Peripheral Artery Disease Lower Extremity
Overview
Overview
Top 10 Take-Home Messages
- Peripheral artery disease (PAD) is a common cardiovascular disease associated with increased risk of amputation, myocardial infarction, stroke, and death, as well as impaired quality of life, walking performance, and functional status.
- This guideline defines 4 clinical subsets of PAD: asymptomatic PAD (may have functional impairment), chronic symptomatic PAD (including claudication), chronic limb-threatening ischemia, and acute limb ischemia.
- Detection of PAD in most patients is accomplished through the history, physical examination, and the resting ankle-brachial index.
- Health disparities in PAD are associated with poor limb and cardiovascular outcomes and must be addressed at the individual patient and population levels, with interventions coordinated between multiple stakeholders across the cardiovascular community and public health infrastructure.
- Effective medical therapies for patients with PAD should be prescribed to prevent major adverse cardiovascular events and major adverse limb events for patients with PAD, including antiplatelet (generally single antiplatelet) and antithrombotic therapy, lipid-lowering (ie, high-intensity statin) and antihypertensive therapy, management of diabetes, and smoking cessation. Rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin (81 mg daily) is effective to prevent major adverse cardiovascular events and major adverse limb events in patients with PAD who are not at increased risk of bleeding.
- Structured exercise is a core component of care for patients with PAD. It includes supervised exercise therapy and community-based (including structured home-based) programs.
- Revascularization (endovascular, surgical, or hybrid) should be used to prevent limb loss in those with chronic limb-threatening ischemia and can be used to improve quality of life and functional status in patients with claudication not responsive to medical therapy and structured exercise.
- Care for patients with PAD, and especially those with chronic limb-threatening ischemia, is optimized when delivered by a multispecialty care team.
- Foot care is crucial for patients with PAD across all clinical subsets and ranges from preventive care and patient education to advanced care in the setting of chronic limb-threatening ischemia. Podiatrists and other specialists with expertise in foot care, wound-healing therapies, and foot surgery are important members of the multispecialty care team.
- The PAD National Action Plan outlines 6 strategic goals to improve awareness, detection, and treatment of PAD nationwide. Implementation of this action plan is recognized as a top advocacy priority by the writing committee.
In the print version of this pocket guide, colors in tables and figures correspond to Class of Recommendations and Level of Evidence tables on pages 54–55.
Table 2. Definitions of PAD Key Terms
| Term | Definition |
|---|---|
| ALI | Acute (≤2 wk) hypoperfusion of the limb that may be characterized by: pain, pallor, pulselessness, poikilothermia, paresthesias, and/or paralysis. ALI is further classified according to the Rutherford classification system (Table 4). |
| Anatomic level | Anatomic subsets to localize disease in the lower extremity. Patients with PAD can have multilevel arterial disease across multiple segments.
