What is the best treatment approach for an elderly female patient with a history of atrial fibrillation and venous thromboembolism, currently on Eliquis (apixaban), residing in a skilled nursing facility, presenting with cold extremities and diagnosed with moderate to severe peripheral artery disease (PAD) bilaterally based on arterial duplex scan results?

Urgent Vascular Surgery Consultation and Revascularization Required

This patient has moderate to severe peripheral artery disease with cold extremities indicating critical limb-threatening ischemia (CLTI), which requires emergent vascular surgery consultation and CT angiography within hours to prevent amputation, regardless of her anticoagulation status. 1

Immediate Actions (Within Hours)

• Obtain urgent vascular surgery consultation immediately – the duplex findings show moderate to severe PAD bilaterally with monophasic waveforms throughout the left leg and absent flow in the right peroneal artery, indicating inadequate collateralization and high risk of limb loss 2, 1

• Start intravenous unfractionated heparin immediately while awaiting imaging to prevent thrombus propagation, even though she is already on Eliquis for atrial fibrillation 1

• Order CT angiography of bilateral lower extremities emergently to define the anatomic level and extent of occlusive disease for revascularization planning 2, 1

• Examine both feet thoroughly for tissue loss, ulceration, gangrene, signs of infection (cellulitis, purulent drainage), or systemic sepsis, as infection with ischemia dramatically worsens prognosis 3, 1

Revascularization Strategy

• Endovascular-first approach is preferred for this elderly skilled nursing facility patient with significant comorbidities, as it provides similar 1-year outcomes to open surgery with lower perioperative risk 1

• Revascularization should proceed if anatomically feasible (Class I, Level B recommendation) – medical therapy alone is insufficient for CLTI and early recognition with referral to a vascular team is essential for limb salvage 3, 1

Anticoagulation Management During and After Revascularization

• Continue full-intensity anticoagulation with Eliquis for her atrial fibrillation, as she has a clear indication for stroke prevention that should not be interrupted 2, 1

• Add aspirin 75-100 mg daily to her Eliquis after endovascular or surgical revascularization (Class IIa, Level C-LD recommendation) to reduce limb-related events, accepting the increased bleeding risk given the severity of her PAD 3, 1

• Do not switch from Eliquis to warfarin – novel oral anticoagulants are preferred over warfarin in elderly patients with atrial fibrillation, and the combination of rivaroxaban with aspirin has shown benefit in PAD patients in the COMPASS trial, suggesting NOACs are appropriate in this population 4

Comprehensive Medical Optimization

Lipid Management

• Initiate high-intensity statin therapy with atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily, targeting LDL-C <55 mg/dL or at least 50% reduction from baseline (Class I, Level A) 3, 1

Blood Pressure Control

• Target blood pressure <130/80 mmHg using ACE inhibitors or ARBs as preferred agents for additional cardiovascular protection beyond blood pressure reduction 3, 1

Glycemic Control (if diabetic)

• Target HbA1c <7% when appropriate, as glycemic control is particularly beneficial in CLTI to reduce limb-related outcomes and promote wound healing 3

Smoking Cessation (if applicable)

• Advise cessation at every visit and prescribe pharmacotherapy such as varenicline, bupropion, and/or nicotine replacement therapy with referral to a smoking cessation program 3

Critical Wound Care Considerations

• Refer to multispecialty care team including podiatrists and wound care specialists for advanced wound management if any tissue loss is present 3

• Manage any infection aggressively with appropriate antibiotics and debridement as needed, as infection with ischemia is a limb-threatening emergency 3, 1

Post-Revascularization Surveillance

• Follow-up within 2 weeks after revascularization to assess limb perfusion, wound healing, access site complications, and renal function if contrast was used 1

• Repeat duplex ultrasound at 1,6, and 12 months after revascularization to monitor for restenosis or graft failure 2, 1

• Continue periodic clinical evaluation including assessment of cardiovascular risk factors, limb symptoms, and functional status as PAD is a lifelong chronic condition 2

Common Pitfalls to Avoid

• Do not delay vascular imaging or consultation while attempting to optimize medical therapy alone – the presence of cold extremities with moderate to severe PAD indicates CLTI requiring urgent intervention within hours 1

• Do not discontinue Eliquis due to concerns about bleeding during revascularization – her CHADS2 score (likely ≥2 given age and history of VTE) indicates high stroke risk requiring continued anticoagulation 2

• Do not prescribe cilostazol – it is contraindicated in heart failure patients and not indicated for CLTI, only for intermittent claudication 3

• Do not assume this is simply "poor circulation" – the monophasic waveforms throughout the left leg and absent right peroneal flow indicate severely compromised perfusion requiring revascularization, not just medical management 2, 1