Management of Patients With Lower Extremity Peripheral Artery Disease

Publication Date: November 13, 2016

Diagnosis

Table 4. History and Physical Examination

Patients at increased risk of PAD (Table 2) should undergo a comprehensive medical history and a review of symptoms to assess for exertional leg symptoms, including claudication or other walking impairment, ischemic rest pain, and nonhealing wounds. (I, B-NR)
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Patients at increased risk of PAD (Table 2) should undergo vascular examination, including palpation of lower extremity pulses (i.e., femoral, popliteal, dorsalis pedis, and posterior tibial), auscultation for femoral bruits, and inspection of the legs and feet. (I, B-NR)
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Patients with PAD should undergo noninvasive blood pressure measurement in both arms at least once during the initial assessment. (I, B-NR)
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Table 5. Resting ABI for Diagnosing PAD

In patients with history or physical examination findings suggestive of PAD (Table 3), the resting ABI, with or without segmental pressures and waveforms, is recommended to establish the diagnosis. (I, B-NR)
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Resting ABI results should be reported as abnormal (ABI ≤0.90), borderline (ABI 0.91–0.99), normal (1.00–1.40), or noncompressible (ABI >1.40). (I, C-LD)
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In patients at increased risk of PAD (Table 2) but without history or physical examination findings suggestive of PAD (Table 3), measurement of the resting ABI is reasonable. (IIa, B-NR)
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In patients not at increased risk of PAD (Table 2) and without history or physical examination findings suggestive of PAD (Table 3), the ABI is NOT recommended. (III - No Benefit, B-NR)
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Table 6. Physiological Testing

TBI should be measured to diagnose patients with suspected PAD when the ABI is >1.40. (I, B-NR)
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Patients with exertional non–joint-related leg symptoms and normal or borderline resting ABI (>0.90 and ≤1.40) should undergo exercise treadmill ABI testing to evaluate for PAD. (I, B-NR)
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In patients with PAD and an abnormal resting ABI (≤0.90), exercise treadmill ABI testing can be useful to objectively assess functional status. (IIa, B-NR)
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In patients with normal (1.00–1.40) or borderline (0.91–0.99) ABI in the setting of non-healing wounds or gangrene, it is reasonable to diagnose CLI by using TBIPO2 with waveforms, Tc, or SPP. (IIa, B-NR)
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In patients with PAD with an abnormal ABI (≤0.90) or with noncompressible arteries (ABI >1.40 and TBI ≤0.70) in the setting of nonhealing wounds or gangrene, TBI with waveforms, TcPO2, or SPP can be useful to evaluate local perfusion. (IIa, B-NR)
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Table 9. Imaging for Anatomic Assessment

Duplex ultrasound, computed tomography angiography (CTA), or magnetic resonance angiography (MRA) of the lower extremities is useful to diagnose anatomic location and severity of stenosis for patients with symptomatic PAD in whom revascularization is considered. (I, B-NR)
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Invasive angiography is useful for patients with CLI in whom revascularization is considered. (I, C-EO)
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Invasive angiography is reasonable for patients with lifestyle-limiting claudication with an inadequate response to GDMT for whom revascularization is considered. (IIa, C-EO)
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Invasive and noninvasive angiography (i.e., CTA, MRA) should NOT be performed for the anatomic assessment of patients with asymptomatic PAD. (III - Harm, B-R)
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Table 10. Abdominal Aortic Aneurysm

A screening duplex ultrasound for AAA is reasonable in patients with symptomatic PAD. (IIa, B-NR)
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Treatment

Table 11. Antiplatelet Agents

Antiplatelet therapy with aspirin alone (range 75–325 mg per day) or clopidogrel alone (75 mg per day) is recommended to reduce MI, stroke, and vascular death in patients with symptomatic PAD. (I, A)
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In asymptomatic patients with PAD (ABI ≤0.90), antiplatelet therapy is reasonable to reduce the risk of MI, stroke, or vascular death. (IIa, C-EO)
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In asymptomatic patients with borderline ABI (0.91–0.99), the usefulness of antiplatelet therapy to reduce the risk of MI, stroke, or vascular death is uncertain. (IIb, B-R)
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The effectiveness of dual-antiplatelet therapy (DAPT) (aspirin and clopidogrel) to reduce the risk of cardiovascular ischemic events in patients with symptomatic PAD is not well established. (IIb, B-R)
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DAPT (aspirin and clopidogrel) may be reasonable to reduce the risk of limb-related events in patients with symptomatic PAD after lower extremity revascularization. (IIb, C-LD)
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The overall clinical benefit of vorapaxar added to existing antiplatelet therapy in patients with symptomatic PAD is uncertain. (IIb, B-R)
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Table 12. Statin Agents

Treatment with a statin medication is indicated for all patients with PAD. (I, A)
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Table 13. Antihypertensive Agents

Antihypertensive therapy should be administered to patients with hypertension and PAD to reduce the risk of MI, stroke, heart failure, and cardiovascular death. (I, A)
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The use of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers can be effective to reduce the risk of cardiovascular ischemic events in patients with PAD. (IIa, A)
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Table 14. Smoking Cessation

