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

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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

...iagnosi...

...cognizing Clinical Subsets of PAD...

...Clinical Subsets of PAD

...le 4. Clinical Subsets of Patients With P...


...ory and Physical Examination to Assess...

...ents at increased risk of PAD (Table 5),...

...patients at increased risk of PAD (Table 5),...

...able 5. Patients at Increased Risk f...

...and Physical Examination Findings Suggestive of P...

...e 7. Alternative Diagnosis for Leg...

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


...ng ABI and Additional Physiological Testing...

...esting A...

...ients with history or physical examin...

...g ABI should be reported as abnormal (ABI, ...

...at increased risk of PAD (Table 5), screenin...

In patients not at increased risk...

...e ABI and Additional Physiological Testing...

...s with suspected PAD, toe pressure/toe-brac...

...Patients with suspected chronic symptoma...

...nts with PAD and an abnormal resting ABI (≤0....

...In patients with chronic symptomatic PAD, it is r...

In patients with suspected CLTI, it is reasona...

...ith CLTI with nonhealing wounds or gangrene, it...

...native Diagnoses for Nonhealing Lower Ex...


.... Imaging for P...

...In patients with functionally limiting claudicat...

...nts with CLTI, duplex ultrasound, CTA,...

...with suspected PAD (ie, potential signs...

...ith a confirmed diagnosis of PAD in whom revascula...


...Special Considerations in PAD: Risk Amplifiers, He...

...of Cardiovascular and Limb-Related Risk in Pati...

...the evaluation of patients with PAD, clinic...

...able 9. PAD-Related Risk AmplifiersHavi...

...ealth Disparities and PAD-Related Ris...

...alth Disparities in PAD...

...icians and health care systems should acti...

...erations in Management of PAD in Older Patients...

In older patients (ie, ≥75 years of age) with...

...iatric Syndromes and Considerations in the Ma...


Treatment

...reatment

...py and Preventive Footcare for Patients With PAD...

...gure 4. Medical Therapy and Foot Care f...

...iplatelet and Antithrombotic Therapy...

...with symptomatic PAD, single antiplatelet therapy...

...In patients with symptomatic PAD, single a...

...ith symptomatic PAD, single antiplatelet therapy w...

...In patients with symptomatic PAD, low-dose ri...

...After endovascular or surgical revascu...

...fter endovascular or surgical revascularization...

...endovascular revascularization for PA...

...fter endovascular or surgical revasculariz...

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

...ith symptomatic PAD without recent revascular...

...with symptomatic PAD, the benefit of vorapa...

...r surgical revascularization for PAD...

...ents with PAD without another indication (eg,...

...id-Lowering Therapy for PAD...

...atients with PAD, treatment with h...

...ents with PAD who are on maximally tole...

...ts with PAD who are on maximally to...

...-, Moderate-, and Low-Intensity Statin Therapy*...

...pertensive Therapy for PAD...

...patients with PAD and hypertension, antihyperte...

...n patients with PAD and hypertension...

...atients with PAD and hypertension,...

...Smoking Cessation for PAD...

...Patients with PAD who smoke cigar...

...s with PAD who smoke cigarettes or use any oth...

...ients with PAD should be advised to avoid expo...

...Diabetes Management for PAD...

...tients with PAD and type 2 diabetes, use of gl...

...with PAD, management of diabetes should be co...

...n patients with PAD and diabetes,...

.... Other Medical Therapies for Cardiovas...

...tients with PAD should receive an annual i...

...with PAD should receive the severe acute respir...

...patients at high cardiovascular risk,...

...with PAD, B-complex vitamin supple...

...In patients with PAD, chelation th...

...In patients with PAD, vitamin D supplementati...

...s for Leg Symptoms in Chronic Symptomatic PAD...

...ilostaz...

...ents with claudication, cilostazol is...

...atients with PAD, cilostazol may be useful to...

...ts with PAD and congestive heart failure...

...ntoxifylline...

...In patients with chronic symptomatic PAD, pentox...

...lation Therapy

...atients with chronic symptomatic PA...

...eventive Foot Care for...

...patients with PAD, providing general prev...

...ts with PAD, foot inspection by a clinician at eve...

...ts with PAD at high risk for ulcers and a...

...In patients with PAD, a comprehensive foot evalu...

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

...12. Risk Factors for Development of Foot Ulcers o...

...nents of a Comprehensive Foot Evaluation for...


...xercise Therapy for PAD...

...In patients with chronic symptomatic PAD, S...

