How should peripheral arterial disease affecting the bilateral dorsalis pedis arteries be managed?

Management of Bilateral Dorsalis Pedis Artery Disease

For peripheral arterial disease affecting the bilateral dorsalis pedis arteries, revascularization (endovascular or surgical bypass) should be considered if the disease severity impairs wound healing or causes lifestyle-limiting claudication unresponsive to 3 months of optimal medical therapy and supervised exercise. 1

Initial Assessment and Severity Stratification

The management approach depends critically on whether the patient has:

• Asymptomatic PAD: Revascularization is not recommended 1
• Symptomatic claudication: Requires 3-month trial of optimal medical therapy (OMT) and exercise before considering revascularization 1
• Chronic limb-threatening ischemia (CLTI): Requires urgent vascular team evaluation and early revascularization consideration 1

Perfusion Assessment to Guide Treatment

Measure objective perfusion parameters to determine if revascularization is needed: 1

• ABI <0.6: Indicates significant ischemia that impairs wound healing—strongly consider revascularization 1
• ABI 0.6-0.9: Measure toe pressure and/or transcutaneous oxygen pressure (TcPO2) 1
  • Toe pressure >55 mmHg and TcPO2 >50 mmHg: Wounds will often heal with conservative management 1
  • Toe pressure <30 mmHg and TcPO2 <30 mmHg: Healing severely impaired—revascularization indicated 1

Medical Management (Foundation for All Patients)

All patients with dorsalis pedis artery disease require guideline-directed medical therapy regardless of symptom status: 1, 2, 3

Antithrombotic Therapy

• Combination rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily should be considered for patients with high ischemic risk and non-high bleeding risk 1
• Clopidogrel monotherapy is indicated to reduce MI and stroke rates in established PAD 4, 3
• Aspirin 75-100 mg daily is an alternative antiplatelet option 1, 3

Cardiovascular Risk Reduction

• High-dose statin therapy is mandatory—reduces coronary events and stroke by approximately 50% 3, 5
• Blood pressure control with ACE inhibitors or other antihypertensives reduces major cardiovascular events 5
• Smoking cessation using physician counseling, nicotine replacement, and/or bupropion 5

Symptom Management

• Cilostazol improves pain-free and peak walking distances in intermittent claudication 6, 7, 8, 5
• Pentoxifylline is a less effective alternative when cilostazol is contraindicated 9, 8

Exercise Therapy (Critical Component)

Supervised exercise training (SET) is recommended as first-line therapy for symptomatic PAD: 1

• Frequency: At least 3 times per week 1
• Duration: At least 30 minutes per session 1
• Program length: Minimum 12 weeks 1
• Intensity: High intensity (77-95% maximal heart rate or 14-17 on Borg scale) improves walking performance 1
• Modality: Walking is first-line; alternatives include strength training, arm cranking, or cycling when walking is not feasible 1

When SET is unavailable, structured home-based exercise training (HBET) with monitoring (calls, logbooks, connected devices) should be considered 1

For patients undergoing endovascular revascularization, SET is recommended as adjuvant therapy 1

Revascularization Decision Algorithm

Step 1: Determine Clinical Category

Asymptomatic PAD: Do not revascularize 1

Symptomatic claudication:

• Initiate 3-month trial of OMT plus exercise therapy 1
• Assess PAD-related quality of life after 3 months 1
• If QoL remains impaired despite optimal conservative therapy, revascularization may be considered 1

CLTI (rest pain, non-healing ulcers, gangrene):

• Urgent vascular team referral 1
• Revascularization must be considered in all patients to achieve limb salvage 1

Step 2: Anatomic Assessment (Only When Revascularization Considered)

Do not obtain anatomic imaging for asymptomatic PAD or patients managed with medical therapy alone 10

When revascularization is being considered: 10

• First-line: Duplex ultrasound to diagnose anatomic location and stenosis severity 10
• Alternatives: MRA with gadolinium or CTA 10

Step 3: Revascularization Approach

The mode and type of revascularization should be adapted to anatomical lesion location, lesion morphology, and general patient condition 1

For runoff disease (tibial/pedal arteries including dorsalis pedis):

• Endovascular approach is typically first-line for distal disease 1
• In patients with severe claudication undergoing femoro-popliteal revascularization, treatment of below-the-knee (BTK) arteries may be considered in the same intervention 1
• Surgical bypass should be considered when autologous vein is available in low surgical risk patients 1

Exceptions to Revascularization

Revascularization may not be appropriate in: 1

• Severely frail patients
• Life expectancy <6-12 months
• Pre-existing severe functional impairment unlikely to improve

Critical Pitfalls to Avoid

• Do not revascularize solely to prevent progression to CLTI—this is not indicated 1
• Do not skip the 3-month OMT/exercise trial in stable claudication before considering revascularization 1
• Always discuss revascularization in a multidisciplinary diabetic foot team before major amputation 1
• Do not rely on symptoms alone—objective perfusion measurements (ABI, toe pressures, TcPO2) are essential for treatment decisions 1
• Monitor prothrombin time more frequently when using pentoxifylline in patients on warfarin 9
• In patients with poor wound healing response after 6 weeks of optimal wound care, reassess perfusion with duplex ultrasound or angiography 1

Follow-Up

Regular follow-up at least once yearly is recommended, assessing: 1

• Clinical and functional status
• Medication adherence
• Limb symptoms
• Cardiovascular risk factors
• Duplex ultrasound as needed 1