What is the difference between peripheral arterial disease (PAD) and peripheral vascular disease (PVD), and how should each be managed?

PAD vs PVD: Terminology and Clinical Implications

Peripheral Artery Disease (PAD) is the preferred and more precise clinical term that specifically denotes atherosclerotic stenotic, occlusive, and aneurysmal diseases of the aorta and its branch arteries (excluding coronary arteries), while Peripheral Vascular Disease (PVD) is an outdated, broader term that has been replaced in modern medical nomenclature. 1

Terminology Clarification

The ACC/AHA guidelines explicitly state that "peripheral arterial disease" is the preferred clinical term that should be used to denote stenotic, occlusive, and aneurysmal diseases of the aorta and its branch arteries, exclusive of the coronary arteries. 1

• The term PAD encompasses atherosclerotic disease of the abdominal aorta, renal and mesenteric arteries, and lower extremity arteries—essentially all infradiaphragmatic arterial disease. 1

• PAD is fundamentally a disease of arterial insufficiency caused by atherosclerotic occlusion, resulting in reduced blood flow to the limbs. 2

• The older term "PVD" has fallen out of favor because it is imprecise and can be confused with venous disease or other vascular pathology. 1

Clinical Scope of PAD

For practical clinical purposes, PAD includes: 1

• Lower extremity arterial disease (most common presentation)
• Abdominal aortic aneurysms
• Renal artery stenosis
• Mesenteric arterial disease

The guidelines deliberately exclude carotid, vertebral, thoracic aortic, and upper extremity arterial diseases from the PAD classification to maintain focus on the infradiaphragmatic arterial system. 1

Clinical Presentations and Diagnosis

PAD affects approximately 8-12 million Americans, with prevalence reaching 29% in patients aged ≥70 years or aged 50-69 years with diabetes or significant smoking history. 1, 3, 4

Key Clinical Features:

• Asymptomatic disease occurs in up to 50% of PAD patients, making screening essential in at-risk populations. 1, 5

• Classic intermittent claudication presents in only 10-30% of patients—the minority of cases. 3, 4, 6

• Physical examination findings include diminished or absent pulses, cool skin temperature, trophic changes, pallor on elevation, and notably the absence of edema (edema suggests alternative diagnoses like venous disease or heart failure). 2

Diagnostic Approach:

• The ankle-brachial index (ABI) is the preferred first-line screening test, with ABI ≤0.90 diagnostic of PAD. 3, 4, 6, 7

• ABI ≥1.40 is noncompressible (common in diabetes and end-stage renal disease) and requires alternative testing. 3

• Exercise ABI should be performed when resting ABI is normal but clinical suspicion remains high. 3

Management Strategy

Cardiovascular Risk Reduction (Primary Goal):

Patients with PAD face markedly increased risk of myocardial infarction, stroke, and cardiovascular death—the systemic nature of atherosclerosis makes cardiovascular risk reduction the priority over limb-specific concerns. 1, 5

• Antiplatelet therapy: Clopidogrel is preferred over aspirin for PAD patients. 3

• High-intensity statin therapy is mandatory regardless of baseline lipid levels. 3

• Blood pressure control with target <140/90 mmHg (or <130/80 mmHg in diabetes). 3

• Smoking cessation is non-negotiable—smoking is the most modifiable risk factor. 5, 4

• Diabetes management with GLP-1 receptor agonists and SGLT-2 inhibitors preferred for cardiovascular benefit. 3

Symptom Management:

• Supervised exercise therapy is first-line for claudication—70-80% of patients remain stable over 10 years with conservative management. 5

• Cilostazol for symptom control if exercise therapy insufficient. 3, 5, 4

• Revascularization reserved for lifestyle-limiting claudication despite medical therapy or chronic limb-threatening ischemia. 3, 4

Urgent Situations:

• Acute limb ischemia requires emergent evaluation within hours to preserve limb viability. 3, 4

Critical Clinical Pitfall

The presence of peripheral edema in a patient with suspected PAD should trigger evaluation for alternative or coexisting conditions (venous insufficiency, heart failure, renal disease, lymphedema) rather than being attributed to PAD itself. 2 PAD causes arterial insufficiency without edema; if both are present, they represent separate pathological processes requiring independent treatment. 2