What is the significance of bilateral posterior tibial artery (PTA) occlusions with otherwise patent vasculature and attenuated biphasic waveforms in vascular disease?

From the Guidelines

The patient with vascular disease characterized by occlusions in both posterior tibial arteries requires prompt medical attention to prevent complications like tissue damage or limb ischemia, and treatment should include antiplatelet therapy, cholesterol management, and lifestyle modifications. The condition of the patient, with occlusions in both posterior tibial arteries and somewhat weakened biphasic waveforms in the rest of the patent vasculature, indicates a need for careful management to prevent progression of the disease and potential complications such as claudication, rest pain, or tissue changes 1. Given the presence of occlusions, it is crucial to assess the patient's overall cardiovascular risk factors and manage them appropriately, including control of hypertension, diabetes if present, and hyperlipidemia, as these factors can exacerbate peripheral arterial disease (PAD) 1. The use of antiplatelet therapy, such as aspirin 81-325mg daily or clopidogrel 75mg daily, is recommended to reduce the risk of myocardial infarction, stroke, and other ischemic events in patients with PAD 1. Cholesterol management with statins, such as atorvastatin 20-40mg daily, is also essential for reducing the risk of cardiovascular events in patients with PAD 1. Lifestyle modifications, including smoking cessation, regular exercise (aiming for at least 30 minutes of walking daily as tolerated), and a heart-healthy diet low in saturated fats, are critical components of the management plan 1. Regular follow-up with a vascular specialist is necessary to monitor disease progression, assess for worsening symptoms, and adjust the treatment plan as needed 1. Patients should be educated on the importance of foot care, including avoiding trauma, and promptly reporting any new pain, color changes, or wounds to prevent complications such as diabetic foot ulcers or gangrene 1. The ankle-brachial index (ABI) and toe-brachial index (TBI) can be useful tools in the diagnosis and management of PAD, especially in patients with noncompressible arteries, and can help guide treatment decisions 1. Overall, a comprehensive approach to managing the patient's vascular disease, including medical therapy, lifestyle modifications, and regular follow-up, is essential for improving outcomes and reducing the risk of complications.

From the Research

Vascular Disease and Occlusions

• The bilateral posterior tibial arteries demonstrate occlusions, which is a common condition in patients with peripheral artery disease (PAD) 2.
• PAD is a manifestation of systemic atherosclerosis, and patients with PAD often have coexistent coronary or cerebrovascular disease, and increased likelihood of major adverse cardiovascular events 3.
• The presence of occlusions in the bilateral posterior tibial arteries may indicate a higher risk of acute and chronic critical limb ischemia, leading to major adverse limb events such as peripheral revascularization or amputation 3.

Treatment Options

• Retrograde pedal access can improve the success rate of recanalization of below-the-knee disease in patients with CLI, and may be considered as a treatment option for patients with occlusions in the bilateral posterior tibial arteries 2.
• Antithrombotic treatment, including single antiplatelet therapy (SAPT) with aspirin or clopidogrel, may be indicated for patients with symptomatic PAD 4.
• Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin may not provide benefit over SAPT with aspirin alone, and is associated with increased risk of major bleeding 4.
• Medical therapies, including smoking cessation, lipid lowering drugs, optimal glucose control, and antithrombotic medications, have demonstrated efficacy in reducing the risk of major adverse cardiovascular events and major adverse limb events in patients with PAD 3.

Management of Peripheral Artery Disease

• The management of peripheral artery disease includes conservative therapies, pharmacological treatments, interventional and surgical revascularization of blood vessels 5.
• Percutaneous transluminal angioplasty with balloons and stents has improved clinical outcomes compared to medical treatment alone 5.
• ACE inhibitors may possess vasoactive properties that improve symptoms of claudication, and may be considered as a treatment option for patients with lower extremity PAD 6.
• Exercise training and cilostazol may improve walking capacity in patients with PAD 3.