Management of Severe Peripheral Artery Disease
Diagnostic Approach
- The American Heart Association and American College of Cardiology recommend anatomic imaging, such as duplex ultrasound, CTA, or MRA, to plan urgent revascularization in patients with an ABI <0.4, indicating severe peripheral artery disease with critical limb ischemia 1, 2
- An ABI <0.4 represents severe arterial insufficiency and typically indicates critical limb ischemia, which carries a high risk for limb loss without intervention, according to the American College of Cardiology 1, 2
- The 2016 AHA/ACC guidelines provide three first-line options for anatomic imaging: duplex ultrasound, CTA, and MRA, with the choice depending on patient factors and institutional availability, as recommended by the American College of Cardiology 1, 2, 3
Perfusion Assessment
- Additional perfusion measures, such as toe-brachial index (TBI) with waveforms, transcutaneous oxygen pressure (TcPO2), and skin perfusion pressure (SPP), should be obtained to assess local tissue viability and predict wound healing potential in patients with nonhealing wounds or gangrene, as suggested by the American College of Cardiology 2, 3
- A TBI <0.70 confirms PAD in noncompressible vessels, while TcPO2 values >30 mm Hg predict ulcer healing, and SPP values ≥30-50 mm Hg are associated with wound healing, according to the American College of Cardiology 2, 3
Revascularization Planning
- Invasive angiography is indicated when revascularization is being considered for patients with critical limb ischemia, which an ABI <0.4 typically represents, as recommended by the American Heart Association and American College of Cardiology 1, 2
- The urgency and approach to revascularization depend on clinical presentation, with rest pain, nonhealing wounds, or gangrene requiring urgent vascular surgery or interventional radiology consultation, according to the American College of Cardiology 1, 2