Peripheral Artery Disease Lower Extremity

Publication Date: May 14, 2024

Overview

Overview

Top 10 Take-Home Messages

  1. 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.
  2. 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.
  3. Detection of PAD in most patients is accomplished through the history, physical examination, and the resting ankle-brachial index.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. Care for patients with PAD, and especially those with chronic limb-threatening ischemia, is optimized when delivered by a multispecialty care team.
  9. 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.
  10. 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.

Note: The numbering of the following tables and figures may differ from that of the Clinical Practice Guideline.

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

Having trouble viewing table?
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.
  • Aortoiliac—Includes infrarenal abdominal aorta, common iliac, and external and internal iliac arteries.
  • Femoropopliteal—Includes common femoral, profunda femoris, superficial femoral, and popliteal arteries.
  • Infrapopliteal—Includes tibial-peroneal trunk, anterior tibial artery, posterior tibial artery, peroneal artery, plantar pedal loop, and pedal vessels (common plantar, medial plantar, and lateral plantar arteries).
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
  • A team of professionals representing different specialties and disciplines to assist in the evaluation and management of the patient with PAD and especially CLTI.
  • For the care of patients with CLTI, the care team should include individuals who are skilled in endovascular revascularization, surgical revascularization, wound-healing therapies and foot surgery, and medical evaluation and care.
  • Table 15 includes the list of multispecialty care team members.
  • Patients and family members collaborate with the multispecialty care team for management of CLTI.
Regions of the foot
  • Forefoot—Extends from the tarsometatarsal joint and incorporates the phalanges, metatarsal, and sesamoid bones.
  • Midfoot—Begins at the transverse tarsal joint and extends to the tarsometatarsal joint, incorporating the navicular, cuboid, and cuneiform bones.
  • Hindfoot—Begins at the ankle joint and ends at the transverse tarsal joint, incorporating the calcaneus and talus bones.
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
  • Minor—Nonhealing ulcer, focal gangrene.
  • Major—Tissue loss extending above the transmetatarsal level; functional foot no longer salvageable.
WIfI
  • A clinical staging system for patients with CLTI that incorporates the wound extent, degree of ischemia, and severity of foot infection.
  • WIfI class correlates with CLTI outcomes, including time to wound healing, amputation rate, and amputation-free survival.

Diagnosis

Diagnosis

.... Recognizing Clinical Subsets of PA...

...Clinical Subsets of PAD...

...cal Subsets of Patients With PADHaving...


.... History and Physical Examination to Assess for...

...tients at increased risk of PAD (Table 5), a...

...patients at increased risk of PAD (Tabl...

Table 5. Patients at Increased Risk for PADHavi...

...le 6. History and Physical Examination Findings...

...ernative Diagnosis for Leg Pain or Claudication...

...2. Algorithm for Diagnostic Testing...


...ABI and Additional Physiological Test...

Resting ABI

...n patients with history or physical examinati...

...resting ABI should be reported as abnorma...

In patients at increased risk of PAD (Table...

...In patients not at increased risk of PAD (Table...

...Additional Physiological Testing...

...patients with suspected PAD, toe p...

...with suspected chronic symptomatic PAD (ie, ex...

...atients with PAD and an abnormal resting ABI...

In patients with chronic symptoma...

In patients with suspected CLTI, it i...

...ts with CLTI with nonhealing wounds o...

...tive Diagnoses for Nonhealing Lower Ex...


3.2. Imaging for...

...ts with functionally limiting claudication w...

...ts with CLTI, duplex ultrasound, CTA, MRA,...

In patients with suspected PAD (ie, potential...

...with a confirmed diagnosis of PAD...


...Special Considerations in PAD: Risk...

...rs of Cardiovascular and Limb-Related Risk...

...e evaluation of patients with PAD, cl...

...Related Risk AmplifiersHaving trouble vi...

Figure 3. Health Disparities and PAD-Relate...

...ealth Disparities in PAD...

...nicians and health care systems should activ...

...ations in Management of PAD in Old...

...lder patients (ie, ≥75 years of age) wi...

...Geriatric Syndromes and Considerations i...


Treatment

...reatmen...

...al Therapy and Preventive Footcare...

...ure 4. Medical Therapy and Foot Care for PAD

...1. Antiplatelet and Antithrombotic...

...ts with symptomatic PAD, single ant...

...ts with symptomatic PAD, single antiplatelet...

...tients with symptomatic PAD, single a...

...patients with symptomatic PAD, low-dose rivar...

...vascular or surgical revascularization for PAD,...

...r endovascular or surgical revascularizatio...

...ovascular revascularization for PAD, dua...

...fter endovascular or surgical revas...

...In patients with asymptomatic PAD single a...

...In patients with symptomatic PAD without rece...

...s with symptomatic PAD, the benefit of vorapaxar a...

...r surgical revascularization for PAD with a prost...

...ents with PAD without another indi...

...Lipid-Lowering Therapy for...

...patients with PAD, treatment with high-intensi...

...with PAD who are on maximally tolerated statin th...

...n patients with PAD who are on maximally t...

...Moderate-, and Low-Intensity Statin Thera...

...3. Antihypertensive Therapy...

...s with PAD and hypertension, antihyp...

...tients with PAD and hypertension, a systolic bl...

...with PAD and hypertension, the selective...

...ng Cessation for PAD...

...with PAD who smoke cigarettes or use any other...

...ients with PAD who smoke cigarettes...

...Patients with PAD should be advised...

....5. Diabetes Management f...

...ents with PAD and type 2 diabetes, use o...

...In patients with PAD, management of diabetes s...

...atients with PAD and diabetes, glycemic...

...r Medical Therapies for Cardiovascula...

