What is the treatment for a 74-year-old female (YOF) with peripheral arterial disease (PAD) and high-grade stenosis, complicated by foot ulceration, diabetes mellitus (DM), and hypertension (HTN)?

From the Guidelines

For a 74-year-old female with peripheral arterial disease (PAD) with high-grade stenosis, foot ulceration, diabetes, and hypertension, a comprehensive treatment approach is needed, with the primary goal of reducing morbidity, mortality, and improving quality of life. The initial management should include antiplatelet therapy with aspirin 81mg daily or clopidogrel 75mg daily, along with high-intensity statin therapy (atorvastatin 40-80mg or rosuvastatin 20-40mg daily) to reduce cardiovascular risk, as recommended by the 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease 1. Blood pressure should be controlled to <140/90 mmHg using medications like ACE inhibitors or ARBs, which also provide renal protection for diabetic patients, as suggested by the same guideline 1. Diabetes management is crucial, aiming for HbA1c <7% using appropriate medications while avoiding hypoglycemia in this elderly patient. For the high-grade stenosis, revascularization is likely necessary given the presence of foot ulceration (critical limb ischemia), with the aim of restoring direct flow to at least one of the foot arteries, preferably the artery that supplies the anatomical region of the wound, as recommended by the IWGDF guidance on the diagnosis, prognosis, and management of peripheral artery disease in patients with foot ulcers in diabetes 1. This may involve endovascular intervention (angioplasty with or without stenting) or surgical bypass, depending on anatomical considerations and patient factors. The foot ulcer requires specialized wound care with regular debridement, appropriate dressings, offloading pressure, and infection management if present. Antibiotics should be prescribed if infection is suspected, with initial empiric coverage for gram-positive and gram-negative organisms. Pain management and smoking cessation (if applicable) are also important components of care. This multidisciplinary approach addresses both the underlying vascular disease and its complications while managing comorbidities that contribute to disease progression, and is in line with the recommendations of the 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease 1. Some key points to consider in the management of this patient include:

• The importance of a comprehensive care plan that includes periodic clinical evaluation by a healthcare provider with experience in the care of vascular patients, as recommended by the 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease 1.
• The use of duplex ultrasound for routine surveillance of infrainguinal, autogenous vein bypass grafts in patients with PAD, as suggested by the same guideline 1.
• The potential benefits and risks of dual antiplatelet therapy in patients with symptomatic PAD after lower extremity revascularization, as discussed in the 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease 1.

From the Research

Treatment Options for Peripheral Arterial Disease with High Grade Stenosis

• For a 74-year-old female patient with peripheral arterial disease (PAD), foot ulceration, diabetes, and hypertension, treatment options should focus on addressing the underlying conditions and managing symptoms.
• According to 2, cilostazol may be a more effective treatment option for wound healing in patients with diabetic foot ulcers and PAD compared to aspirin.
• Lifestyle modifications, such as smoking cessation and supervised exercise therapy, are also recommended for patients with PAD, as stated in 3.
• Secondary prevention medications, including antiplatelet therapy, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins, may be beneficial for patients with PAD, as mentioned in 3 and 4.

Management of Peripheral Arterial Disease

• The management of PAD includes conservative therapies, pharmacological treatments, interventional, and surgical revascularization of blood vessels, as discussed in 5.
• Percutaneous transluminal angioplasty with balloons and stents has improved clinical outcomes compared to medical treatment alone, according to 5.
• Indications for lower extremity percutaneous transluminal angioplasty or bypass surgery include incapacitating claudication, limb salvage, and vasculogenic impotence, as stated in 4.

Considerations for Diabetic Patients with Foot Ulcers

• The International Working Group on the Diabetic Foot has produced guidelines on the diagnosis and treatment of PAD in patients with diabetes and a foot ulcer, as mentioned in 6.
• Diagnosis and treatment of PAD in diabetic patients with foot ulcers should take into account both risks and benefits, as discussed in 6.
• Treatment modalities for PAD in diabetic patients with foot ulcers may include a combination of lifestyle modifications, pharmacological treatments, and interventional procedures, as suggested by 2, 3, and 4.