Population: Adults with lower extremity peripheral arterial disease (PAD).
Organizations
NICE 2020, ACC/AHA 2016
Recommendations
–If history or physical examination suggest PAD (most common initial symptom: intermittent claudication), use the resting ankle-brachial index (ABI) to establish the diagnosis.
• Ensure patient is resting and supine while obtaining systolic blood pressures of brachial arteries, posterior tibialis artery, dorsal pedal artery, and peroneal arteries. If a wave exists, consider using a Doppler probe to determine type of velocity wave form (triphasic, biphasic, or monophasic).
• Report resting ABI results as abnormal (ABI ≤ 0.90), borderline (ABI 0.91–0.99), normal (1.00–1.40), or noncompressible (ABI > 1.40).
–Measure toe-brachial index (TBI) to diagnose patients with suspected PAD when the ABI >1.40 (noncompressible).
–As the ABI in longstanding T2DM may be normal or elevated due to systemic hardening of the arteries, consider imaging if clinically concerned.
–Use duplex ultrasound of the lower extremities to diagnose anatomic location and severity of stenosis for patients with symptomatic PAD if revascularization is being considered. If nondiagnostic, use MRA. If MRA is contraindicated, use CTA.
–Counsel patients with PAD and diabetes mellitus about self–foot examination and healthy foot behaviors.
–Use antiplatelet therapy with aspirin alone (range 75–325 mg/d) or clopidogrel alone (75 mg/d), smoking cessation, a statin, and good glycemic control to reduce MI, stroke, and vascular death in patients with symptomatic PAD.
–Use cilostazol to improve symptoms and increase walking distance in patients with claudication.
–Recommend a supervised exercise program for patients with claudication to improve functional status and quality of life and to reduce leg symptoms. A supervised program should involve 120 min of supervised exercise a week for at least 3 mo. The exercise should reach a point of maximal reproduced pain.
–Refer to angioplasty if the exercise program is nonsatisfactory and modifiable risk factors are addressed but nonsatisfactory for symptoms. Endovascular procedures are effective as a revascularization option for patients with lifestyle-limiting claudication and hemodynamically significant aortoiliac occlusive disease.
–Endovascular procedures establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene.
–In patients with critical limb ischemia, perform revascularization when possible and construct bypass to the popliteal or infrapopliteal arteries (ie, tibial, pedal) with suitable autogenous vein. Critical limb ischemia shows diminished circulation, ischemic pain, ulceration, tissue loss, or gangrene. 20% of critical limb ischemia goes onto amputation.
–In patients with acute limb ischemia (ALI), give systemic anticoagulation with heparin immediately unless contraindicated.
–Monitor and treat patients with ALI (eg, fasciotomy) for compartment syndrome after revascularization.
–Perform amputation as the first procedure in patients with a nonsalvageable limb.
Practice Pearls
• Recommend bare metal stents when stenting people with intermittent claudication.
• Prefer autologous vein bypass when possible for infrainguinal bypass surgery.
• Prefer bypass surgery over stenting for aortoiliac or femoropopliteal stenosis causing intermittent claudication or critical limb ischemia.
• Stenting is an option for complete aortoiliac occlusion.
Sources
–NICE guidelines CG147. Peripheral arterial disease: diagnosis and management. Updated 11 December 2020.
–2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease: executive summary. Circulation. 2017;135:e686-e725.