Patients with PAD who smoke cigarettes or use other forms of tobacco should be advised at every visit to quit. (I, A)
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Patients with PAD who smoke cigarettes should be assisted in developing a plan for quitting that includes pharmacotherapy (i.e., varenicline, bupropion, and/or nicotine replacement therapy) and/or referral to a smoking cessation program. (I, A)
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Patients with PAD should avoid exposure to environmental tobacco smoke at work, at home, and in public places. (I, B-NR)
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Table 15. Glycemic Control

Management of diabetes mellitus in the patient with PAD should be coordinated between members of the healthcare team. (I, C-EO)
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Glycemic control can be beneficial for patients with CLI to reduce limb-related outcomes. (IIa, B-NR)
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Table 16. Oral Anticoagulation

The usefulness of anticoagulation to improve patency after lower extremity autogenous vein or prosthetic bypass is uncertain. (IIb, B-R)
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Anticoagulation should NOT be used to reduce the risk of cardiovascular ischemic events in patients with PAD. (III - Harm, A)
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Table 17. Recommendation for Cilostazol

Cilostazol is an effective therapy to improve symptoms and increase walking distance in patients with claudication. (I, A)
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Table 18. Recommendation for Pentoxifylline

Pentoxifylline is not effective for treatment of claudication. (III - No Benefit, B-R)
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Table 19. Recommendation for Chelation Therapy

Chelation therapy (e.g., ethylenediaminetetraacetic acid) is NOT beneficial for treatment of claudication. (III - No Benefit, B-R)
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Table 20. Recommendation for Homocysteine Lowering

B-complex vitamin supplementation to lower homocysteine levels for prevention of cardiovascular events in patients with PAD is NOT recommended. (III - No Benefit, B-R)
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Table 21. Recommendation for Influenza Vaccination

Patients with PAD should have an annual influenza vaccination. (I, C-EO)
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Table 22. Structured Exercise Therapy

In patients with claudication, a supervised exercise program is recommended to improve functional status and QoL and to reduce leg symptoms. (I, A)
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A supervised exercise program should be discussed as a treatment option for claudication before possible revascularization. (I, B-R)
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In patients with PAD, a structured community- or home-based exercise program with behavioral change techniques can be beneficial to improve walking ability and functional status. (IIa, A)
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In patients with claudication, alternative strategies of exercise therapy, including upper-body ergometry, cycling, and pain-free or low-intensity walking that avoids moderate-to-maximum claudication while walking, can be beneficial to improve walking ability and functional status. (IIa, A)
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Table 24. Minimizing Tissue Loss in Patients With PAD

Patients with PAD and diabetes mellitus should be counseled about self-foot examination and healthy foot behaviors. (I, C-LD)
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In patients with PAD, prompt diagnosis and treatment of foot infection are recommended to avoid amputation. (I, C-LD)
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In patients with PAD and signs of foot infection, prompt referral to an interdisciplinary care team (Table 25) can be beneficial. (IIa, C-LD)
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It is reasonable to counsel patients with PAD without diabetes mellitus about self-foot examination and healthy foot behaviors. (IIa, C-EO)
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Biannual foot examination by a clinician is reasonable for patients with PAD and diabetes mellitus. (IIa, C-EO)
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Table 26. Recommendation for Revascularization for Claudication

Revascularization is a reasonable treatment option for the patient with lifestyle-limiting claudication with an inadequate response to GDMT. (IIa, A)
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Table 27. Endovascular Revascularization for Claudication

Endovascular procedures are effective as a revascularization option for patients with lifestyle-limiting claudication and hemodynamically significant aortoiliac occlusive disease. (I, A)
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Endovascular procedures are reasonable as a revascularization option for patients with lifestyle-limiting claudication and hemodynamically significant femoropopliteal disease. (IIa, B-R)
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The usefulness of endovascular procedures as a revascularization option for patients with claudication due to isolated infrapopliteal artery disease is unknown. (IIb, C-LD)
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Endovascular procedures should NOT be performed in patients with PAD solely to prevent progression to CLI. (III - Harm, B-NR)
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Table 28. Surgical Revascularization for Claudication

When surgical revascularization is performed, bypass to the popliteal artery with autogenous vein is recommended in preference to prosthetic graft material. (I, A)
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Surgical procedures are reasonable as a revascularization option for patients with lifestyle-limiting claudication with inadequate response to GDMT, acceptable perioperative risk, and technical factors suggesting advantages over endovascular procedures. (IIa, B-NR)
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Femoral-tibial artery bypasses with prosthetic graft material should NOT be used for the treatment of claudication. (III - Harm, B-R)
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Surgical procedures should NOT be performed in patients with PAD solely to prevent progression to CLI. (III - Harm, B-NR)
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Table 29. Revascularization for CLI

In patients with CLI, revascularization should be performed when possible to minimize tissue loss. (I, B-NR)
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An evaluation for revascularization options should be performed by an interdisciplinary care team (Table 25) before amputation in the patient with CLI. (I, C-EO)
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Table 30. Endovascular Revascularization for CLI

