2011 ACCF/AHA Focused Update of the

Management of Patients With Peripheral

Artery Disease Guideline
(Updating the 2005 Guideline)

Developed in Collaboration With the Society for Cardiovascular Angiography and

Interventions, Society of Interventional Radiology, Society of Vascular Medicine and
Society for Vascular Surgery

© American College of Cardiology Foundation and American Heart Association, Inc.

 Citation
This slide set was adapted from the 2011 ACCF/AHA
Focused Update of the Guideline for the Management of
Patients With Peripheral Artery Disease
(Journal of the American College of Cardiology).
Published online September 29, 2011, ahead of print at:
http://content.onlinejacc.org/cgi/content/full/j.jacc.2011.08.023
The 2005 full-text guidelines are also available on the following
Web sites:
ACC (www.cardiosource.org) and AHA (my.americanheart.org)
 Special Thanks to:
Slide Set Editor
Alan T. Hirsch, MD, FACC
The 2011 Peripheral Artery Disease Focused Update Writing Committee
Members:

Thom W. Rooke, MD, FACC, Chair
Alan T. Hirsch, MD, FACC, Vice Chair
Sanjay Misra, MD, Vice Chair
Anton N. Sidawy, MD, MPH, FACS, Vice Chair
Joshua A. Beckman, MD, FACC, FAHA
Laura K. Findeiss, MD
Jafar Golzarian, MD
Heather L. Gornik, MD, FACC, FAHA
Jonathan L. Halperin, MD, FACC, FAHA
Michael R. Jaff, DO, FACC
Gregory L. Moneta, MD, FACS
Jeffrey W. Olin, DO, FACC, FAHA
James C. Stanley, MD, FACS
Christopher J. White, MD, FACC, FAHA, FSCAI
John V. White, MD, FACS
R. Eugene Zierler, MD, FACS
Classification of Recommendations and Levels of Evidence
A recommendation with
Level of Evidence B or C
does not imply that the
recommendation is weak.
Many important clinical
questions addressed in
the guidelines do not lend
themselves to clinical
trials. Although
randomized trials are
unavailable, there may be
a very clear clinical
consensus that a
particular test or therapy
is useful or effective.

*Data available from

clinical trials or registries
about the usefulness/
efficacy in different
subpopulations, such as
sex, age, history of
diabetes, history of prior
myocardial infarction,
history of heart failure,
and prior aspirin use.

†For comparative
effectiveness
recommendations (Class I
and IIa; Level of Evidence
A and B only), studies
that support the use of
comparator verbs should
involve direct
comparisons of the
treatments or strategies
being evaluated.
Scope of the 2011 PAD Focused Update
• For each guideline, an annual review is performed to assess new
evidence that may be relevant to the management of patients with PAD.
• An update to the 2005 PAD guideline was deemed necessary for the
lower extremity PAD and abdominal aortic disease recommendations.
• There was inadequate new evidence to merit an update to the renal and
mesenteric artery disease sections.
• Although the specific recommendations for renal and mesenteric
disease did not change, the following observations were made:
– Medical RAS therapy: There have been no new pivotal trials that alter the medical
therapy recommendations for patients with renal artery disease.
– Endovascular RAS therapy: New studies support a more limited role for renal
revascularization. The ASTRAL study concluded that there were substantial risks but
inadequate benefit from renal artery revascularization in patients with atherosclerotic
RAS. This trial may have excluded patients who might have benefitted from
endovascular care. The ongoing CORAL trial will provide additional evidence relevant
to these recommendations in the near future.
Scope of the 2011 PAD Focused Update
• Methods of revascularization for renal disease:
– The 2005 recommendations remain current.
– The 2011 focused update of the guideline acknowledges the declining use of
surgical revascularization and the increasing use of catheter-based
revascularization for renal artery stenoses.
– New data support the equivalency of surgical and endovascular treatment, with
lower morbidity and mortality associated with endovascular treatment, but
higher patency rates with surgical treatment in those patients who survived for
at least 2 years after randomization.
– The writing group also notes that new data suggest that:
1) the efficacy of revascularization may be reduced in patients with branch
artery stenoses, and
2) patients undergoing renal artery bypass may do best when surgery is
performed in high-volume centers.
Guideline for the Management of Patients
with PAD

