What is the treatment for bilateral peripheral arterial (P.A.) stenosis?

From the Guidelines

Treatment of bilateral peripheral arterial stenosis should prioritize a comprehensive approach combining lifestyle modifications, medical therapy, and revascularization procedures when necessary, with a focus on reducing morbidity, mortality, and improving quality of life, as recommended by the 2024 lower extremity peripheral artery disease guideline-at-a-glance 1. The cornerstone of treatment includes smoking cessation, regular exercise therapy (30-45 minutes of supervised walking 3-5 times weekly), and management of cardiovascular risk factors.

• First-line medical therapy includes antiplatelet agents such as aspirin (75-100 mg daily) or clopidogrel (75 mg daily), along with statins like atorvastatin (40-80 mg daily) or rosuvastatin (20-40 mg daily) to reduce cardiovascular events and improve claudication symptoms, as supported by the 2024 acc/aha/aacvpr/apma/abc/scai/svm/svn/svs/sir/vess guideline for the management of lower extremity peripheral artery disease 1.
• For hypertension control, ACE inhibitors or ARBs are preferred.
• Cilostazol (100 mg twice daily) can improve walking distance in patients with intermittent claudication, as shown in the 2024 acc/aha/aacvpr/apma/abc/scai/svm/svn/svs/sir/vess guideline for the management of lower extremity peripheral artery disease 1.
• For patients with lifestyle-limiting symptoms despite optimal medical therapy, revascularization should be considered, with options including endovascular procedures (angioplasty with or without stenting) or surgical bypass, depending on lesion location, extent, and patient factors, as outlined in the 2024 acc/aha/aacvpr/apma/abc/scai/svm/svn/svs/sir/vess guideline for the management of lower extremity peripheral artery disease 1. Following revascularization, continued medical therapy and risk factor modification remain essential to prevent disease progression and maintain patency of treated vessels, with regular follow-up with ankle-brachial index measurements helping to monitor disease progression and treatment effectiveness, as recommended by the 2024 acc/aha/aacvpr/apma/abc/scai/svm/svn/svs/sir/vess guideline for the management of lower extremity peripheral artery disease 1. Key aspects of care include:
• Lipid-lowering therapies to reduce the risk of major adverse cardiovascular events (MACE) and major adverse limb events (MALE) 1.
• Antiplatelet and antithrombotic therapies to prevent MACE and MALE, with rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin (81 mg daily) being effective in reducing the risk of MACE and MALE in patients with symptomatic PAD 1.
• Management of diabetes and hypertension as important components of care for patients with PAD, with glycemic control being especially important for patients with chronic limb-threatening ischemia (CLTI) and nonhealing wounds 1.
• Maintenance of smoking cessation as critical for patients with PAD 1.

From the Research

Treatment Options for Bilateral Peripheral Arterial Stenosis

• Lifestyle modifications, including smoking cessation and supervised exercise therapy, are recommended for patients with peripheral arterial disease (PAD) 2.
• Secondary prevention medications, such as antiplatelet therapy, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins, are also recommended for patients with PAD 2, 3.
• Surgical revascularization should be considered for patients with lifestyle-limiting claudication who have an inadequate response to lifestyle modifications and secondary prevention medications 2.

Medical Management of Peripheral Artery Disease

• Effective medical management is key in reducing the risk of major adverse cardiovascular events and major adverse limb events in patients with PAD 4.
• International guidelines recommend the management of key modifiable risk factors, including prescription of anti-platelet and anticoagulation drugs, and medications to control low-density lipoprotein cholesterol, blood pressure, and diabetes 4.
• Holistic medical management programs that include smoking cessation, antiplatelet therapy, and statins have been shown to be effective in reducing adverse events in patients with PAD 4.

Antithrombotic Treatment in Peripheral Artery Disease

• Aspirin or clopidogrel are recommended for symptomatic PAD, while dual antiplatelet therapy with clopidogrel and aspirin does not provide benefit over single antiplatelet therapy with aspirin alone 5.
• Rivaroxaban plus aspirin has been shown to be effective in reducing total mortality and cardiovascular mortality in patients with symptomatic PAD 5.
• Anticoagulation is mandatory to prevent arterial occlusion during radial or brachial invasive procedures, and vitamin K antagonists may be considered after autologous vein infrainguinal bypass 5.

Aspirin and Clopidogrel Resistance in Peripheral Arterial Disease

• Aspirin resistance and clopidogrel resistance are common in patients with PAD, with prevalence rates up to 60% and 65%, respectively 6.
• Antiplatelet resistance is associated with increased risk of major adverse cardiovascular events, and newer antiplatelet agents such as ticagrelor and prasugrel may be effective in reducing this risk 6.
• Further research is required to clarify the role of platelet assays and potential for individualized antiplatelet therapy in patients with PAD 6.