Management of Leg Swelling Due to Arterial Atherosclerosis

Assessment and Diagnosis

• The American College of Cardiology recommends a comprehensive vascular examination and inspection of the legs and feet to assess the severity of the condition 1
• The European Society of Cardiology indicates that ankle-brachial index (ABI) testing is a first-line non-invasive test for diagnosis of lower extremity arterial disease (LEAD), and if ankle arteries are incompressible or ABI >1.40, alternative methods such as toe-brachial index, Doppler waveform analysis, or pulse volume recording should be used 2
• Duplex ultrasound (DUS) is indicated as a first-line imaging method to confirm arterial lesions, and further anatomical characterization with DUS, CT angiography (CTA), or MR angiography (MRA) is indicated to guide optimal revascularization strategy 2

Medical Management

• The European Society of Cardiology recommends statins to improve walking distance in patients with intermittent claudication, with a strength of evidence based on multiple clinical trials 2, 3
• Optimal glycemic control is recommended for patients with diabetes, as part of a comprehensive medical management plan 2, 3

Exercise Therapy

• The European Society of Cardiology strongly recommends supervised exercise training for patients with intermittent claudication, with a minimum of 3 hours per week, involving walking to maximal or submaximal distance, and resulting in improved maximal walking distance by almost 5 minutes compared to usual care 2, 4
• Exercise therapy increases pain-free and maximal walking distance by 82 and 109 meters respectively, and should last at least 3 months 4

Revascularization Options

• Revascularization should be considered when daily life activities are compromised despite exercise therapy, and for limb salvage in chronic limb-threatening ischemia (CLTI), revascularization is indicated whenever feasible 2, 3, 5
• An endovascular-first strategy is recommended for short (<5 cm) occlusive lesions in the aorto-iliac region, and for short (<25 cm) lesions in the femoro-popliteal region 2, 5
• Bypass surgery using autologous saphenous vein is indicated for long (≥25 cm) superficial femoral artery lesions, when the vein is available and life expectancy is >2 years 2, 5
• Drug-eluting treatment should be considered as first-choice strategy for femoro-popliteal lesions 7

Special Considerations

• Early recognition of tissue loss and/or infection with referral to a vascular team is mandatory to improve limb salvage, and heparin and analgesics should be administered as soon as possible in acute limb ischemia 2, 3, 6
• Post-revascularization, monitor for compartment syndrome and treat with fasciotomy if needed, and regular follow-up is essential to ensure perfusion improvement, address cardiovascular risk factors, and evaluate functional capacity 7, 8

Important Pitfalls to Avoid

• Stem cell/gene therapy is not indicated for patients with CLTI, and routine revascularization is not recommended solely to prevent progression to CLTI 2, 3, 7
• Revascularization is not recommended in asymptomatic patients, and do not delay treatment in acute limb ischemia with neurological deficit; urgent intervention is required 6, 7
• Avoid missing concurrent atherosclerotic disease in other vascular beds, as multisite artery disease is common in patients with atherosclerosis 6