What are the best management strategies for a patient with peripheral arterial disease?

Management of Peripheral Arterial Disease

All patients with PAD require comprehensive cardiovascular risk reduction with antiplatelet therapy, statin therapy, and aggressive risk factor modification, regardless of symptom severity, because PAD is a marker of systemic atherosclerosis with high risk of MI and stroke. 1, 2

Initial Assessment and Diagnosis

Symptom Assessment:

• Perform a vascular review assessing for walking impairment, claudication (reproducible leg discomfort with exertion that resolves with rest), ischemic rest pain, and nonhealing wounds 3, 1
• Conduct comprehensive pulse examination of all lower extremity pulses and direct foot inspection with shoes and socks removed 3, 1
• Measure blood pressure in both arms to identify subclavian stenosis (difference >15-20 mmHg is significant) 1

Diagnostic Testing:

• Ankle-brachial index (ABI) is the initial diagnostic test, with ABI ≤0.90 confirming PAD 1
• If ABI is normal but clinical suspicion remains high, obtain post-exercise ABI (>20% decrease is diagnostic) 1
• For non-compressible vessels (ABI >1.40, common in diabetes), use toe-brachial index instead 1
• Arterial imaging is NOT indicated for patients with normal post-exercise ABI unless other causes are suspected 3

Medical Management (All PAD Patients)

Antiplatelet Therapy:

• Clopidogrel 75 mg daily is the preferred antiplatelet agent to reduce MI, stroke, and vascular death 2, 4
• Aspirin 75-325 mg daily is an acceptable alternative if clopidogrel is not tolerated 2
• For high ischemic risk patients without high bleeding risk, consider combination therapy with low-dose rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily 1
• Anticoagulation alone (without antiplatelet therapy) should NOT be used for cardiovascular event reduction in PAD as it increases bleeding without benefit 2

Lipid Management:

• Statin therapy is mandatory for ALL PAD patients regardless of baseline cholesterol levels 2

Blood Pressure Control:

• Target <140/90 mmHg in patients without diabetes 2
• Target <130/80 mmHg in patients with diabetes or chronic kidney disease 2
• Beta-blockers are NOT contraindicated in PAD and are effective antihypertensive agents 2

Smoking Cessation:

• Ask about tobacco use at every visit 2
• Offer pharmacotherapy with varenicline, bupropion, and/or nicotine replacement therapy unless contraindicated 2

Diabetes Management:

• Target hemoglobin A1C <7% to reduce microvascular complications 2

Management by Clinical Presentation

Intermittent Claudication (Lifestyle-Limiting Symptoms)

First-Line Treatment:

• Supervised exercise therapy is the initial treatment before considering revascularization 3, 2
• Exercise program should include at least 30-45 minutes per session, minimum 3 times weekly, for at least 12 weeks 3, 2

Pharmacotherapy for Claudication:

• Cilostazol should be considered for all patients with lifestyle-limiting claudication (contraindicated in heart failure) 3
• Pentoxifylline 400 mg three times daily may be considered as second-line alternative, though effectiveness is marginal 3
• Chelation therapy is NOT indicated and may cause harm 3

Revascularization Criteria: Before offering endovascular or surgical intervention, patients must meet ALL of the following 3, 2:

1. Received information about supervised exercise therapy and pharmacotherapy
2. Completed comprehensive risk factor modification and antiplatelet therapy
3. Have significant disability (unable to perform normal work or serious impairment of important activities)
4. Have lesion anatomy with low procedural risk and high probability of success
5. Have inadequate response after 3 months of optimal medical therapy and exercise 1, 2

Endovascular Approach:

• Endovascular intervention is the preferred revascularization technique for TASC type A iliac and femoropopliteal lesions 3
• Stenting is effective as primary therapy for common iliac and external iliac artery stenosis/occlusions 3
• Primary stent placement is NOT recommended in femoral, popliteal, or tibial arteries 3
• Endovascular intervention is NOT indicated as prophylactic therapy in asymptomatic patients 3

Critical Limb Ischemia (CLI)

Immediate Actions:

• Patients with CLI require expedited evaluation and treatment of factors increasing amputation risk 3
• Assess cardiovascular risk if open surgical repair is anticipated 3
• Initiate systemic antibiotics promptly if skin ulcerations with evidence of infection are present 3
• Refer to healthcare providers with specialized wound care expertise for skin breakdown 3
• Evaluate for aneurysmal disease (AAA, popliteal, or common femoral aneurysms) if atheroembolization is suspected 3

High-Risk Patients Requiring Regular Foot Inspection:

• ABI <0.4 in individuals with diabetes 3
• Any individual with diabetes and known lower extremity PAD 3
• Patients with diabetes, neuropathy, chronic renal failure, or infection who develop acute limb symptoms represent vascular emergencies and require immediate specialist assessment 3

Revascularization:

• Perform revascularization as soon as possible in CLI patients 1

Acute Limb Ischemia

• Patients with acute limb ischemia and salvageable extremity require emergent evaluation defining anatomic occlusion level leading to prompt endovascular or surgical revascularization 3
• Patients with nonviable extremity should NOT undergo vascular anatomy evaluation or revascularization attempts 3

Follow-Up and Surveillance

Standard PAD Patients:

• Follow up at least annually to assess clinical status, medication adherence, limb symptoms, and cardiovascular risk factors 1, 2

Post-CLI Patients:

• Evaluate at least twice annually by a vascular specialist due to high recurrence risk 3, 2
• Perform direct foot examination with shoes and socks removed at regular intervals 3
• Provide verbal and written instructions regarding self-surveillance for potential recurrence 3

Post-Revascularization:

• Long-term patency of infrainguinal bypass grafts should be evaluated in a surveillance program including interval vascular history, resting ABIs, physical examination, and duplex ultrasound at regular intervals (especially for venous conduits) 3
• Consider exercise ABIs and arterial imaging at regular intervals for endovascular sites 3

Common Pitfalls to Avoid

• Do NOT withhold beta-blockers in PAD patients—they are safe and effective 2
• Do NOT use anticoagulation alone for cardiovascular event reduction (increases bleeding without benefit) 2
• Do NOT proceed to revascularization without first attempting supervised exercise and optimal medical therapy for claudication 3, 2
• Do NOT use omeprazole or esomeprazole with clopidogrel as they significantly reduce antiplatelet activity 4
• Do NOT discontinue clopidogrel without careful consideration as this increases cardiovascular event risk; when surgery is necessary, interrupt for five days prior and resume as soon as hemostasis is achieved 4