What is the diagnosis and treatment for critical peripheral arterial disease (PAD)?

From the Guidelines

Critical peripheral artery disease (PAD) requires immediate medical attention, and patients should be taken to the emergency department right away for evaluation and treatment. The initial steps in managing PAD, as outlined in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1, include screening patients at risk of PAAD, enabling early access to treatment, and ensuring optimal medical treatment.

Key Considerations

• The affected limb should be kept at heart level, avoiding elevation or dependency, to prevent further ischemia.
• Urgent vascular surgery consultation is essential for revascularization, which may involve thromboembolectomy, bypass surgery, or endovascular procedures like angioplasty with stenting.
• After revascularization, patients should receive antiplatelet therapy and high-intensity statin therapy to reduce the risk of major adverse cardiac events (MACE) and major adverse limb events (MALE), as recommended in the 2024 lower extremity peripheral artery disease guideline-at-a-glance 1.
• The treatment of PAD should be part of a comprehensive care plan that includes treatment of infection, frequent debridement, biomechanical offloading, blood glucose control, and treatment of co-morbidities, especially in patients with diabetes and ulceration of the foot 1.

Management Strategies

• Anticoagulation with intravenous unfractionated heparin (initial bolus of 80 units/kg followed by continuous infusion at 18 units/kg/hr, adjusted to maintain aPTT at 1.5-2.5 times normal) may be considered in the initial management of critical PAD.
• Pain management with opioid analgesics like morphine 2-4mg IV every 4 hours as needed should be provided to alleviate pain and discomfort.
• Revascularization is essential to prevent limb loss in those with chronic limb-threatening ischemia and can be used to improve quality of life (QOL) and functional status in patients with claudication not responsive to medical therapy and structured exercise 1.

Multidisciplinary Approach

• Care for patients with PAD, and especially those with chronic limb-threatening ischemia, is optimized when delivered by a multispecialty care team, including podiatrists and other specialists with expertise in foot care, wound-healing therapies, and foot surgery 1.
• Foot care is crucial for patients with PAD across all clinical subsets and ranges from preventive care and patient education to advanced care in the setting of chronic limb-threatening ischemia.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Critical PAD Overview

• Peripheral artery disease (PAD) is a condition where the arteries that supply blood to the limbs become narrowed or blocked, leading to reduced blood flow and potentially severe complications 2.
• The management of PAD involves antiplatelet therapy, which aims to prevent blood clots from forming and reduce the risk of ischemic events 3, 4.

Antiplatelet Therapy Options

• Aspirin is a commonly used antiplatelet agent for the prevention of ischemic events in patients with PAD, but its efficacy is controversial 2.
• Clopidogrel is another antiplatelet agent that has been shown to be effective in reducing the risk of major adverse cardiovascular events in patients with PAD 2, 5.
• Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin may not provide additional benefit over single antiplatelet therapy with aspirin alone and is associated with an increased risk of major bleeding 2, 6.
• Ticagrelor is not superior to clopidogrel in reducing major adverse cardiovascular events and major adverse limb events, but it lowers the risk of ischemic stroke 2.

Combination Therapy

• The combination of rivaroxaban and aspirin has been shown to be effective in reducing the risk of adverse cardiovascular and limb events in patients with PAD 2, 3.
• The use of vorapaxar, a thrombin receptor antagonist, on top of single or dual antiplatelet therapy, reduces the risk of acute limb ischemia and peripheral artery revascularization in patients with symptomatic PAD, but increases the risk of bleeding 2.
• The addition of clopidogrel to rivaroxaban and aspirin does not modify the efficacy and safety of rivaroxaban, but a short course of clopidogrel (≤30 days) is associated with less bleeding 3.