Peripheral Arterial Occlusive Disease Guidelines

In July 2022, a guideline for diagnosis and management of peripheral arterial disease (PAD) in diabetes was published by the Australian Diabetes-Related Foot Disease Guidelines working group and an expert panel, with the authorization of Diabetes Feet Australia (DFA). ^[20] Guideline recommendations were adopted or adapted from International Working Group on the Diabetic Foot (IWGDF) guidelines.

Diagnosis

Clinically examine (eg, by relevant history and palpation of foot pulses) the feet of all diabetic patients annually for PAD, even in the absence of foot ulceration. Clinically examine all diabetic patients with foot ulceration for PAD.

Because clinical examination does not reliably exclude PAD in most diabetic persons with foot ulceration, evaluate pedal Doppler arterial waveforms, and measure ankle systolic pressure and systolic ankle-brachial index (ABI) or toe systolic pressure and toe-brachial index (TBI).

Prognosis

Perform at least one of the following bedside tests in a patient with a diabetes-related foot ulcer (DFU) and PAD: skin perfusion pressure (≥40 mm Hg), toe pressure (≥30 mm Hg), or transcutaneous oxygen pressure (TcPO₂; ≥25 mm Hg).

Use the WIfI (Wound, Ischemia, foot Infection) classification to stratify amputation risk and revascularization benefit in a patient with a DFU and PAD.

Always consider urgent vascular imaging and revascularization in a patient with a DFU and ankle pressure <  50 mm Hg, ABI <  0.5, toe pressure <  30 mm Hg, or TcPO2 <  25 mm Hg.

Always consider vascular imaging in patients with a DFU, regardless of bedside test results, when the ulcer is not healing within 4-6 weeks despite good care.

Always consider revascularization in a patient with a DFU and PAD, regardless of bedside test results, when the ulcer is not healing within 4-6 weeks despite optimal management.

Do not assume diabetes-related microangiopathy, when present, to be the cause of poor healing in patients with a DFU; always consider other possible causes.

Treatment

When considering lower-extremity revascularization, obtain anatomic information with color duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, or intra-arterial digital subtraction angiography. Evaluate the entire lower-extremity arterial circulation.

When performing revascularization in a patient with a DFU, aim to restore direct blood flow to at least one of the foot arteries (preferably the one supplying the anatomic region of the ulcer). After the procedure, objectively measure perfusion to evaluate its effectiveness.

Because it has not been established whether endovascular, open, or hybrid revascularization technique is superior, base the decision on individual factors (eg, morphologic distribution of PAD or availability of autogenous vein).

Any center treating patients with a DFU should have expertise in and/or rapid access to facilities necessary to diagnose and treat PAD (including both endovascular techniques and bypass surgery).

After revascularization in a patient with a DFU, ensure that the patient is treated by a multidisciplinary team as part of a comprehensive care plan.

Urgently assess and treat patients with signs or symptoms of PAD and a diabetes-related foot infection.

Avoid revascularization if, from the patient’s perspective, the risk-benefit ratio is unfavorable.

Provide intensive cardiovascular risk management for any patient with diabetes and an ischemic foot ulcer.

In May 2022, the Canadian Cardiovascular Society (CCS) published guidelines on the management of peripheral arterial disease (PAD). ^[19] Strong recommendations included the following.

Diagnosis and screening

Use an ankle-brachial index (ABI) and/or toe-brachial index (TBI) to confirm PAD in symptomatic patients.

A broad, population-based PAD screening strategy is not recommended for individuals without claudication signs/symptoms.

Management

Smoking cessation is recommended to prevent PAD, as well as to prevent major adverse cardiovascular (CV) events (MACE) and major adverse limb events (MALE) in those with PAD. Recommended smoking cessation interventions include but are not limited to intensive counseling; pharmacotherapy (eg, nicotine replacement therapy [NRT], bupropion, varenicline); and, occasionally, nicotine-containing e-cigarettes.

Offer a sodium-glucose cotransporter 2 inhibitor (SGLT-2I) to diabetic patients with PAD rather than usual diabetic control for MACE reduction without a rise in amputation risk.

