Peripheral Arterial Disease Guidelines:

Management of Patients with Lower Extremity PAD

A Collaboration of the American College of Cardiology, the American Heart
Association, the American Association for Vascular Surgery/Society for
Vascular Surgery, Society for Cardiovascular Angiography and Interventions,
Society of Interventional Radiology, Society for Vascular Medicine and
Biology, and the PAD Coalition.
The PAD Coalition
SVMB
Why A PAD Guideline?
To enhance the quality of patient care
Increasing recognition of the importance of
atherosclerotic lower extremity PAD:
High prevalence
High cardiovascular risk
Poor quality of life
Improved ability to detect and treat renal artery
disease
Improved ability to detect and treat AAA
The evidence base has become increasingly robust,
so that a data-driven care guideline is now possible
Peripheral Arterial Disease Guideline:
The Target Audiences Are Diverse
Primary care clinicians
Family practice
Internal medicine
PA, NP, nurse clinicians
Cardiovascular/vascular medicine,
vascular surgical, & interventional
radiology trainees and vascular
specialists
This was not intended to be a procedural guideline;
it is intended to provide a guide to optimal lifelong PAD care.
Defining a Population At Risk
for Lower Extremity PAD
Age less than 50 years with diabetes, and one additional
risk factor (e.g., smoking, dyslipidemia, hypertension, or
hyperhomocysteinemia)
Age 50 to 69 years and history of smoking or diabetes
Age 70 years and older
Leg symptoms with exertion (suggestive of claudication)
or ischemic rest pain
Abnormal lower extremity pulse examination
Known atherosclerotic coronary, carotid, or renal artery
disease

The First Tool to Establish the PAD Diagnosis:
The HPI, ROS, and Physical Examination
Individuals with asymptomatic PAD should be
identified in order to offer therapeutic
interventions known to diminish their increased
risk of myocardial infarction, stroke, and death.
A history of walking impairment, claudication,
and ischemic rest pain is recommended as a
required component of a standard review of
systems for adults >50 years who have
atherosclerosis risk factors, or for adults >70
years.
The First Tool to Establish the PAD Diagnosis:
The HPI, ROS, and Physical Examination
Pulse intensity should be assessed and should be recorded
numerically as follows:
0, absent
1, diminished
2, normal
3, bounding


Use of a standard examination should
facilitate clinical communication
Individuals with PAD Present in Clinical
Practice with Distinct Syndromes
Asymptomatic: Without obvious symptomatic
complaint (but usually with a functional impairment).

Classic Claudication: Lower extremity symptoms
confined to the muscles with a consistent (reproducible)
onset with exercise and relief with rest.

Atypical leg pain: Lower extremity discomfort that is
exertional, but that does not consistently resolve with
rest, consistently limit exercise at a reproducible
distance, or meet all Rose questionnaire criteria.

This guideline recognizes that:
Individuals with PAD Present in Clinical Practice
with Distinct Syndromes
Critical Limb Ischemia: Ischemic rest pain, non-
healing wound, or gangrene

Acute limb ischemia: The five Ps, defined by the
clinical symptoms and signs that suggest
potential limb jeopardy:
Pain
Pulselessness
Pallor
Paresthesias
Paralysis (& polar, as a sixth p).
This guideline recognizes that:
Hemodynamic Noninvasive Tests
Resting Ankle-Brachial Index (ABI)

Exercise ABI

Segmental pressure examination

Pulse volume recordings
These traditional tests continue to provide a simple, risk-free,
and cost-effective approach to establishing the PAD diagnosis
as well as to follow PAD status after procedures.
Lower extremity systolic pressure
Brachial artery systolic pressure
ABI =
The ankle-brachial index is 95% sensitive and 99% specific for PAD
Establishes the PAD diagnosis
Identifies a population at high risk of CV ischemic events
Population at risk can be clinically & epidemiologically defined:
The Ankle-Brachial Index
Exertional leg symptoms, non-
healing wounds, age > 70, age > 50
years with a history of smoking or
diabetes.
Toe-brachial index (TBI) useful in
individuals with non-compressible pedal
pulses
Lijmer JG. Ultrasound Med Biol 1996;22:391-8; Feigelson HS. Am J Epidemiol 1994;140:526-34;
Baker JD. Surgery 1981;89:134-7; Ouriel K. Arch Surg 1982;117:1297-13; Carter SA. J Vasc Surg 2001;33:708-14
Exercise ABI
Confirms the PAD diagnosis

