Chronic Arterial Occlusive Disease Management

Evaluation and Diagnosis

The American College of Radiology recommends initial evaluation to include measurement of the ankle-brachial index (ABI) and pulse volume recording (PVR) for diagnosis and follow-up of patients with chronic limb ischemia 1, 3
Duplex Doppler ultrasound of the lower extremities is highly recommended (score 8/9) as an initial study to evaluate arterial occlusive disease 3
Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) of the pelvis with runoff is indicated (score 7/9) to determine the anatomical location of the disease and plan revascularization if necessary 1, 3

The American College of Radiology recommends analysis of risk factors and lipid profile (score 9/9) in all patients 3
Statin use is recommended in all patients with chronic arterial occlusive disease, regardless of lipid profile results 2, 4
Control of comorbidities such as diabetes, hypertension, and hyperlipidemia should be an integral part of treatment 2
Smoking cessation is fundamental in the management of these patients 5

Optimal medical therapy that includes a supervised exercise program is highly recommended (score 9/9) as initial treatment 3, 6
Studies demonstrate that supervised exercise programs can be superior to primary stenting in improving walking performance at 6 months in patients with aortoiliac peripheral artery disease 5
The IRONIC study showed that at 5 years, revascularization lost its early benefit and there was no long-term improvement in quality of life or walking ability compared to a non-invasive treatment strategy 2

The American College of Cardiology recommends the use of aspirin (75-325 mg/day) in all patients with symptomatic peripheral artery disease to reduce the risk of major adverse cardiac events 2, 4
Clopidogrel (75 mg/day) is recommended as an alternative in patients with aspirin intolerance 4, 7
Cilostazol has been shown to be an effective therapy for improving walking distance in patients with intermittent claudication 2

Revascularization should be considered when optimal medical therapy and supervised exercise programs do not control symptoms or in cases of critical limb ischemia 2
Revascularization options include:

Annual clinical follow-up is recommended to evaluate symptoms, changes in functional status, adherence to lifestyle and medical interventions, and monitoring of complications 8
Periodic evaluation should include measurement of ABI and assessment of disease progression 1
In patients with worsening symptoms, stress imaging or invasive coronary angiography with functional tests should be considered 4

In patients with chronic arterial occlusive disease and atrial fibrillation who require anticoagulation, the use of direct oral anticoagulants (DOACs) is recommended instead of vitamin K antagonists 4, 7
Concomitant use of proton pump inhibitors is recommended in patients receiving monotherapy with aspirin, dual antiplatelet therapy, or monotherapy with oral anticoagulants who have a high risk of gastrointestinal bleeding 4, 7