Ankle-Brachial Index, Toe-

Brachial Index, and Segmental
Pressure Examination
 Recommendations for ABI, Toe-Brachial
Index, and Segmental Pressure Examination

I IIa IIb III

The resting ABI should be used to establish the
lower extremity PAD diagnosis in patients with
suspected lower extremity PAD, defined as
MODIFIED
individuals with 1 or more of the following:
exertional leg symptoms, nonhealing wounds,
age ≥65 years, or ≥50 years with a history of
smoking or diabetes.
 Recommendations for ABI, Toe-Brachial
Index, and Segmental Pressure Examination

I IIa IIb III The ABI should be measured in both legs in all
new patients with PAD of any severity to confirm
the diagnosis of lower extremity PAD and
establish a baseline.
 Recommendations for ABI, Toe-Brachial
Index, and Segmental Pressure Examination

I IIa IIb III The toe-brachial index should be used to establish the
lower extremity PAD diagnosis in patients in whom
lower extremity PAD is clinically suspected but in whom
the ABI test is not reliable due to noncompressible
vessels (usually patients with long-standing diabetes or
advanced age).

I IIa IIb III Leg segmental pressure measurements are useful to

establish the lower extremity PAD diagnosis when
anatomic localization of lower extremity PAD is required
to create a therapeutic plan.
 Recommendations for ABI, Toe-Brachial
Index, and Segmental Pressure Examination

I IIa IIb III ABI results should be uniformly reported

with noncompressible values defined as
>1.40, normal values 1.00 to 1.40,
NEW borderline 0.91 to 0.99, and abnormal
≤0.90.
Guideline for the Management of Patients
with PAD

Smoking Cessation
Recommendations for Smoking Cessation

I IIa IIb III Patients who are smokers or former smokers

should be asked about status of tobacco use at
every visit.
NEW

I IIa IIb III

Patients should be assisted with counseling and
developing a plan for quitting that may include
pharmacotherapy and/or referral to a smoking
NEW cessation program.
Recommendations for Smoking Cessation
I IIa IIb III Individuals with lower extremity PAD who
smoke cigarettes or use other forms of tobacco
should be advised by each of their clinicians to stop
MODIFIED smoking and offered behavioral and
pharmacological treatment.

I IIa IIb III In the absence of contraindication or other

compelling clinical indication, 1 or more of the
following pharmacological therapies should be
NEW offered: varenicline, bupropion, and nicotine
replacement therapy.
Guideline for the Management of Patients
with PAD

Antiplatelet and Antithrombotic Drugs

 Recommendations for Antiplatelet and
Antithrombotic Drugs
I IIa IIb III Antiplatelet therapy is indicated to reduce the risk of MI, stroke,
and vascular death in individuals with symptomatic
atherosclerotic lower extremity PAD, including those with
intermittent claudication or CLI, prior lower extremity
MODIFIED revascularization (endovascular or surgical), or prior amputation
for lower extremity ischemia.

I IIa IIb III Aspirin, typically in daily doses of 75 to 325 mg, is recommended
as safe and effective antiplatelet therapy to reduce the risk of MI,
stroke, or vascular death in individuals with symptomatic
atherosclerotic lower extremity PAD, including those with
MODIFIED intermittent claudication or CLI, prior lower-extremity
revascularization (endovascular or surgical), or prior amputation
for lower-extremity ischemia.
 Recommendations for Antiplatelet and
Antithrombotic Drugs

I IIa IIb III Clopidogrel (75 mg per day) is recommended as a safe and
effective alternative antiplatelet therapy to aspirin to reduce
the risk of MI, ischemic stroke, or vascular death in
individuals with symptomatic atherosclerotic lower-extremity
MODIFIED PAD, including those with intermittent claudication or CLI,
prior lower-extremity revascularization (endovascular or
surgical), or prior amputation for lower-extremity ischemia.

I IIa IIb III Antiplatelet therapy can be useful to reduce the

risk of MI, stroke, or vascular death in
asymptomatic individuals with an ABI ≤0.90.
NEW
 Recommendations for Antiplatelet and
Antithrombotic Drugs
I IIa IIb III The usefulness of antiplatelet therapy to reduce the risk of MI,
stroke, or vascular death in asymptomatic individuals with
borderline abnormal ABI, defined as 0.91 to 0.99, is not well
NEW established.

