American College of Physicians: Internal Medicine — Doctors for Adults ®


Peripheral arterial disease

Prevention and Screening



Management consultation

Patient education and follow-up



Some patients with PAD require hospitalization. Patients with acute critical limb ischemia need prompt revascularization or risk limb loss. Markers of acute limb ischemia are pain, poikilothermia, pulselessness, paralysis, paresthesias and pallor. Consider causes such as thromboembolism, thrombosis in situ, arterial dissection, peripheral aneurysm and trauma.

For limbs without development of arterial collaterals, acute arterial ischemia is associated with a high risk of limb loss if not promptly revascularized. Heparin is essential to decrease thrombus propagation in the setting of arterial embolic or thrombotic occlusion. In one retrospective study, patients with acute limb ischemia who were given heparin after embolectomy had a lower risk of amputation and death.

Heparin is essential to decrease thrombus propagation in the setting of arterial embolic or thrombotic occlusion.

Urgent amputation may be lifesaving if extremities are paralyzed or insensate, with fixed skin mottling and hard calf musculature. If the thrombosis is in a native artery, determine the level of ischemia and the viability of the distal limb then begin therapeutic anticoagulation and refer for possible surgical embolectomy or catheter-directed thrombolysis.

In the case of graft occlusion, usually due to local thrombosis, recommend rapid therapeutic anticoagulation with heparin. Obtain an urgent vascular surgery consultation for open or endovascular therapy. For spontaneous embolization, most commonly at aortic and femoral artery bifurcations, recommend embolectomy.

Admit patients with infectious complications of PAD, such as infected wounds requiring intravenous antibiotics and elevation, evidence of bacteremia or progressive tissue loss. Diabetic patients are at particular risk for severe foot infection. Normal renal function, palpable pedal pulses, and patent tibial arteries are factors associated with wound healing.

Complications are fairly common after both endovascular and surgical interventions, given the underlying nature of the atherosclerotic disease and associated comorbidities. Hospitalization may be needed to treat complications such as contrast nephropathy, symptomatic groin or arm hematoma, surgical wound infection, heart attack, stroke, pneumonia, or graft failure.

The need for readmission following an open operation for limb salvage is so common that patient counseling is recommended before the intervention occurs. In one prospective database study within the Veterans Affairs Medical Center, readmission after infrainguinal bypass occurred in 85% of patients over a four-year follow-up period.


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