What is the appropriate diagnostic workup and management for peripheral arterial disease, including confirmation with ankle‑brachial index, risk‑factor modification, supervised exercise, pharmacologic therapy, and revascularization options?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: February 20, 2026 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Peripheral Arterial Disease: Diagnostics and Management

Diagnostic Workup

Initial Screening and Confirmation

The resting ankle-brachial index (ABI) is the mandatory first-line diagnostic test for PAD and should be performed in all patients at increased risk. 1

Screen patients who meet any of these criteria: 1

  • Age ≥65 years
  • Age 50-64 years with atherosclerosis risk factors (smoking, diabetes, hypertension, hyperlipidemia) or family history of PAD
  • Age <50 years with diabetes plus one additional atherosclerosis risk factor
  • Known atherosclerotic disease in another vascular bed (coronary, carotid, renal)

ABI interpretation and next steps: 1

  • ABI ≤0.90: Confirms PAD diagnosis
  • ABI 0.91-0.99: Borderline—proceed to exercise treadmill ABI testing if symptomatic
  • ABI 1.00-1.40: Normal
  • ABI >1.40: Non-compressible vessels—must obtain toe-brachial index (TBI)

For non-compressible vessels (ABI >1.40), measure TBI immediately: 1

  • TBI ≤0.70 confirms PAD
  • This is particularly common in patients with diabetes or chronic kidney disease

Exercise Testing for Equivocal Cases

In patients with exertional leg symptoms and normal or borderline resting ABI (>0.90 and ≤1.40), exercise treadmill ABI testing is required to diagnose PAD. 1 A post-exercise ABI drop >20% or ankle pressure decrease >30 mmHg confirms PAD. 2

Anatomic Imaging for Revascularization Planning

When revascularization is being considered, obtain anatomic imaging to determine location and severity of stenosis: 1

First-line anatomic imaging options (in order of preference): 1

  • Duplex ultrasound: 85-90% sensitivity, >95% specificity for >50% stenosis; no contrast or radiation 1, 2
  • CT angiography (CTA): 96-98% sensitivity and 94-98% specificity for aortoiliac stenoses >50%; provides comprehensive anatomic detail including calcification, stents, and bypasses 1, 2
  • MR angiography (MRA): 95% sensitivity and specificity; no radiation but tends to overestimate stenosis 1, 2

Critical caveat: Do not perform invasive or non-invasive angiography in asymptomatic PAD patients—imaging is only indicated when revascularization is being considered. 1

Risk Factor Modification (Guideline-Directed Medical Therapy)

Lipid Management

All PAD patients require high-intensity statin therapy regardless of baseline LDL-C. 1

For patients on maximally tolerated statin with LDL-C ≥70 mg/dL: 1

  • Add ezetimibe (reasonable, Class IIa)
  • Add PCSK9 inhibitor (reasonable, Class IIa)

Antithrombotic Therapy

For symptomatic PAD, single antiplatelet therapy is the foundation: 1

  • Aspirin 75-100 mg daily (Class I, Level A) OR
  • Clopidogrel 75 mg daily (Class I, Level A)

Do not use dual antiplatelet therapy (aspirin + clopidogrel) for stable PAD. 1

Do not combine antiplatelet therapy with warfarin in stable PAD. 1

For symptomatic PAD or after revascularization, low-dose rivaroxaban (2.5 mg twice daily) combined with aspirin 100 mg daily is recommended to reduce major adverse cardiovascular events (MACE) and major adverse limb events (MALE). 1 This represents the most potent evidence-based antithrombotic strategy.

For asymptomatic PAD (ABI ≤0.90), single antiplatelet therapy is reasonable to reduce MACE risk. 1

Blood Pressure Control

Target blood pressure <130/80 mmHg in patients with PAD, especially those with diabetes. 1, 3

Glycemic Control

In diabetic patients with PAD, target HbA1c <7% to improve limb outcomes. 1, 3

Smoking Cessation

Smoking cessation is mandatory and must be addressed at every visit. 1

Structured Exercise Therapy

Supervised exercise therapy (SET) is a core component of care for claudication and should be prescribed before considering revascularization. 1

For patients with refractory claudication despite exercise therapy and smoking cessation, add cilostazol 100 mg twice daily to antiplatelet therapy. 1 Do not use pentoxifylline or prostanoids for claudication. 1