|
| Angiosome-based blood flow | Uninterrupted arterial flow to the anatomic territory of a source artery in the skin and deep tissues. In the context of PAD, the angiosome refers to the skin region and underlying tissue, generally with a wound, supplied by a specific infrapopliteal artery. |
| Claudication | Fatigue, cramping, aching, pain, or other discomfort of vascular origin in the muscles of the lower extremities that is consistently induced by walking and consistently relieved by rest (usually within approximately 10 min). Claudication that limits functional status is known as functionally limiting claudication. Claudication is recognized as a manifestation of chronic symptomatic PAD (see Section 2.1, “Recognizing Clinical Subsets for PAD”). |
| CLTI | A condition characterized by chronic (>2 wk) ischemic rest pain, nonhealing wounds and ulcers, or gangrene attributable to objectively proven arterial occlusive disease. Current nomenclature has evolved from the previous commonly used term of CLI to reflect the chronic nature of this condition and its potentially limb-threatening nature with associated risk for amputation and to distinguish it from ALI. |
| Endovascular revascularization | Catheter-based revascularization procedures employing modalities such as percutaneous transluminal (balloon) angioplasty, drug-coated balloon angioplasty, stenting (bare metal, drug coated, or covered), and atherectomy. |
| Functional status | Patient’s ability to meet basic needs, fulfill usual roles, and maintain health and well-being (activities of daily living). Walking ability/ performance and mobility are components of functional status. |
| Hybrid revascularization | Approach to revascularization that includes endovascular and surgical components either concomitantly or in a staged manner. |
| In-line (pulsatile) blood flow | Uninterrupted arterial flow via named infrapopliteal arteries to the foot. |
| Inflow versus outflow | Inflow refers to arteries proximal to the superficial femoral artery (aortoiliac, common femoral arteries). Outflow refers to arteries distal to the superficial femoral artery (popliteal and infrapopliteal arteries). |
| MACE | Variably defined but usually includes death (all-cause or cardiovascular), MI, acute coronary syndrome (acute MI, unstable angina), and stroke. May also include heart failure, rehospitalization for cardiovascular causes, and other cardiovascular endpoints. |
| MALE | Variably defined but usually includes major amputation and endovascular or surgical lower extremity revascularization (initial or reintervention). May also include ALI. |
| Multispecialty care team for PAD |
|
| Regions of the foot |
|
| Structured exercise program | An exercise program planned by a qualified health care professional that provides recommendations for exercise training with a goal of improving functional status over time. The program provides individualized recommendations for frequency, intensity, time, and type of exercise. |
| Structured community-based exercise program | A structured exercise program that takes place in the personal setting of the patient (eg, home, surrounding neighborhood, fitness facility). The program is self-directed with as-needed guidance of health care professionals who prescribe a structured exercise regimen similar to that performed in a supervised program setting. Community-based programs may incorporate behavioral change techniques, delivered by in-person or virtual health coaching or the use of activity monitors. Table 14 provides more detail regarding this form of structured exercise. |
| Supervised exercise therapy | A supervised, structured exercise program that takes place in a hospital or outpatient facility that is directly supervised by a physician or advanced practice provider and most often implemented by a clinical exercise physiologist or nurse. Table 14 includes more detail regarding this form of structured exercise. |
| Surgical revascularization | Surgical procedures that may involve endarterectomy to remove plaque, thrombectomy, or bypass surgery to reconstruct arterial blood flow. |
| Thrombolysis | Administration of thrombolytic agents, generally through a catheter placed directly within an area of thrombus in an artery. |
| Tissue loss |
|
| WIfI |
|
Diagnosis
Diagnos...
...1. Recognizing Clinical Subsets of...
...Clinical Subsets of PAD...
...4. Clinical Subsets of Patients With PADHaving tro...
...istory and Physical Examination to...
...tients at increased risk of PAD (Table...
...In patients at increased risk of PAD (Table 5),...
...e 5. Patients at Increased Risk for PADHavi...
...ory and Physical Examination Findings...
...able 7. Alternative Diagnosis for Leg Pain or Clau...
...orithm for Diagnostic Testing for PAD*If...
...BI and Additional Physiological Testing...
...sting ABI
...In patients with history or physical ex...
...The resting ABI should be reporte...
...patients at increased risk of PAD (Table 5), scree...
...not at increased risk of PAD (Table 5) and withou...
...cise ABI and Additional Physiological T...
...In patients with suspected PAD, toe pressure/to...
...ts with suspected chronic symptomatic P...
...atients with PAD and an abnormal resting...
In patients with chronic symptomatic PAD, it is...
...patients with suspected CLTI, it is reasonabl...
...s with CLTI with nonhealing wounds or gangrene, i...
...able 8. Alternative Diagnoses for Nonhealing...
...Imaging for PAD
...atients with functionally limiting claudication...
...with CLTI, duplex ultrasound, CTA, MRA, or cathet...
...tients with suspected PAD (ie, potent...
...In patients with a confirmed diagnosis of PAD in...
