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Peripheral artery disease

Definition
PAD is a term that encompasses diseases characterized by narrowing of arteries distal to the aortic arch (non-cardiac and non-intracranial).
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Pathophysiology
The most common cause of PAD is atherosclerosis; less common causes include inflammatory disorders of the arterial wall (vasculitis) and noninflammatory arteriopathies, such as FMD. Athero-thrombosis due to hypercoagulable states may also lead to the development of PAD.
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Epidemiology
In patients ≥ 40 years of age living in the US, the incidence and prevalence of PAD are estimated at 2.35% and 10.69%, respectively.
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Disease course
The key clinical presentations of PAD are intermittent claudication and critical limb ischemia. Intermittent claudication refers to symptoms of pain in the muscles of the lower extremities that are brought on by physical activity and relieved by rest. Critical limb ischemia is a more severe manifestation of PAD that presents as rest pain, ischemic ulceration or gangrene of the foot.
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Prognosis and risk of recurrence
PAD is associated with increased mortality rates, with most deaths occurring due to coronary artery disease (40-60%) and cerebrovascular disease (10-20%). Critical limb ischemia is associated with an estimated 1-year mortality of 20-25%, and an estimated 5-year mortality of 40-50%.
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Key sources
The following summarized guidelines for the evaluation and management of peripheral artery disease are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2024), the American Heart Association (AHA/HRS/ACC/ACCP 2024), the Canadian Cardiovascular Society (CCS 2022), the American College of Radiology (ACR 2022), the European Society of Cardiology (ESC/ESVS 2018), the U.S. Preventive Services Task Force (USPSTF 2018), the American Heart Association (AHA/ACC 2017), and the Society for Vascular Surgery (SVS 2015).
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Guidelines

1.Screening and diagnosis

Indications for screening, asymptomatic, ESVS
Do not screen for lower limb PAD with ABI measurements in asymptomatic individuals without increased cardiovascular risk.
D
Consider obtaining focused screening for PAD with ABI measurements based on the lowest recorded ankle pressure to support secondary prevention strategies in clinically asymptomatic individuals at increased risk of lower limb PAD.
C
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  • Indications for screening (undergoing cardiovascular procedures)

  • Indications for screening (symptomatic)

2.Diagnostic investigations

History and physical examination: elicit a comprehensive medical history in patients with increased risk of PAD and conduct a review of symptoms to assess for exertional leg symptoms, including claudication or other walking impairment, ischemic rest pain, and nonhealing wounds.
B
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  • ABI (indications)

  • ABI (technical considerations)

  • ABI (treadmill)

  • TBI

  • Other perfusion assessment modalities

  • 6MWD

  • Diagnostic imaging

  • Laboratory tests

  • Screening for other arterial diseases

  • Screening for CVD risks

  • Patient-reported outcomes

3.Medical management

General principles: offer a stepwise approach in patients with intermittent claudication, providing risk factor management, best medical treatment, and exercise therapy as a first step and revascularization as a second step in compliant patients with continued disabling limb symptoms.
B

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  • Management of claudication (cilostazol and naftidrofuryl)

  • Management of claudication (other agents)

  • Management of hypertension (targets)

  • Management of hypertension (drugs)

  • Management of diabetes mellitus

  • Antiplatelet therapy

  • Anticoagulation therapy

  • Lipid-lowering therapy

4.Nonpharmacologic interventions

Exercise therapy: as per ESVS 2024 guidelines, advise striving for at least 150-300 minutes a week of moderate-intensity or 75-150 minutes a week of vigorous-intensity aerobic physical activity to reduce all-cause and cardiovascular mortality and cardiovascular morbidity in all patients with lower limb PAD (including asymptomatic stages).
A
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  • Smoking cessation

  • Dietary changes

  • Supplements

5.Therapeutic procedures

Indications for revascularization, symptomatic, CCS: consider performing revascularization in patients with intermittent claudication affecting vocational, recreational, or daily living activities and having an acceptable risk profile, reasonable expectation for function and life expectancy, and if a trial of nonoperative therapy with an exercise program and optimal medical therapy has failed.
C

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  • Indications for revascularization (asymptomatic)

  • Choice of revascularization (general principles)

  • Choice of revascularization (aortoiliac)

  • Choice of revascularization (femoropopliteal)

  • Choice of revascularization (infrapopliteal)

6.Perioperative care

Preoperative risk assessment: do not use the RCRI for preoperative assessment of cardiac risk in patients undergoing peripheral arterial surgery.
D
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7.Specific circumstances

Female patients
Offer similar evidence-based cardiovascular primary and secondary preventive strategies in males and females with PAD.
B
Do not use hormone replacement therapy with estrogen or progestin for the prevention of CVD in postmenopausal females.
D

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  • Patients with acute limb ischemia

  • Patients with chronic limb-threatening ischemia

  • Patients with foot infection

  • Patients requiring OACs

  • Patients undergoing coronary artery intervention

8.Patient education

Counseling on foot care
Counsel patients with PAD and diabetes mellitus about self-foot examination and healthy foot behaviors.
B
Consider counseling patients with PAD without diabetes mellitus on self-foot examination and healthy foot behaviors.
C

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  • General counseling

9.Preventative measures

Influenza vaccination: as per ESVS 2024 guidelines, offer annual influenza vaccination to reduce the risk of severe influenza infection in patients with lower limb PAD.
B

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  • COVID-19 vaccination

10.Follow-up and surveillance

Serial clinical assessment
As per AHA 2017 guidelines:
Obtain periodic clinical evaluation, including assessment of cardiovascular risk factors, limb symptoms, and functional status in patients with PAD.
B
Consider performing biannual foot examinations in patients with PAD and diabetes mellitus.
C

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  • Post-revascularization assessment (clinical)

  • Post-revascularization assessment (imaging)

  • Post-revascularization antithrombotic therapy

  • Management of restenosis

11.Quality improvement

Hospital requirements: set up a multidisciplinary vascular team in healthcare centers to make decisions for the management of patients with PADs.
B

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  • Public health measures

  • Research considerations