...ith PAD should receive an annual influen...

...PAD should receive the severe acute respirato...

...at high cardiovascular risk, a die...

...nts with PAD, B-complex vitamin supplementati...

...patients with PAD, chelation therapy (eg, ED...

...ts with PAD, vitamin D supplementation is...

...for Leg Symptoms in Chronic Symptomati...

...ilostazol

...with claudication, cilostazol is recommended t...

In patients with PAD, cilostazol may be usefu...

...atients with PAD and congestive he...

...ntoxifylline

...n patients with chronic symptomatic PAD, pent...

Chelation Thera...

...patients with chronic symptomatic PAD, chela...

...ntive Foot Care for PA...

...ts with PAD, providing general preventive foo...

...with PAD, foot inspection by a clinician...

...patients with PAD at high risk for ulcer...

...with PAD, a comprehensive foot evaluat...

...s with PAD, referral to a foot care specia...

...e 12. Risk Factors for Development of Foo...

...omponents of a Comprehensive Foot Evaluati...


...Exercise Therapy for P...

...ith chronic symptomatic PAD, SET is recomme...

...ents with chronic symptomatic PAD, a structure...

...atients who have undergone revascularization for...

...s with functionally limiting claudicati...

...n patients with chronic symptomatic PAD, al...

...ts with chronic symptomatic PAD, the us...

...In patients with chronic symptom...

...ble 14. Structured Exercise Programs for P...


.... Revascularization for Asymptomat...

...s with asymptomatic PAD, it is reasonable to perfo...

...ients with asymptomatic PAD, revascul...


...ithm for Revascularization for Claudica...


...arization for Claudication...

...ation for Claudication: Initial Decision-Ma...

...ith functionally limiting claudica...

...with functionally limiting claudication and...

...ents with claudication who have had an ade...

...larization for Claudication: Aortoiliac D...

...In patients with functionally limiting claud...

...ients with functionally limiting claud...

...ation for Claudication: Common Femoral Artery Dise...

In patients with functionally limit...

...patients with functionally limiting c...

...ation for Claudication: Infrapopliteal...

...patients with functionally limiting claud...

...with functionally limiting claudication...


...Conduit for Surgical Revascularization for...

...ts who are undergoing surgical revascular...


...Components of Care for CLTI...


...Algorithm for Management of CLT...


...am-Based Care for CLTI...

...ts with CLTI, a multispecialty care team...


...e 15. Multispecialty Care Team for PADHaving...


...16. Factors That May Influence Reva...


.... Revascularization for C...

...ularization Goals for CLTI...

...tients with CLTI, surgical, endovascular, or hybr...

...patients with CLTI, an evaluation for re...

...evascularization Strategy...

...undergoing surgical revascularization for CL...

...patients with CLTI due to infrainguin...

...ients with CLTI who are candidates for surgic...

...patients with CLTI for whom a surgical approach...

...s with CLTI and nonhealing wounds or...

...nts with CLTI with ischemic rest pain (ie, wi...


10.3. Minimizing Tissue Loss for...

...ressure Offloading for CLTI...

...with CLTI and diabetic foot ulcers should receiv...

...nts with PAD and previous diabetic foot ulcers...

...Patients with CLTI and foot ulcers...

...ound Care and Management of Infect...

...with CLTI, prompt management of foot inf...

...ients with CLTI with nonhealing wounds,...

...ients with CLTI with nonhealing diabetic foot ulce...

...Components of Wound Care for Patients Wit...

....3. Approach to the “No Option”...

...ts with CLTI for whom revascularization i...

...In patients with CLTI for whom rev...

...In patients with CLTI for whom arterial r...

...ic Classification of the "No Option" Pat...

...Amputation for CLTI...

...n patients with CLTI who require amputat...

...patients with CLTI, primary amputation...

...ents with CLTI, a patient-centered approach u...

...with CLTI undergoing minor amputati...

...For patients with CLTI, retrospective...

...e 19. Major Factors Influencing QOL Among Amputee...

Patient Fact...

...Walking with prosthesis Above knee (versu...

...fessional-Controlled...

...iming of amputation Informed deci...


...ute Limb Ischemi...

...gorithm for Diagnosis and Management of AL...

...Clinical Evaluation and Diagnosti...

...with ALI should be evaluated on an emerge...

...with suspected ALI, the initial clinic...

...In patients with ALI who have a complicated his...


...Management of ALI...

...1.2.1. Revascularization for ALI

In patients with ALI and a salvageabl...

...nts with ALI and a salvageable limb who a...

...atients presenting with ALI from chemotherapeutic...

...ents with ALI with a nonsalvageabl...

...nctive Therapies to Minimize Tissu...

...atients with ALI should be monitored and treated...

...ients with ALI with a threatened but s...

...ents with ALI and prolonged ischemia in w...

...3. Anticoagulation for ALI...

In patients with ALI, regardless of...

...c Evaluation for the Cause of ALI...

...In patients with ALI, a comprehensive medical h...

...patients with ALI, testing for a cardiovascular...

.... Underlying Causes of ALIHaving trouble viewing t...

12. Longitudinal Follow-Up...

...neral Principles...

...atients with PAD, with or without revasculari...

...ts with PAD, coordination of care among...

...nctional Status and QO...

...s with PAD, with or without revascularization, p...

...al Therapy...

...ith PAD, long-term use of GDMT to prevent MACE...

...scularization Follow-Up...

...with PAD who have undergone lower extr...

...ts with PAD who have undergone lower extremit...

...atients with PAD who have undergone i...

...patients with PAD who have undergone endova...

...s with PAD who have undergone infr...

...elehealt...

...r patients with PAD, telehealth can be...