I IIa IIb III The combination of aspirin and clopidogrel may be considered to
reduce the risk of cardiovascular events in patients with
symptomatic atherosclerotic lower-extremity PAD, including those
with intermittent claudication or CLI, prior lower-extremity
NEW revascularization (endovascular or surgical), or prior amputation
for lower-extremity ischemia and who are not at increased risk of
bleeding and who are at high perceived cardiovascular risk.
 Recommendations for Antiplatelet
and Antithrombotic Drugs

I IIa IIb III In the absence of any other proven indication for
warfarin, its addition to antiplatelet therapy to reduce
the risk of adverse cardiovascular ischemic events in
No Benefit individuals with atherosclerotic lower extremity PAD is
MODIFIED of no benefit and is potentially harmful due to
increased risk of major bleeding.
Guideline for the Management of Patients
with PAD

Critical Limb Ischemia:

Endovascular and Open Surgical
Treatment for Limb Salvage
 Recommendations for CLI: Endovascular and Open
Surgical Treatment for Limb Salvage

I IIa IIb III

If it is unclear whether hemodynamically significant
inflow disease exists, intra-arterial pressure
measurements across suprainguinal lesions should
be measured before and after the administration of
a vasodilator.
 Recommendations for CLI: Endovascular and
Open Surgical Treatment for Limb Salvage

I IIa IIb III For patients with limb-threatening lower extremity ischemia and
an estimated life expectancy of <2 years or in patients in whom
an autogenous vein conduit is not available, balloon angioplasty
is reasonable to perform when possible as the initial procedure
NEW to improve distal blood flow.

I IIa IIb III For patients with limb-threatening ischemia and an

estimated life expectancy of >2 years, bypass surgery,
when possible and when an autogenous vein conduit is
available, is reasonable to perform as the initial treatment
NEW to improve distal blood flow.
Guideline for the Management of Patients
with PAD

Management of Abdominal
Aortic Aneurysm
Recommendations for Management of Abdominal
Aortic Aneurysm
I IIa IIb III Open or endovascular repair of infrarenal AAAs and/or
common iliac aneurysms is indicated in patients who
are good surgical candidates.
MODIFIED

I IIa IIb III Periodic long-term surveillance imaging should be

performed to monitor for endoleak, confirm graft
position, document shrinkage or stability of the
excluded aneurysm sac, and determine the need for
MODIFIED
further intervention in patients who have undergone
endovascular repair of infrarenal aortic and/or iliac
aneurysms.
 Recommendations for Management of
Abdominal Aortic Aneurysm
I IIa IIb III Open aneurysm repair is reasonable to perform in
patients who are good surgical candidates but who
cannot comply with the periodic long-term surveillance
required after endovascular repair.
NEW

I IIa IIb III Endovascular repair of infrarenal aortic aneurysms in

patients who are at high surgical or anesthetic risk as
determined by the presence of coexisting severe
NEW cardiac, pulmonary, and/or renal disease is of
uncertain effectiveness.
 2011 PAD Focused Update
Summary
• Clinicians should proactively identify individuals with lower
extremity PAD, using age and risk factor tools.
• Cardiovascular ischemic risk can be lowered by smoking
cessation, antiplatelet therapies, and targeted risk factor
management.
• Both endovascular and open surgical revascularization are
indicated for individuals with CLI, based on patient age,
prognosis, and other individual factors.
• Both endovascular and open surgical revascularization are
indicated for individuals with AAA, based on patient anatomy,
cardiovascular procedural risk, and adherence to follow-up
recommendations.
 Additional Tools
• Clinicians should be familiar with the recommendations of the
2005 PAD guideline, as most have not changed. This
guideline is available at:
http://content.onlinejacc.org/cgi/content/full/47/6/e1
• Clinicians should be familiar with the 2010 PAD Performance
Measures, which identify key clinical recommendations, and
highlight measurable and achievable outcomes. This
document is available at:
http://content.onlinejacc.org/cgi/content/full/j.jacc.2010.08.606
• Two relevant AHA Scientific Statements are anticipated for
publication in 2011:
– The Measurement and Interpretation of the Ankle-Brachial Index
– PAD in Women: A Call to Action