The ERASE trial demonstrated that combining endovascular revascularization with SET produces superior walking distance and quality of life outcomes compared to SET alone at 12 months. 1 However, the IRONIC trial showed this benefit may not persist at 5 years. 1

Revascularization

Indications for Revascularization

Revascularization is indicated for: 1

  • Chronic limb-threatening ischemia (CLTI) to prevent limb loss
  • Lifestyle-limiting claudication unresponsive to medical therapy and structured exercise

Post-Revascularization Antithrombotic Management

After endovascular revascularization: 1

  • Low-dose rivaroxaban 2.5 mg twice daily + aspirin 100 mg daily (Class I recommendation)
  • OR Dual antiplatelet therapy (P2Y12 inhibitor + aspirin) for at least 1-6 months (Class IIa)

After surgical revascularization with prosthetic graft: 1

  • Dual antiplatelet therapy (P2Y12 inhibitor + aspirin) may be reasonable for at least 1 month (Class IIb)

For patients requiring full-intensity anticoagulation for another indication after revascularization, adding single antiplatelet therapy is reasonable if not at high bleeding risk. 1

Chronic Limb-Threatening Ischemia (CLTI)

Diagnostic Criteria

CLTI is defined by: 1

  • Ankle pressure <50 mmHg
  • Toe pressure <30 mmHg
  • Transcutaneous oxygen pressure (TcPO₂) <30 mmHg
  • Plus rest pain, non-healing wounds, or gangrene

Management

For CLTI patients who are not candidates for revascularization and have rest pain, prostanoids are suggested in addition to antiplatelet therapy. 1 However, patients must value uncertain relief of rest pain greater than high likelihood of drug-related side effects. 1

Revascularization is the primary treatment for CLTI to prevent limb loss and should be pursued whenever anatomically feasible. 1

Acute Limb Ischemia

In patients with acute limb ischemia due to acute thrombosis or embolism, surgery is recommended over peripheral arterial thrombolysis. 1

For acute limb ischemia, initiate anticoagulation immediately and obtain CT angiography for rapid anatomic diagnosis and revascularization planning. 3

Common Pitfalls

Do not rely solely on resting ABI in symptomatic patients—nearly half of patients with PAD symptoms have normal resting ABI and require exercise testing. 4

Do not use ABI in patients with heavily calcified vessels (common in diabetes and chronic kidney disease)—proceed directly to TBI, TcPO₂, or skin perfusion pressure. 1, 2

Do not screen asymptomatic patients without risk factors—ABI is not recommended in low-risk populations. 1

Do not perform anatomic imaging in asymptomatic PAD—imaging is only indicated when revascularization is being considered. 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Diagnostic Tests for Peripheral Artery Disease

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Acute Limb Ischemia Diagnosis and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Related Questions

What diagnostic tests and labs should be ordered for a patient with suspected Peripheral Arterial Disease (PAD), Deep Vein Thrombosis (DVT), and statin-induced myopathy due to Rosuvastatin (rosuvastatin)?
What is the role of Ankle-Brachial Index (ABI) testing in diagnosing Peripheral Artery Disease (PAD)?
In a diabetic patient with a plantar foot ulcer, diminished sensation, intact peripheral pulses, and a non‑healing ulcer with central erythema, what is the most critical test to perform to reach the diagnosis?
What is the purpose and interpretation of the ankle brachial index (ABI) in diagnosing peripheral artery disease (PAD)?
What is the initial diagnostic test for patients suspected of having peripheral artery disease (PAD), Ankle-Brachial Index (ABI) or arterial Doppler?
What are the indications and dosing protocol for intravenous sodium bicarbonate in a tricyclic antidepressant (TCA) overdose?
How should intraductal papillary mucinous neoplasm (IPMN) be managed, including indications for surgery versus surveillance for main‑duct and branch‑duct lesions?
In an adult HIV patient with CD4 count 15 cells/µL presenting with fever, headache, vomiting, altered mental status, rapid weight loss and MRI showing three large ring‑enhancing necrotic brain lesions, CSF with mononuclear pleocytosis, elevated protein, high LDH and EBV DNA but negative Toxoplasma PCR, what is the recommended empiric first‑line treatment?
What is an appropriate first‑line muscle relaxant for a 23‑year‑old female athlete with mild hip pain due to strenuous activity?
How many minutes before a meal should levothyroxine be taken on an empty stomach?
Does an upper extremity deep vein thrombosis cause numbness or tingling in the hand and color change?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question