4. Special Considerations in PAD:...
...Amplifiers of Cardiovascular and Limb-Related...
...tion of patients with PAD, clinicians shoul...
...le 9. PAD-Related Risk AmplifiersHavin...
...3. Health Disparities and PAD-Rel...
...Health Disparities in PAD...
...Clinicians and health care systems should activ...
...iderations in Management of PAD in Older Patie...
...ients (ie, ≥75 years of age) with P...
...Geriatric Syndromes and Considerations in t...
Treatment
Treatme...
...al Therapy and Preventive Footcare for Patient...
...dical Therapy and Foot Care for P...
...elet and Antithrombotic Therapy for PAD...
...nts with symptomatic PAD, single antiplatelet t...
...with symptomatic PAD, single antiplatelet...
...In patients with symptomatic PAD, s...
...ith symptomatic PAD, low-dose rivaroxaban (...
...r endovascular or surgical revascularization for...
...fter endovascular or surgical revasculari...
...After endovascular revascularizatio...
...endovascular or surgical revascularization in pa...
...In patients with asymptomatic PAD single antipla...
...atients with symptomatic PAD without recent revas...
...In patients with symptomatic PAD, t...
...al revascularization for PAD with a...
...s with PAD without another indication (e...
.... Lipid-Lowering Therapy f...
...ith PAD, treatment with high-intensi...
...patients with PAD who are on maximally tolerat...
...ents with PAD who are on maximally t...
...gh-, Moderate-, and Low-Intensity Statin Ther...
...ertensive Therapy for PAD...
...ith PAD and hypertension, antihype...
...with PAD and hypertension, a systolic b...
...ients with PAD and hypertension, the selective us...
5.4. Smoking Cessation f...
...atients with PAD who smoke cigaret...
...ts with PAD who smoke cigarettes or use any oth...
...h PAD should be advised to avoid exposure t...
...iabetes Management for PAD...
...ts with PAD and type 2 diabetes, use of glucagon-l...
...ts with PAD, management of diabetes should...
...patients with PAD and diabetes, glycemic control...
...Other Medical Therapies for Cardiovascular R...
...ith PAD should receive an annual influenz...
Patients with PAD should receive th...
In patients at high cardiovascular risk,...
...ith PAD, B-complex vitamin supplementa...
...with PAD, chelation therapy (eg, EDTA)...
...with PAD, vitamin D supplementation is not...
...cations for Leg Symptoms in Chronic Sympt...
...ilostazol
In patients with claudication, cilostazol...
...ts with PAD, cilostazol may be useful t...
...ients with PAD and congestive heart failure of...
Pentoxifylline
...patients with chronic symptomatic PAD, pento...
...elation Ther...
...ents with chronic symptomatic PAD, chelation thera...
...8. Preventive Foot Car...
...s with PAD, providing general preventive fo...
...In patients with PAD, foot inspection by a...
...ith PAD at high risk for ulcers and amputat...
...ients with PAD, a comprehensive foot evaluat...
...atients with PAD, referral to a foot care speci...
...actors for Development of Foot Ulcers or...
Table 13. Components of a Comprehensi...
...rcise Therapy for PAD...
...n patients with chronic symptomatic PAD, SET is...
...patients with chronic symptomatic PAD, a...
...who have undergone revascularizati...
...ts with functionally limiting claudication, SET...
...atients with chronic symptomatic PAD, alternative...
...ith chronic symptomatic PAD, the usefulness...
...In patients with chronic symptomatic PAD, the...
...Structured Exercise Programs for PADHavin...
.... Revascularization for Asymptomatic...
...atients with asymptomatic PAD, it is reasonab...
...ts with asymptomatic PAD, revascularizat...
...5. Algorithm for Revascularization for...
...larization for Claudication...
...larization for Claudication: Initial Decision-Maki...
...tients with functionally limiting claudica...
...In patients with functionally limiting cl...
...ith claudication who have had an adequate cli...
