Management of Peripheral Arterial Disease

Initial Assessment and Diagnosis

The American College of Cardiology recommends performing a vascular review assessing for walking impairment, claudication, ischemic rest pain, and nonhealing wounds in patients with Peripheral Arterial Disease (PAD) 3, 1
A comprehensive pulse examination of all lower extremity pulses and direct foot inspection with shoes and socks removed is recommended for patients with PAD 3, 1
Measuring blood pressure in both arms to identify subclavian stenosis (difference >15-20 mmHg is significant) is recommended for patients with PAD 1
The ankle-brachial index (ABI) is the initial diagnostic test, with ABI ≤0.90 confirming PAD 1
If ABI is normal but clinical suspicion remains high, obtaining post-exercise ABI (>20% decrease is diagnostic) is recommended 1
For non-compressible vessels (ABI >1.40, common in diabetes), using toe-brachial index instead is recommended 1

The American College of Cardiology recommends clopidogrel 75 mg daily as the preferred antiplatelet agent to reduce MI, stroke, and vascular death in patients with PAD 2, 1
Statin therapy is mandatory for all PAD patients regardless of baseline cholesterol levels, according to the American College of Cardiology 2
Target blood pressure <140/90 mmHg in patients without diabetes and <130/80 mmHg in patients with diabetes or chronic kidney disease, as recommended by the American College of Cardiology 2
Beta-blockers are not contraindicated in PAD and are effective antihypertensive agents, according to the American College of Cardiology 2

Supervised exercise therapy is the initial treatment before considering revascularization for patients with intermittent claudication, as recommended by the American College of Cardiology 5, 2
Cilostazol should be considered for all patients with lifestyle-limiting claudication, according to the American College of Cardiology 5
Revascularization criteria include significant disability, completed comprehensive risk factor modification and antiplatelet therapy, and lesion anatomy with low procedural risk and high probability of success, as recommended by the American College of Cardiology 4, 3, 2
Endovascular intervention is the preferred revascularization technique for TASC type A iliac and femoropopliteal lesions, according to the American College of Cardiology 5

Follow-up at least annually to assess clinical status, medication adherence, limb symptoms, and cardiovascular risk factors is recommended for standard PAD patients, according to the American College of Cardiology 1, 2
Evaluate post-CLI patients at least twice annually by a vascular specialist due to high recurrence risk, as recommended by the American College of Cardiology 4, 3, 2
Long-term patency of infrainguinal bypass grafts should be evaluated in a surveillance program including interval vascular history, resting ABIs, physical examination, and duplex ultrasound at regular intervals, according to the American College of Cardiology 4