...ients with chronic symptomatic PAD, a s...

...patients who have undergone revascu...

...atients with functionally limiting clau...

...ith chronic symptomatic PAD, alterna...

...nts with chronic symptomatic PAD, the usefuln...

...tients with chronic symptomatic PAD, the usefulne...

...Structured Exercise Programs for PADHaving tr...


...Revascularization for Asymptomatic PA...

...tients with asymptomatic PAD, it is...

...atients with asymptomatic PAD, revascularizatio...


...5. Algorithm for Revascularization for Cl...


...ascularization for Claudication...

...ularization for Claudication: Initial De...

...nts with functionally limiting claudication wh...

...ts with functionally limiting claudication...

...s with claudication who have had an ad...

...rization for Claudication: Aortoilia...

...ients with functionally limiting claud...

...ts with functionally limiting claud...

...arization for Claudication: Common Femora...

...nts with functionally limiting claudication and h...

...In patients with functionally li...

...ascularization for Claudication: Infrapo...

...ients with functionally limiting claud...

...patients with functionally limiting claudica...


....2. Conduit for Surgical Revascularization...

...n patients who are undergoing surgica...


...ure 6. Components of Care for CLTI...


...orithm for Management of CLTI...


...eam-Based Care for CLTI...

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


...Multispecialty Care Team for PADHav...


...rs That May Influence Revascularizat...


...vascularization for CLTI...

Revascularization Goals for...

...In patients with CLTI, surgical, end...

...tients with CLTI, an evaluation for revascula...

...vascularization Strategy fo...

...undergoing surgical revascularization for CLTI...

...patients with CLTI due to infraing...

...patients with CLTI who are candidate...

...In patients with CLTI for whom a surgica...

...atients with CLTI and nonhealing woun...

...ts with CLTI with ischemic rest pain (...


...Minimizing Tissue Loss for CLTI...

...sure Offloading for CLTI...

...s with CLTI and diabetic foot ulcer...

...ith PAD and previous diabetic foot ulcers...

...with CLTI and foot ulcers who do not have...

...Care and Management of Infection for CLTI...

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

...ith CLTI with nonhealing wounds, wound care should...

...atients with CLTI with nonhealing diab...

...ponents of Wound Care for Patients...

...to the “No Option” Patient With CLTI...

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

...with CLTI for whom revascularization is...

...with CLTI for whom arterial revasculariz...

...Anatomic Classification of the "No Option" Pa...

.... Amputation for CLTI...

...with CLTI who require amputation, evaluatio...

...s with CLTI, primary amputation is indicated...

In patients with CLTI, a patient-centered ap...

...nts with CLTI undergoing minor amputation (ie, in...

...patients with CLTI, retrospective assessment o...

Table 19. Major Factors Influencing QOL Among Ampu...

...tient Facto...

...r QOL Walking with prosthesis Above kne...

...essional-Controlled Factors...

...of amputation Informed decision making Post...


...Acute Limb Ischemia...

...igure 8. Algorithm for Diagnosis and Manage...

...Clinical Evaluation and Diagnostic Approach...

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

...In patients with suspected ALI, the i...

...ients with ALI who have a complicated...


...anagement of ALI...

....2.1. Revascularization...

...tients with ALI and a salvageable limb, rev...

...In patients with ALI and a salva...

...In patients presenting with ALI from chemo...

...patients with ALI with a nonsalvag...

....2.2. Adjunctive Therapies to Minimize Tissue Los...

...ients with ALI should be monitored and tre...

...s with ALI with a threatened but salvageable limb...

...In patients with ALI and prolonged i...

...2.3. Anticoagulation for ALI

...In patients with ALI, regardless of cause or...

.... Diagnostic Evaluation for the Cause of ALI...

In patients with ALI, a comprehensive...

...nts with ALI, testing for a cardiovascu...

...e 20. Underlying Causes of ALIHaving...

.... Longitudinal Follow-Up of P...

...ral Principles...

...ents with PAD, with or without revasculari...

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

...ctional Status an...

...with PAD, with or without revascularization,...

...dical Therapy...

...In patients with PAD, long-term use of GDMT to pr...

...scularization Follow-Up...

...patients with PAD who have undergone l...

In patients with PAD who have undergone l...

...tients with PAD who have undergone infrainguina...

...ts with PAD who have undergone endovascular proced...

...atients with PAD who have undergone infraingui...

...lehealth...

...ients with PAD, telehealth can be an alternative...