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Peripheral artery disease

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Updated 2024 ESC guidelines for the diagnosis and management of peripheral artery disease.

Background

Overview

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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Guidelines

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 American Heart Association (AHA/HRS/ACC/ACCP 2024), the European Society for Vascular Surgery (ESVS 2024), the European Society of Cardiology (ESC 2024), the Vascular and Endovascular Surgery Society (VESS/SCAI/ABC/SVM/SVN/SVS/AHA/AACVPR/ACC/APMA/SIR 2024), the Wound Healing Society (WHS 2024), the American ...
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Screening and diagnosis

Indications for screening, general population: as per ESVS 2024 guidelines, do not obtain screening for lower extremity PAD with ABI in asymptomatic individuals without increased cardiovascular risk.
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  • Indications for screening (patients at risk)

  • Indications for screening (HF)

  • Indications for screening (before cardiovascular procedures)

Classification and risk stratification

Amputation risk assessment: as per ESC 2024 guidelines, consider using the WIfI classification system to estimate individual risk of amputation in patients with peripheral arterial disease and chronic wounds.
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Diagnostic investigations

History and physical examination: as per ESC 2024 guidelines, consider obtaining an overall assessment of functional (physical functioning) performance with objective tests in patients with symptomatic and asymptomatic chronic PAD.
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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

Medical management

General principles: as per ESC 2024 guidelines, adopt a comprehensive approach addressing the entirety of the arterial circulation for the management of patients with PAD.
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  • Management of claudication (cilostazol and naftidrofuryl)

  • Management of claudication (other agents)

  • Management of arterial ulcers (nonpharmacological management)

  • Management of arterial ulcers (pharmacological management)

  • Management of arterial ulcers (pain management)

  • Management of arterial ulcers (surgical management)

  • Management of hypertension (targets)

  • Management of hypertension (drugs)

  • Management of diabetes mellitus

  • Antiplatelet therapy (asymptomatic)

  • Antiplatelet therapy (symptomatic)

  • Anticoagulation therapy

  • Lipid-lowering therapy

  • Chelation therapy

Nonpharmacologic interventions

Exercise therapy: as per ESC 2024 guidelines, offer supervised exercise training in patients with symptomatic PAD.
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  • Smoking cessation

  • Dietary changes

  • Supplements

Therapeutic procedures

Indications for revascularization, symptomatic
As per ESC 2024 guidelines:
Obtain a PAD-related QoL assessment in patients with symptomatic PAD after a 3-month period of optimal medical therapy and exercise therapy.
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Consider performing revascularization in patients with symptomatic PAD and impaired PAD-related QoL after a 3-month period of optimal medical therapy and exercise therapy.
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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

Perioperative care

Preoperative risk assessment: as per CCS 2022 guidelines, do not use the RCRI for preoperative assessment of cardiac risk in patients undergoing peripheral arterial surgery.
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Specific circumstances

Female patients
As per ESVS 2024 guidelines:
Offer similar evidence-based cardiovascular primary and secondary preventive strategies in males and females with PAD.
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Do not use hormone replacement therapy with estrogen or progestin for the prevention of CVD in postmenopausal females.
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  • Patients with polyvascular disease

  • Patients with AF

  • Patients with subclavian artery stenosis

  • Patients requiring OACs

  • Patients undergoing coronary artery intervention

Patient education

General counseling: as per ESC 2024 guidelines, provide behavioral counselling to promote healthy diet, smoking cessation, and physical activity to improve the cardiovascular risk profile in patients with PAD.
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  • Foot care

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 extremity PAD.
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  • COVID-19 vaccination

Follow-up and surveillance

Clinical follow-up: as per ESC 2024 guidelines, follow up patients with PAD regularly, at least once a year, assessing clinical and functional status, medication adherence, limb symptoms, and cardiovascular risk factors with duplex ultrasound assessment as needed.
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  • Post-revascularization assessment (clinical)

  • Post-revascularization assessment (imaging)

  • Post-revascularization antithrombotic therapy

  • Management of restenosis

Quality improvement

Hospital requirements: as per ESC/ESVS 2018 guidelines, set up a multidisciplinary vascular team in healthcare centers to make decisions for the management of patients with PADs.
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  • Public health measures

  • Research considerations