Assesses the functional severity of
claudication

May unmask PAD when resting the ABI
is normal
Arterial Duplex Ultrasound Testing
Duplex ultrasound of the extremities
is useful to diagnose anatomic
location and degree of stenosis of
peripheral arterial disease.

Duplex ultrasound is useful to
provide surveillance following
femoral-popliteal bypass using
venous conduit (but not prosthetic
grafts).

Duplex ultrasound of the extremities
can be used to select candidates for:
(a) endovascular intervention;
(b) surgical bypass, and
(c) to select the sites of surgical
anastomosis.
However, the data that
might support use of
duplex ultrasound to
assess long-term
patency of PTA is not
robust.
Noninvasive Imaging Tests
Duplex Ultrasound
Duplex ultrasound of the extremities is useful
to diagnose the anatomic location and degree
of stenosis of PAD.


Duplex ultrasound is recommended for routine
surveillance after femoral-popliteal or femoral-
tibial-pedal bypass with a venous conduit.
minimum surveillance intervals are
approximately 3,6, and 12 months, and then
yearly after graft placement.

MRA of the extremities is useful to diagnose
anatomic location and degree of stenosis of
PAD.

MRA of the extremities should be performed
with a gadolinium enhancement.

MRA of the extremities is useful in selecting
patients with lower extremity PAD as candidates
for endovascular intervention.
Magnetic Resonance Angiography (MRA)
Noninvasive Imaging Tests
Noninvasive Imaging Tests
CTA of the extremities may be considered
to diagnose anatomic location and
presence of significant stenosis in
patients with lower extremity PAD.


CTA of the extremities may be considered
as a substitute for MRA for those patients
with contraindications to MRA.


Computed Tomographic Angiography (CTA)
Natural History of PAD
Age > 50 years
Limb
Morbidity
Cardiovascular
Morbidity /
Mortality
Worsening
Claudication
10-20%
Critical
Limb
Ischemia
1-2%
Nonfatal
CV Events
20%
Mortality
15-30%
Stable
Claudication
70-80%
CV Causes
75%
Non CV Causes
25%
Lipid Lowering and Antihypertensive Therapy
Treatment with an HMG coenzyme-A reductase inhibitor
(statin) medication is indicated for all patients with
peripheral arterial disease to achieve a target LDL
cholesterol of less than 100 mg/dl.
Antihypertensive therapy should be administered to
hypertensive patients with lower extremity PAD to a goal
of less than 140/90 mmHg (non-diabetics) or less than
130/80 mm/Hg (diabetics and individuals with chronic
renal disease) to reduce the risk of myocardial infarction,
stroke, congestive heart failure, and cardiovascular
death.
Antiplatelet Therapy
Antiplatelet therapy is indicated to reduce the risk of
myocardial infarction, stroke, or vascular death in
individuals with atherosclerotic lower extremity PAD.
Aspirin, in daily doses of 75 to 325 mg, is recommended
as safe and effective antiplatelet therapy to reduce the
risk of myocardial infarction, stroke, or vascular death in
individuals with atherosclerotic lower extremity PAD.
Clopidogrel (75 mg per day) is recommended as an
effective alternative antiplatelet therapy to aspirin to
reduce the risk of myocardial infarction, stroke, or
vascular death in individuals with atherosclerotic lower
extremity PAD.
Supervised Exercise Rehabilitation
A program of supervised exercise training is
recommended as an initial treatment
modality for patients with intermittent
claudication.
Supervised exercise training should be
performed for a minimum of 30 to 45
minutes, in sessions performed at least
three times per week for a minimum of 12
weeks.
Pharmacotherapy of Claudication
Cilostazol (100 mg orally two times per
day) is indicated as an effective therapy
to improve symptoms and increase
walking distance in patients with lower
extremity PAD and intermittent
claudication (in the absence of heart
failure).
Endovascular procedures are indicated for
individuals with a vocational or lifestyle-
limiting disability due to intermittent
claudication when clinical features
suggest a reasonable likelihood of
symptomatic improvement with
endovascular intervention and

