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

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Peripheral arterial disease

Prevention and Screening

Diagnosis

Hospitalization

Management consultation

Patient education and follow-up

Home

Therapy

Lifestyle modifications

  • Smoking cessation may reduce progression of PAD. Inform patients that continuing to smoke increases their risk of death and amputation, as well as graft failure after surgery.

  • Exercise—specifically, walking for 30-40 minutes, stopping as necessary, four to five times a week—improves muscle efficiency for patients with mild to moderate PAD and alters the pain threshold for distance traveled. The best results are associated with a motivated patient on a treadmill in a supervised setting. Although such exercise programs are more effective and significantly less expensive than drug therapy or surgery, many patients stop the regimen once out of structured supervision. Exercise therapy is currently not reimbursed by major insurers for PAD but is for cardiac rehabilitation.

  • TreadmillRecommend patients consume a heart-healthy diet to alter lipid profiles and thus reduce PAD risk. Such a diet is low in saturated fats and high in fresh vegetables and fruits. Avoid deep-fried foods or foods with highly processed sugars such as corn syrup. Advise patients to eat frequent small meals as opposed to a few large meals. In a case-control study of patients with and without PAD, a “grazing” eating habit (many small meals) as compared with the typical three meals per day was associated with a reduction in PAD by approximately 50%.

  • Multivitamins, including B vitamins and folate, although not harmful, provide no benefit in reduction of cardiovascular events.

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Drug therapy

See chart, "Drug Treatment for PAD," from PIER's module on peripheral arterial disease.

Cilostazol, a phosphodiesterase inhibitor, is the most effective agent for treating claudication and usually improves ambulatory distance and time to fatigue by >50%. Recommended dosage is 100 mg twice daily. Cilostazol is costly, however, and it cannot be used by patients with a history of congestive heart failure. It should not replace diet, exercise and smoking cessation. An alternative for patients who cannot tolerate cilostazol is pentoxifylline. Most patients, however, will not experience symptomatic improvement with pentoxifylline. Data are accruing that prostaglandin agonists such as beraprost are not beneficial either.

Estrogen replacement therapy, vitamin E and chelation therapy are not effective therapies for claudication.

Prescribe a statin for secondary prevention in all patients with PAD, regardless of total cholesterol level. Target LDL cholesterol is less than 100 mg/dL. Statins have effects beyond that of direct cholesterol reduction, including anti-inflammatory and pro-endothelial effects, improving bypass graft patency, increasing ambulation distance, and perhaps even decreasing the risk of perioperative cardiac events. Use caution with stasis in those patients with liver disease. Consider additional drug therapy to reduce hypertriglyceridemia, such as niacin.

Antiplatelet therapy is also important for secondary prevention. It reduces the risk of myocardial infarction, stroke and vascular death (differential effect by gender). Use aspirin (81 mg/d) as a first-line antiplatelet agent for primary prevention of cardiovascular morbidity, and consider adding clopidogrel (75 mg/d) in symptomatic patients with PAD or as a substitute for aspirin in patients with aspirin intolerance.

Continue peri- and post-operative antiplatelet therapy after infrainguinal bypass graft to significantly reduce the risk of graft occlusion. Continue peri- and post-intervention clopidogrel after angioplasty and stenting.

Avoid warfarin, even for patients with severe PAD, because its significant bleeding risks are not outweighed by its clinical benefits, except in patients with documented hypercoagulable states.

Consider ACE inhibitors (angiotensin-converting-enzyme) for patients with PAD who have poorly controlled hypertension as it may have benefits that are independent of the antihypertensive effects. Although once contraindicated, β-blockers should be used routinely to reduce perioperative risk in patients with peripheral vascular disease undergoing surgery.

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Surgical and endovascular procedures

Recommend endovascular or surgical intervention to increase limb perfusion in cases of severe claudication, rest pain or tissue loss. Reserve such invasive procedures for patients who fail medical therapy, have severe disability and have approachable anatomic lesions for peripheral artery bypass or angioplasty/stenting. Deferring these interventions until medical therapy is exhausted is safe for most patients with claudication, and there is no evidence this increases the risk for limb loss.

arterial angioplasty


Arterial angioplasty



Since overall amputation-free survival is similar for the two therapies, in general, choose angioplasty over surgery based on local expertise, location of the diseased arteries and patient comorbidities. For best medical evidence, consult the TransAtlantic Inter-Society Consensus (TASC) and AHA/ACC guidelines on intervention decision making. Although endovascular interventions are less invasive, their durability has not been rigorously evaluated. Base a recommendation about the type of intervention on these criteria:

Endovascular interventions. These include angioplasty with stenting, subintimal recanalization and atherectomy. Consider these if failure will not make the patient inoperable for a future bypass. More proximal artery lesions (e.g. iliac) have better patency rates and durability than more distal lesions (e.g. popliteal).

Surgical bypass. Consider bypass for long-segment occlusive disease that is not amenable to endovascular approaches. Patients with renal failure are at high risk for patency failure and have high short-term mortality. Keep in mind that advanced age, smoking, female gender and systemic hypertension are associated with worse outcomes for surgical bypass. Autologous tissue is a better conduit than prosthetic material in all situations.

After any intervention to improve limb perfusion, provide adjunctive wound care treatment to promote tissue healing, including the following:

  • elevation,
  • keeping the limb clean and dry,
  • local debridement of necrotic and infected tissue and application of saline wet-to-dry dressing changes,
  • hydrocolloid topical dressing,
  • topical antibiotic therapy,
  • IV antibiotics directed by tissue culture or biopsy, and
  • vacuum-assisted closure.

Provide long-term antiplatelet therapy (aspirin 81-325 mg daily) to patients who have undergone peripheral bypass surgery with prosthetic grafts. If aspirin-intolerant, consider clopidogrel. Avoid routinely prescribing warfarin alone, or in combination with aspirin, except for those patients at highest risk for bypass occlusion and limb loss.

For patients who have exhausted all potential interventions but who still have poor functional status, consider amputation of a nonfunctional and painful limb at the most distal site to preserve ambulation with a prosthesis. Contemplate amputation in these situations specifically for patients:

  • with severe dementia,
  • who have a very short life expectancy (of less than one year),
  • for whom there are no bypass or interventional options, and
  • who have no bypass or interventional options for limb salvage

Younger age and lack of vascular disease in the contralateral limb significantly correlates with greater postoperative autonomy and mobility. Similarly, better preoperative functional status correlates with better post operative outcomes.

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