Endovascular procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene. (I, B-R)
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A staged approach to endovascular procedures is reasonable in patients with ischemic rest pain. (IIa, C-LD)
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Evaluation of lesion characteristics can be useful in selecting the endovascular approach for CLI. (IIa, B-R)
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Use of angiosome-directed endovascular therapy may be reasonable for patients with CLI and non-healing wounds or gangrene. (IIb, B-NR)
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Table 32. Surgical Revascularization for CLI

When surgery is performed for CLI, bypass to the popliteal or infrapopliteal arteries (i.e., tibial, pedal) should be constructed with suitable autogenous vein. (I, A)
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Surgical procedures are recommended to establish in-line blood flow to the foot in patients with non-healing wounds or gangrene. (I, C-LD)
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In patients with CLI for whom endovascular revascularization has failed and a suitable autogenous vein is not available, prosthetic material can be effective for bypass to the below-knee popliteal and tibial arteries. (IIa, B-NR)
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A staged approach to surgical procedures is reasonable in patients with ischemic rest pain. (IIa, C-LD)
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Table 33. Wound Healing Therapies for CLI

An interdisciplinary care team should evaluate and provide comprehensive care for patients with CLI and tissue loss to achieve complete wound healing and a functional foot. (I, B-NR)
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In patients with CLI, wound care after revascularization should be performed with the goal of complete wound healing. (I, C-LD)
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In patients with CLI, intermittent pneumatic compression (arterial pump) devices may be considered to augment wound healing and/or ameliorate severe ischemic rest pain. (IIb, B-NR)
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In patients with CLI, the effectiveness of hyperbaric oxygen therapy for wound healing is unknown. (IIb, C-LD)
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Prostanoids are NOT indicated in patients with CLI. (III - No Benefit, B-NR)
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Table 34. Clinical Presentation of ALI

Patients with ALI should be emergently evaluated by a clinician with sufficient experience to assess limb viability and implement appropriate therapy. (I, C-EO)
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In patients with suspected ALI, initial clinical evaluation should rapidly assess limb viability and potential for salvage and does not require imaging. (I, C-LD)
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Table 35. ALI Medical Therapy

In patients with ALI, systemic anticoagulation with heparin should be administered unless contraindicated. (I, C-EO)
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Table 36. Revascularization for ALI

In patients with ALI, the revascularization strategy should be determined by local resources and patient factors (e.g., etiology and degree of ischemia). (I, C-LD)
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Catheter-based thrombolysis is effective for patients with ALI and a salvageable limb. (I, A)
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Amputation should be performed as the first procedure in patients with a non-salvageable limb. (I, C-LD)
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Patients with ALI should be monitored and treated (e.g., fasciotomy) for compartment syndrome after revascularization. (I, C-LD)
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In patients with ALI with a salvageable limb, percutaneous mechanical thrombectomy can be useful as adjunctive therapy to thrombolysis. (IIa, B-NR)
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In patients with ALI due to embolism and with a salvageable limb, surgical thromboembolectomy can be effective. (IIa, C-LD)
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The usefulness of ultrasound-accelerated catheter-based thrombolysis for patients with ALI with a salvageable limb is unknown. (IIb, C-LD)
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Table 37. Diagnostic Evaluation of the Cause of ALI

In the patient with ALI, a comprehensive history should be obtained to determine the cause of thrombosis and/or embolization. (I, C-EO)
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In the patient with a history of ALI, testing for a cardiovascular cause of thromboembolism can be useful. (IIa, C-EO)
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Table 38. Longitudinal Follow-Up

Patients with PAD should be followed up with periodic clinical evaluation, including assessment of cardiovascular risk factors, limb symptoms, and functional status. (I, C-EO)
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Patients with PAD who have undergone lower extremity revascularization (surgical and/or endovascular) should be followed up with periodic clinical evaluation and ABI measurement. (I, C-EO)
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Duplex ultrasound can be beneficial for routine surveillance of infrainguinal, autogenous vein bypass grafts in patients with PAD. (IIa, B-R)
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Duplex ultrasound is reasonable for routine surveillance after endovascular procedures in patients with PAD. (IIa, C-LD)
573
The effectiveness of duplex ultrasound for routine surveillance of infrainguinal prosthetic bypass grafts in patients with PAD is uncertain. (IIb, B-R)
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Recommendation Grading

Disclaimer

Overview

Title

Management of Patients With Lower Extremity Peripheral Artery Disease

Authoring Organizations

Endorsing Organizations

Publication Month/Year

November 13, 2016

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room

Intended Users

Podiatrist, nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Prevention, Management

Diseases/Conditions (MeSH)

D058729 - Peripheral Arterial Disease

Keywords

peripheral artery disease (P.A.D.), claudication, lower extremity, endovascular procedures, PAD, critical limb ischemia, Peripheral artery disease

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
419
Literature Search Start Date
January 1, 2015
Literature Search End Date
September 30, 2016
Specialties Involved
Cardiology, Family Medicine, Internal Medicine General, Vascular Surgery, Interventional Radiology, Radiology