What is the appropriate management for an 80‑year‑old woman with a completely occluded left superficial femoral artery (high‑grade stenosis), mild‑to‑moderate right popliteal artery disease, and severe distal tibial (posterior tibial/dorsalis pedis) artery disease?

Management of Multilevel Lower Extremity Peripheral Arterial Disease in an 80-Year-Old Woman

This patient requires immediate clinical assessment to determine symptom severity, followed by aggressive medical therapy and consideration for revascularization based on whether she has critical limb ischemia versus claudication. 1

Immediate Clinical Assessment

First, determine her symptom category—this dictates urgency and treatment approach:

• If she has rest pain, non-healing ulcers, or gangrene: This is critical limb ischemia (CLI) requiring semi-urgent vascular surgery consultation for revascularization within days to weeks 1
• If she has lifestyle-limiting claudication only: She needs a trial of medical therapy and supervised exercise for at least 3 months before considering revascularization 1
• If she is asymptomatic: Medical therapy alone is appropriate 1

Examine all four pulses bilaterally (femoral, popliteal, dorsalis pedis, posterior tibial), assess for dependent rubor, elevation pallor, cool skin, and non-healing wounds 1, 2. Auscultate for femoral bruits indicating proximal stenosis 1, 2.

Mandatory Medical Therapy (Regardless of Symptoms)

Initiate immediately for all patients with documented PAD:

• Antiplatelet therapy: Start aspirin or clopidogrel 2
• High-intensity statin therapy regardless of baseline cholesterol 2
• Aggressive cardiovascular risk factor modification: smoking cessation, diabetes control (if present), hypertension management 1, 2
• Consider cilostazol if claudication is present to improve walking distance 1

Understanding Her Anatomic Disease Pattern

This patient has multilevel "outflow" and "runoff" disease:

• Left superficial femoral artery (SFA) occlusion: This is the most common lesion causing intermittent claudication, typically producing calf discomfort with ambulation 1
• Severe distal tibial disease bilaterally: Popliteal and tibial arterial occlusions are more commonly associated with limb-threatening ischemia because of the paucity of collateral vascular pathways beyond these lesions 1, 3
• The combination of SFA occlusion with severe distal disease increases risk for CLI, though isolated SFA occlusion rarely causes advanced ischemia because the deep femoral artery provides collateral circulation to reconstitute the popliteal artery 1, 3

Revascularization Decision Algorithm

If She Has Critical Limb Ischemia (Rest Pain, Ulcers, Gangrene):

Revascularization is indicated urgently 1

1. Obtain additional imaging to define anatomy for intervention planning: duplex ultrasound, CT angiography, or catheter angiography 1

2. For the left SFA occlusion:

   • Complete SFA occlusion is classified as TASC type D femoropopliteal disease 1
   • Surgical bypass is the preferred treatment for TASC type D lesions 1
   • Femoral-popliteal or femoral-tibial bypass should be constructed with autogenous saphenous vein when possible 1
   • The most distal artery with continuous flow and without stenosis >20% should be the origin point 1
   • The tibial or pedal artery capable of providing continuous uncompromised outflow to the foot should be the distal anastomosis site 1

3. For the severe distal tibial disease:

   • Femoral-tibial artery bypasses should be constructed with autogenous vein (ipsilateral greater saphenous vein preferred, or other leg/arm vein sources if unavailable) 1
   • If no adequate autogenous vein is available, composite sequential bypass or bypass to an isolated popliteal segment with collateral outflow are acceptable alternatives 1

4. Given her age (80 years):

   • Age ≥80 years is associated with reduced 2-year survival estimates 1
   • Assess for other high-risk comorbidities: BMI <18 kg/m², non-ambulatory status, hemodialysis, cerebrovascular disease, LVEF <40%, which further impact prognosis 1
   • If she is not a surgical candidate due to prohibitive risk, endovascular intervention may be considered as a palliative measure despite lower long-term patency 4

If She Has Lifestyle-Limiting Claudication Only:

She must complete a 3-month trial of conservative therapy first 1

1. Supervised exercise therapy: 30-45 minutes, 3 times weekly, for minimum 12 weeks 1
2. Cilostazol for ≥3 months to improve absolute claudication distance 1
3. Aggressive medical therapy as outlined above 1

After 3 months, if symptoms remain lifestyle-limiting despite optimal medical therapy:

• Endovascular procedures are indicated when clinical features suggest reasonable likelihood of symptomatic improvement and there is a favorable risk-benefit ratio 1
• For complete SFA occlusion (TASC type D), surgical bypass remains preferred over endovascular intervention due to superior long-term patency 1
• Endovascular therapy for long SFA occlusions has historically shown disappointing long-term results despite high initial procedural success 4

If She Is Asymptomatic:

No revascularization is indicated—medical therapy alone 1

Critical Pitfalls to Avoid

• Do not assume her symptoms are benign claudication without thorough assessment—the combination of complete SFA occlusion with severe distal disease places her at higher risk for CLI 1, 3
• Do not delay revascularization if CLI is present—untreated CLI leads to major amputation within 6 months and 25-35% one-year mortality 2
• Do not attempt endovascular intervention for TASC type D lesions as first-line therapy in surgical candidates—surgery offers superior long-term patency 1
• Recognize that her cardiovascular mortality risk is markedly elevated with documented PAD—aggressive risk factor modification is as important as limb-specific treatment 2
• In an 80-year-old, carefully weigh surgical risk against potential benefit—her age alone places her in a higher-risk category for perioperative complications 1