Management of Peripheral Artery Disease

Medical Therapy

The American College of Radiology recommends graduated compression stockings with a pressure of 20-30 mmHg for mild disease and 30-40 mmHg for more severe disease 1
Antiplatelet therapy (aspirin 75-325 mg daily or clopidogrel 75 mg daily) can be considered for patients with PAD 2, 3
Statin therapy should target LDL-C <70 mg/dL for patients at very high risk 2
Antihypertensive therapy should target BP <130/80 mmHg for patients with diabetes, and ACE inhibitors may be beneficial 2, 3
Target HbA1c <7% to reduce microvascular complications in patients with diabetes mellitus, as recommended by the American College of Cardiology 2, 3

A structured exercise program can improve circulation in patients with peripheral artery disease, as recommended by the American Heart Association 4
Supervised exercise programs can also be beneficial for patients with peripheral artery disease, according to the American Heart Association 4
For patients with peripheral artery disease and diabetes, the American Heart Association recommends biannual foot examinations 4
Smoking cessation, diabetes control, and management of hypertension and dyslipidemia are important for risk factor modification, as recommended by the American Diabetes Association 5, 6
All patients who smoke should be strongly advised to quit and offered pharmacotherapy (varenicline, bupropion, nicotine replacement) 2

The American Heart Association recommends urgent evaluation by a vascular specialist if signs of critical limb ischemia are present, such as rest pain, non-healing wounds, or gangrene 4
Revascularization should be performed when possible to minimize tissue loss in patients with critical limb ischemia, as recommended by the American Heart Association 4
For marginally or immediately threatened limbs, the American Heart Association recommends revascularization be performed emergently (within 6 hours) 4
For viable limbs, the American Heart Association recommends revascularization be performed on an urgent basis (within 6-24 hours) 4
Revascularization aims to restore direct flow to at least one foot artery, preferably the one supplying the affected area, in patients with inadequate perfusion (ABI <0.5 or ankle pressure <50 mmHg) 7
Both endovascular techniques and bypass surgery should be available for revascularization, with the decision between techniques made by a multidisciplinary team based on morphological distribution of PAD, availability of autogenous vein, patient comorbidities, and local expertise 7

Prompt diagnosis and treatment of foot infection can help avoid amputation in patients with peripheral artery disease, as recommended by the American Heart Association 4
The American College of Cardiology recommends a comprehensive approach to managing foot edema, including addressing the underlying cause and implementing interventions such as elevation, compression, diuretics, and addressing vascular insufficiency when present 8
Evaluate patients for cardiac causes of foot edema, such as heart failure, and look for signs of heart failure (dyspnea, orthopnea, jugular venous distention) 4
Rule out infection by checking for local pain/tenderness, erythema, warmth, purulent discharge, and evaluate for systemic signs of infection (fever, tachycardia) 4
Regular foot examination and education about foot care is recommended 9, 4
Evaluate for PAD severity by measuring ankle-brachial index (ABI) and consider toe pressure measurements or transcutaneous oxygen pressure (TcPO2) in patients with diabetes mellitus and peripheral artery disease, as recommended by the American College of Cardiology 7
An Ankle-Brachial Pressure Index (ABPI) of 0.7 indicates significant peripheral arterial disease (PAD) that will impair wound healing, with a threshold of 0.9 considered abnormal and strongly suggesting PAD, as recommended by the International Working Group on the Diabetic Foot (IWGDF) guidelines 7, 10

Debride necrotic tissue and surrounding callus 5
Select dressings to control excess exudation and maintain moist environment 5
Consider negative pressure wound therapy for post-operative wounds 8
Regular debridement of necrotic tissue and surrounding callus, appropriate dressings to control exudate and maintain moist environment, and considering negative pressure wound therapy for post-operative wounds, as recommended by the Wound, Ostomy and Continence Nurses Society 5
Use non-removable knee-high offloading devices (total contact cast) for plantar ulcers and appropriate footwear modifications for non-plantar ulcers, as suggested by the American Podiatric Medical Association 5

Treatment should involve vascular specialists, podiatrists, and wound care specialists, and when feasible, revascularization should target the artery supplying the anatomical region of the wound, as suggested by the Society for Vascular Surgery and the International Working Group on the Diabetic Foot (IWGDF) 7, 10
A multidisciplinary team approach is essential for optimal management of diabetic foot ulcers, according to the American College of Cardiology and the International Working Group on the Diabetic Foot (IWGDF) 7, 10
Proper foot care education is essential for patients with diabetes mellitus and peripheral artery disease 11, 2, 3

Regularly assess edema severity and response to treatment 4
Monitor for complications (skin breakdown, infection) 4
Adjust therapy based on response 4
For patients with PAD and diabetes, biannual foot examination by a clinician is recommended 4
Regular evaluation by a multidisciplinary team, reassessment of perfusion if wound healing is poor, and long-term measures to prevent recurrence due to high recurrence rates of diabetic foot ulcers, as recommended by the American College of Cardiology 7, 10