...evascularization for Claudication: Aortoiliac D...
...atients with functionally limiting cl...
...In patients with functionally limiting claudica...
...n for Claudication: Common Femoral Arte...
In patients with functionally limitin...
...n patients with functionally limitin...
...zation for Claudication: Infrapopliteal Disease...
...In patients with functionally limiti...
...patients with functionally limiting claudica...
9.2. Conduit for Surgical Revascular...
...n patients who are undergoing surgical revascular...
...igure 6. Components of Care for CLT...
...e 7. Algorithm for Management of C...
...eam-Based Care for CLT...
...ith CLTI, a multispecialty care team...
...Multispecialty Care Team for PADHavi...
...ctors That May Influence Revascularization...
...evascularization for CL...
...arization Goals for CLTI...
...n patients with CLTI, surgical, endovascular, o...
In patients with CLTI, an evalua...
...evascularization Strategy for CLTI...
...nts undergoing surgical revascularization for C...
...s with CLTI due to infrainguinal disease...
...patients with CLTI who are candidates for s...
...with CLTI for whom a surgical approach is sel...
...with CLTI and nonhealing wounds or...
...ents with CLTI with ischemic rest pain (ie...
...Minimizing Tissue Loss for C...
...essure Offloading for CLTI...
...with CLTI and diabetic foot ulcers should...
...ts with PAD and previous diabetic foot ulce...
...atients with CLTI and foot ulcers who do not have...
...und Care and Management of Infectio...
...tients with CLTI, prompt management of...
...patients with CLTI with nonhealing wounds, wou...
...In patients with CLTI with nonhealing diabetic...
...onents of Wound Care for Patients Wi...
10.3.3. Approach to the “No Option” Patie...
...with CLTI for whom revascularization is not...
...tients with CLTI for whom revascularization is n...
...ients with CLTI for whom arterial revasc...
...ble 18. Anatomic Classification of the "N...
...mputation for CLTI...
...In patients with CLTI who require amputatio...
...atients with CLTI, primary amputation is...
...In patients with CLTI, a patient-centered approa...
In patients with CLTI undergoing mi...
...s with CLTI, retrospective assessment of i...
...19. Major Factors Influencing QOL Among...
...atient Factor...
...Walking with prosthesis Above knee (...
...nal-Controlled Factors...
...Timing of amputation Informed deci...
.... Acute Limb Ischemia...
...Algorithm for Diagnosis and Management of ALI...
....1. Initial Clinical Evaluation and Diagnostic...
...ents with ALI should be evaluated on...
...nts with suspected ALI, the initial clinical e...
...ents with ALI who have a complicated history of re...
...anagement of ALI...
....2.1. Revascularization for ALI...
...nts with ALI and a salvageable limb, revascular...
...In patients with ALI and a salvageable...
...In patients presenting with ALI from chemo...
...atients with ALI with a nonsalvageable limb, re...
...ve Therapies to Minimize Tissue Loss in...
...tients with ALI should be monitored and treated...
...ts with ALI with a threatened but...
...s with ALI and prolonged ischemia in whom reva...
...1.2.3. Anticoagulation for A...
In patients with ALI, regardless of cause or...
...ic Evaluation for the Cause of ALI...
...In patients with ALI, a comprehensive medical h...
...s with ALI, testing for a cardiovascu...
...le 20. Underlying Causes of ALIHaving...
...2. Longitudinal Follow-Up of PAD...
...eral Principles...
...n patients with PAD, with or without re...
...tients with PAD, coordination of care among...
...tional Status and...
...nts with PAD, with or without revascula...
...dical Therapy...
...with PAD, long-term use of GDMT to preve...
...evascularization Follow-U...
...with PAD who have undergone lower extremity rev...
In patients with PAD who have unde...
...ents with PAD who have undergone in...
...s with PAD who have undergone endovasc...
...patients with PAD who have undergone infraingu...
...elehealt...
...ents with PAD, telehealth can be a...