Society for Vascular Surgery Guidelines for Peripheral Artery Disease Management | Ten Points to Remember
- Pomposelli FB, Clair DG, Geraghty PJ, 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 Society for Vascular Surgery has published a guideline statement regarding the management of patients with asymptomatic peripheral arterial disease (PAD) and claudication. The following are 10 key points from the guideline statement:
- An estimated 8-12 million Americans are affected by PAD. PAD is closely associated with age, with a prevalence range of 0.9%-14.5% in patients ages 40-49 to >69 years. The prevalence of PAD is expected to increase as the population ages; smoking status persists; and the prevalence of diabetes, hypertension, and obesity grow.
- Evidence of underlying PAD may exist in the absence of symptoms (asymptomatic disease). Symptomatic PAD may present as intermittent claudication or with signs/symptoms of limb-threatening ischemia (critical limb ischemia). Intermittent claudication is defined as a reproducible discomfort in a specific muscle group induced by exercise and relieved with rest. Many other “atypical” leg symptoms can mimic intermittent claudication. In contrast to intermittent claudication from PAD, neurogenic claudication symptoms are often of a radiating nature, starting at the hips or buttocks and extending down the affected leg. Additionally, radicular pain is often elicited by any weight bearing or changes in posture (e.g., rising from a seated position) and relieve with sitting or lumbar flexion.
- The diagnosis of PAD is primarily achieved through the ankle-brachial index (ABI). An ABI ≤0.90 has a high sensitivity and specificity for PAD when compared to invasive angiography. An ABI ≥1.4 is suggestive of noncompressible, calcified arteries, and should be followed up with a toe-brachial index (TBI). A TBI ≤0.7 is indicative of significant PAD. In the setting of convincing symptoms but normal resting ABIs, a repeat ABI following exercise can identify significant PAD. An ABI of >1.4 or <0.9 is associated with an increased risk of major cardiovascular events, beyond traditional risk scores (e.g., Framingham).
- In symptomatic patients who are being considered for revascularization, use of physiologic noninvasive studies (e.g., segmental pressures and pulse volume recordings) are recommended to help quantify the arterial insufficiency and to localize the level of obstruction. Similarly, anatomic imaging studies (e.g., arterial duplex ultrasound, computed tomography angiography, magnetic resonance angiography, and invasive angiography) are recommended.
- Management of asymptomatic PAD should focus on risk factor modification. This includes tobacco cessation and education about the signs and symptoms of PAD progression. There is not adequate evidence to recommend for the use of antiplatelet therapy or statin medications in asymptomatic PAD patients. The guidelines recommend against the use of invasive treatments for asymptomatic PAD patients, regardless of the hemodynamic measurements of imaging findings.
- Management of PAD patients with intermittent claudication should focus both on risk factor modification and quality of life optimization. Risk factor modification includes tobacco cessation, use of statin therapy, optimizing diabetes control (goal glycated hemoglobin <7.0%), use of beta-blockers when otherwise indicated (e.g., hypertension and coronary artery disease management), and aspirin therapy (81-325 mg). Pharmacologic quality of life treatments may include cilostazole (100 mg twice daily in patients without a history of heart failure), pentoxifylline (400 mg three times daily in patients with a contraindication to cilostazole), and ramipril (10 mg daily).
- Exercise therapy is central to the quality of life treatment for PAD patients. Use of a supervised exercise program is first-line therapy. Home-based exercise with a goal of 30 minutes walking 3-4 times per week is a viable alternative when supervised exercise is not available. Exercise therapy is recommended even in patients who have undergone revascularization therapy. Yearly ABI testing may be of value to provide objective evidence of disease progression.
- Endovascular interventions are preferred over open surgery for focal aortoiliac disease, common iliac arterial disease, or external iliac arterial disease causing intermittent claudication. The use of covered stents or bare-metal stents is recommended. Patients with diffuse aortoiliac disease may benefit from either endovascular therapy or open surgical revascularization. Assessment and revascularization of common femoral arterial disease is recommended when present.
- Endovascular intervention is recommended over open surgery for focal occlusive disease of the superficial femoral artery. Use of stenting in superficial femoral arterial disease should be reserved for unsatisfactory results of focal lesions (<5 cm) or intermediate-length lesions (5-15 cm). Endovascular therapy is not advised for isolated infrapopliteal disease associated with intermittent claudication.
- All patients undergoing endovascular or open surgical intervention for claudication should receive optimal medical therapy. Use of antiplatelet therapy (aspirin and clopidogrel) is necessary for at least 30 days in endovascular patients. All patients undergoing peripheral arterial revascularization should receive antiplatelet therapy (aspirin, clopidogrel, or both).
Keywords: Peripheral Arterial Disease, Peripheral Vascular Diseases, Ankle Brachial Index, Intermittent Claudication, Asymptomatic Diseases, Disease Progression, Exercise Therapy, Femoral Artery, Heart Failure, Hemodynamics, Magnetic Resonance Angiography, Stents, Hypertension, Quality of Life, Prevalence, Risk Factors, Smoking, Diabetes Mellitus, Ticlopidine, Aspirin, Leg
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