Guidelines for Atherosclerotic Occlusive Disease of the Lower Extremities | Ten Points to Remember
- Conte MS, Pomposelli FB, Clair DG, et al., on behalf of the Society for Vascular Surgery Lower Extremity Guidelines Writing Group.
- Society for Vascular Surgery Practice Guidelines for Atherosclerotic Occlusive Disease of the Lower Extremities: Management of Asymptomatic Disease and Claudication. J Vasc Surg 2015;61:2S-41S.
The following are 10 points to remember from this Society for Vascular Surgery guideline statement for management of patients with asymptomatic or claudication related to atherosclerotic lower extremity peripheral arterial disease (PAD):
- PAD is growing in prevalence, increasing health care resources. Rates of PAD intervention have been steadily rising for years. Use of the ankle-brachial index (ABI) as a first-line test for diagnosis is recommended. Anatomic imaging is recommended for symptomatic patients in whom revascularization treatment is being considered.
- The management of PAD is multidisciplinary, involving primary care providers and vascular specialists with a variety of expertise in the diagnoses and management of PAD.
- In patients with asymptomatic PAD, emphasis is placed on risk factor modification (including tobacco cessation), medical therapies, and broader use of exercise programs to improve cardiovascular health and functional performance for patients with PAD.
- Medical therapy for patients with intermittent claudication includes statin therapy, optimal diabetes control (hemoglobin A1c <7.0%), and aspirin therapy. The use of a beta-blocker, when otherwise indicated (e.g., hypertension or coronary arterial disease), is appropriate. A 3-month trial of cilostazol is appropriate for patients with intermittent claudication who do not have congestive heart failure. Use of ramipril is also reasonable to improve pain-free and maximal walking times.
- A supervised exercise program or home-based exercise program of at least 30 minutes of walking 3-5 times weekly is recommended for patients with intermittent claudication.
- Revascularization for intermittent claudication is appropriate for selected patients with disabling symptoms. However, careful risk-benefit analysis is needed to individualize decision making for patients based on comorbidities, degree of functional impairment, and anatomic factors. A minimum threshold of >50% likelihood of sustained efficacy for at least 2 years is suggested for invasive therapy in patients with intermittent claudication.
- Endovascular approaches are favored for most candidates with aortoiliac disease. Endovascular approaches are appropriate for select patients with femoropopliteal disease in whom anatomic durability is expected, but caution is warranted when anatomic durability is limited (e.g., extensive calcification, small-caliber arteries, diffuse infrainguinal disease, poor runoff).
- Surgical bypass may be a preferred strategy in acceptable risk patients with disease patterns that portend poor anatomic patency prognosis with endovascular approaches.
- Common femoral arterial disease should be treated surgically, preferably with the saphenous vein as a conduit.
- Patients who undergo invasive treatment for intermittent claudication should be monitored regularly in a surveillance program. This program should record symptoms, assess risk factors, optimize cardioprotective medications, and monitor hemodynamic/patency status.
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