AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery Disease

Authors:
Gerhard-Herman MD, Gornick HL, Barrett C, et al.
Citation:
2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016;Nov 13:[Epub ahead of print].

The following are key points to remember from this Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease (PAD):

  1. Patients at increased risk for PAD include patients aged ≥65 years, those with other risk factors for atherosclerosis (e.g., diabetes, any smoking history, hyperlipidemia, hypertension), a family history of PAD, or other known forms of atherosclerosis (e.g., coronary or carotid atherosclerosis, renal or mesenteric atherosclerosis, abdominal aortic aneurysms).
  2. In patients with possible PAD, a resting ankle-brachial index (ABI), with or without segmental pressures and waveforms, is recommended to establish a diagnosis. ABI readings (the higher of each arterial pressure in each limb) are categorized as abnormal (ABI ≤0.90), borderline (ABI 0.91-0.99), normal (ABI 1.00-1.40), or noncompressible (ABI >1.40).
  3. A toe-brachial index (TBI) should be measured to diagnose patients suspected of PAD when the resting ABI is >1.40. An exercise ABI should be performed in patients with exertional nonjoint-related leg symptoms and normal or borderline resting ABI (0.90-1.40).
  4. In patients suspected of having critical limb ischemia (CLI; e.g., rest pain, nonhealing wound, or gangrene), an anatomic study, such as duplex ultrasound, computed tomography angiogram, magnetic resonance angiogram, or invasive angiogram should be performed when arterial pressures are abnormal (ABI or TBI).
  5. Patients with symptomatic PAD should be initiated on antiplatelet therapy (aspirin 75-325 mg daily or clopidogrel 75 mg daily) and statin therapy, preferably atorvastatin 80 mg daily. Antihypertensive therapy, smoking cessation, and coordinated diabetes management should also be initiated.
  6. Use of cilostazol may improve symptoms and increase walking distance in patients with claudication. Cilostazole is contraindicated in patients with congestive heart failure. Pentoxifylline is not effective for treatment of claudication.
  7. Supervised exercise is recommended to improve functional status and quality of life as well as to reduce leg symptoms. This should be discussed prior to possible revascularization treatment options. Structured community-based or home-based exercise programs are an alternative to supervised exercise for patients with claudication.
  8. Revascularization is a reasonable treatment option for patients with lifestyle-limiting claudication and an inadequate response to medical management and exercise.
  9. Endovascular intervention is effective for patients with lifestyle-limiting claudication and hemodynamically significant aortoiliac occlusive disease (Class I) or femoropopliteal disease (Class IIa). Endovascular procedures should not be performed in patients with PAD solely to prevent progression to CLI (Class III: Harm).
  10. When surgical revascularization is performed, bypass to the popliteal artery with autogenous vein is recommended over prosthetic graft material. Femoral-tibial artery bypasses with prosthetic graft material should not be used to treat claudication (Class III: Harm). Surgical procedures should not be performed in patients with PAD solely to prevent progression to CLI (Class III: Harm).
  11. In patients with CLI, revascularization should be performed to minimize tissue loss. Evaluation should be performed by an interdisciplinary care team prior to amputation. Endovascular or surgical procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene.
  12. Patients with acute limb ischemia (ALI) should be emergently evaluated by a clinician experienced in assessing limb viability and revascularization techniques. Imaging is not necessary if clinical findings are highly suggestive of ALI. Instead, patients should proceed to revascularization and anticoagulation should be initiated. If the limb is found to be irreversible, then amputation should be performed.
  13. Patients with PAD should be followed periodically to assess cardiovascular risk factors, limb symptoms, functional status, and ABI testing.
  14. Clinical Topics: Anticoagulation Management, Cardiac Surgery, Diabetes and Cardiometabolic Disease, Clinical Topic Collection: Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Nonstatins, Novel Agents, Statins, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Computed Tomography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging, Exercise, Hypertension, Smoking

    Keywords: AHA Annual Scientific Sessions, Amputation, Aneurysm, Angiography, Ankle Brachial Index, Anticoagulants, Antihypertensive Agents, Aortic Diseases, Atherosclerosis, Blood Glucose, Critical Illness, Diagnostic Imaging, Diagnostic Techniques, Cardiovascular, Embolectomy, Endovascular Procedures, Exercise, Extremities, Fibrinolytic Agents, Functional Residual Capacity, Guideline, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hyperbaric Oxygenation, Hyperlipidemias, Hypertension, Intermittent Claudication, Ischemia, Life Style, Limb Salvage, Lower Extremity, Magnetic Resonance Angiography, Mass Screening, Motor Activity, Multidetector Computed Tomography, Myocardial Revascularization, Patient Care Team, Peripheral Arterial Disease, Peripheral Vascular Diseases, Platelet Aggregation Inhibitors, Primary Prevention, Quality of Life, Reperfusion, Risk Reduction Behavior, Self Care, Smoking, Surgical Procedures, Operative, Therapeutics, Thrombectomy, Thromboembolism, Tobacco, Ultrasonography, Vascular Diseases, Wounds and Injuries


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