Perspective:

The following are 10 points to remember about this guideline update:

1. This focused update of the ACCF/AHA Guideline for the Management of Patients With Peripheral Artery Disease (PAD), originally published in 2005, contains a number of additions or changes. It is important to notice what has not changed, however. In spite of 6 years having passed since the guideline publication, there are no new recommendations regarding procedural or medical therapy to improve symptoms of PAD, nor any new recommendations regarding therapy for renal artery stenosis.

2. In the area of noninvasive testing, the focused update now includes a recommended definition and interpretation of ankle-brachial index (ABI). The focused update guidelines now specify that ABI interpretation should be uniform, as follows: >1.40 is “noncompressible”; ABI between 1.00 and 1.40 is “normal”; 0.91 to 0.99 is “borderline”; and values less than 0.90 are “abnormal.” The importance of this change is the recommendation of uniformity, but also the recognition that values between 0.90 and 1.00 identify a group that is clearly not normal. Published data show that patients with values in this range have worse outcomes than those falling clearly in the normal range.

3. The level of evidence cited in support of a Class I recommendation for using screening ABI to establish the diagnosis of PAD in patients with symptoms or at high risk for PAD, was raised from C to B.

4. In the area of smoking cessation, new Class I recommendations include a statement that all smokers or former smokers should be asked about their smoking status at every visit, and that smokers should be assisted with counseling and the development of a quit-smoking treatment plan. This recommendation not only follows evidence of efficacy with regard to intervention by care providers at office visits, but also reflects the increasing prevalence of quality of care metrics, which evaluate providers based on the documentation of such efforts.

5. Another new Class I recommendation is that pharmacological therapy, with varenicline, bupropion, or nicotine replacement therapy, should be offered to all smokers. This recommendation clearly recognizes the efficacy of these agents in clinical trials.

6. In the area of antiplatelet therapy, a new Class IIa recommendation states that antiplatelet therapy “can be useful” in patients with abnormal ABI who are currently asymptomatic, with a level of evidence C. There are also two new Class IIb recommendations suggesting it is unclear whether or not to recommend antiplatelet therapy for patients with borderline ABI (0.91-0.99), or whether to recommend the combination of aspirin and clopidogrel for patients with symptomatic PAD.

7. In the area of critical limb ischemia, there are two new Class IIa recommendations. These suggest that both endovascular and surgical revascularization (with a vein conduit) are reasonable as initial procedures for critical limb ischemia. This recommendation clearly reflects the data and current clinical practice at most centers, suggesting that both limb and mortality outcomes are similar between the two approaches.

8. In the area of abdominal aortic aneurysm treatment, the level of evidence was increased from B to A for the Class I recommendations that open or endovascular repair are both indicated for infrarenal abdominal aortic aneurysm, and that periodic long-term surveillance imaging should be performed after endovascular repair.

9. A new Class IIa recommendation suggests that open repair is reasonable in patients who cannot comply with long-term surveillance after endovascular repair. This recommendation has level of evidence C, and reflects the clinical inclination not to perform repair endovascularly when follow-up imaging is not feasible.

10. The guidelines also now suggest that endovascular repair for abdominal aortic aneurysm is of “uncertain effectiveness” in patients at high surgical risk (level of evidence: B).