a. Response to exercise or pharmacologic
therapy is inadequate, and/or
b. there is a very favorable risk-benefit ratio
(e.g. focal aortoiliac occlusive disease)
Endovascular Treatment for Claudication
Endovascular intervention is recommended as
the preferred revascularization technique for
TASC type A iliac and femoropopliteal lesions.
TASC A:
(PTA recommended)
Iliac
Femoropopliteal
TASC B: (insufficient data to recommend)
Endovascular Treatment for Claudication
Provisional stent placement is indicated for
use in iliac arteries as salvage therapy for
suboptimal or failed result from balloon
dilation (e.g. persistent gradient, residual
diameter stenosis >50%, or flow-limiting
dissection).

Stenting is effective as primary therapy for
common iliac artery stenosis and
occlusions.

Stenting is effective as primary therapy in
external iliac artery stenosis and
occlusions.

Endovascular Treatment for Claudication:
Iliac Arteries
Endovascular intervention is not indicated if
there is no significant pressure gradient
across a stenosis despite flow
augmentation with vasodilators.


Primary stent placement is not
recommended in the femoral, popliteal, or
tibial arteries.


Endovascular intervention is not indicated
as prophylactic therapy in an asymptomatic
patient with lower extremity PAD.

Endovascular Treatment for Claudication
Surgery for Critical Limb Ischemia
Patients who have significant necrosis of the
weight-bearing portions of the foot, an
uncorrectable flexion contracture, paresis of the
extremity, refractory ischemic rest pain, sepsis,
or a very limited life expectancy due to co-
morbid conditions should be evaluated for
primary amputation.

Surgery is not indicated in patients with severe
decrements in limb perfusion in the absence of
clinical symptoms of critical limb ischemia.

Surgery for Critical Limb Ischemia
For individuals with combined inflow and
outflow disease with critical limb ischemia,
inflow lesions should be addressed first.


When surgery is to be undertaken, an aorto-
bifemoral bypass is recommended for patients
with symptomatic, hemodynamically
significant, aorto-bi-iliac disease requiring
intervention.
Surgery for Critical Limb Ischemia

Bypasses to the above-knee popliteal
artery should be constructed with autogenous
saphenous vein when possible.

Bypasses to the below-knee popliteal artery
should be constructed with autogenous vein
when possible.

Prosthetic material can be used effectively
for bypasses to the below knee popliteal
artery when no autogenous vein from ipsilateral
or contralateral leg or arm is available.

Surgery for Critical Limb Ischemia
Femoral-tibial artery bypasses should be
constructed with autogenous vein, including
ipsilateral greater saphenous vein, or if
unavailable, other sources of vein from the leg
or arm.

Composite sequential femoropopliteal-tibial
bypass, or bypass to an isolated popliteal
arterial segment that has collateral outflow to
the foot, are acceptable methods of
revascularization and should be considered
when no other form of bypass with adequate
autogenous conduit is possible.
Acute Limb Ischemia (ALI)
Patients with ALI and a salvageable
extremity should undergo an emergent
evaluation that defines the anatomic level of
occlusion, and that leads to prompt
endovascular or surgical intervention.

Patients with ALI and a non-viable extremity
should not undergo an evaluation to define
vascular anatomy or efforts to attempt
revascularization.

Population at risk is now defined by epidemiologic
criteria applied to practice.
ACC/AHA Guidelines for the Management of PAD:
Major Contributions to Improved Care Standards
Presentation-specific algorithms will expedite care (e.g.,
asx, atypical leg pain, classic claudication, critical limb
ischemia, & acute arterial occlusion).
Use of exercise, pharmacologic, endovascular, and
surgical interventions are emplaced in care as
defined by evidence.