a combination of lifestyle modifications, pharmacologic agents, and other interventions.

• Lifestyle modifications include smoking cessation, weight reduction, and regular physical activity 3, 4, 5.
• Pharmacologic agents such as antiplatelet agents (e.g., aspirin, clopidogrel) and cilostazol may be used to prevent secondary ischemic events and improve claudication symptoms 4, 6.
• The treatment of cardiovascular risk factors, including hyperlipidemia, hypertension, and diabetes mellitus, is also crucial in managing PAOD 3, 4, 5.

Staged Therapy for PAOD

The therapy for PAOD is staged, with conservative treatment (e.g., cessation of smoking, administration of acetylsalicylic acid, walking training) sufficing for early stages (I and IIa), while invasive measures (e.g., percutaneous transluminal angioplasty (PTA), revascularization, amputation) are required for more advanced stages (IIb and higher) 3, 4, 7.

• Walking exercise is the first-line active treatment for claudicant patients, with revascularization indicated in patients with insufficient improvement in walking exercise and in patients with critical limb ischemia 3.
• Endovascular therapy possibilities have expanded significantly in recent years, with increasing experience and technological innovations, especially for patients with high perioperative risk 3, 4.

Antithrombotic Treatment for PAOD

Antithrombotic treatment is used to prevent cardiovascular events and vascular events affecting the limbs in patients with PAOD.

• The goals of antithrombotic treatment are to keep vessels open after revascularization, prevent cardiovascular events, and lessen the frequency of peripheral ischemia and amputation 6.
• Intensifying antithrombotic treatment with stronger antiplatelet therapy, dual antiplatelet therapy, or antiplatelet therapy combined with anticoagulation may lower the rate of peripheral revascularization, amputation, and stroke, but raises the risk of bleeding 6.