Administer lipid-modifying therapy to patients with PAD to lower death and CV death, nonfatal myocardial infarction (MI) and nonfatal stroke (MACE), and MALE. Use the maximally tolerated statin therapy. Use statin add-on therapies (ezetimibe and/or proprotein convertase subtilisin/kexin-9 inhibitors [PCSK-9Is]) if, while on maximally tolerated statin therapy, the level of low-density lipoprotein cholesterol (LDL-C) is ≥1.8 mmol/L, of non-high-density lipoprotein cholesterol (non-HDL-C) is ≥2.4 mmol/L, or of apolipoprotein B100 is ≥0.7 mg/dL.

For those who have PAD on maximally tolerated statin therapy but have a triglyceride level of 1.5-5.6 mmol/L, consider using icosapent ethyl to reduce CV death, nonfatal MI, and nonfatal stroke.

Unless there are contraindications, first-line treatment of hypertension in PAD consists of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs).

Routine antithrombotic therapy (antiplatelet or anticoagulant) is not recommended for those with isolated asymptomatic lower extremity (LE) PAD.

For patients with symptomatic LE PAD and who are:

• At high risk for ischemic events (high-risk comorbidities [eg, polyvascular disease, diabetes, heart failure history, renal insufficiency]) and/or high-risk limb presentation (following peripheral revascularization, limb amputation, rest pain, ischemic ulcers), and at low bleeding risk: Use rivaroxaban 2.5 mg twice daily (BID) with aspirin (80-100 mg daily)
• At low bleeding risk and without high-risk limb comorbidities or high-risk limb presentation: Use rivaroxaban 2.5 mg BID with aspirin or single antiplatelet therapy (SAPT)
• At high bleeding risk and still eligible for antithrombotic therapy: Consider SAPT with aspirin (75-325 mg) or clopidogrel (75 mg)

For those with stable LE PAD, additional full-dose anticoagulation with antiplatelet therapy is not recommended to reduce MACE and MALE events.

Administer rivaroxaban 2.5 mg BID daily with aspirin (80-100 mg daily) for patients with LE PAD after elective open revascularization, and with or without short-term clopidogrel for elective endovascular revascularization.

For those with PAD and intermittent claudication, supervised exercise programs are first-line therapy to improve maximal and pain-free walking distance and time, as well as quality of life (QoL); walking is the preferred form of exercise in exercise programs. When there are no available supervised exercise programs or when not desired by the patient, offer a structured home-based or community exercise program to improve leg symptoms and QoL.

Revascularization interventions

The Revised Cardiac Risk Index (RCRI) is not recommended for preoperative evaluation of cardiac risk and 30-day mortality in peripheral arterial surgery.

Revascularization is not recommended for those with asymptomatic PAD.

Selection of the revascularization procedure should be specific to the patient, expected to have low perioperative morbidity, and be reasonably likely to provide sustained symptomatic benefit. Selection of endovascular versus open revascularization strategies for PAD should take into account anatomic, patient, and procedural factors, as well as operator expertise and resource availability.

For patients with chronic limb-threatening ischemia (CLTI):

• Provide urgent referral to vascular specialists for consideration of revascularization
• Consider endovascular, open, or hybrid revascularization on the basis of the anatomic disease pattern, degree of ischemia, expected procedure durability, perioperative risk, and patient life expectancy
• Primary major amputation is recommended for those with nonreconstructible disease, nonsalvageable limb, nonambulatory status, severe sepsis, or for palliation for those with a short life expectancy and who are not suitable revascularization candidates

Depending on the severity of tissue loss, gangrene, and/or infection, wound debridement and/or minor amputation concurrent with revascularization or in a staged manner is recommended.

Endovascular therapy is recommended for appropriately selected patients with claudication or CLTI.

Endovascular therapy is not recommended in the common femoral or profunda femoris arteries; for lesions in asymptomatic patients; and for nonhemodynamically significant lesions.

Surgical revascularization

For intermittent claudication, perform surgical bypass to the popliteal artery (when indicated) with an autogenous vein preferred over prosthetic graft material. Femoral-tibial artery bypasses are not recommended.

For chronic limb-threatening ischemia, perform surgical bypass to the popliteal or infrapopliteal arteries with an autogenous vein. In those with CLTI for whom endovascular revascularization is not feasible and a suitable autogenous vein is not available, prosthetic material can be effective for bypass to the below-knee popliteal and tibial arteries as a last resort in cases of limb salvage.

Clinical guidelines on CLTI were released in June 2019 by the Society for Vascular Surgery (SVS), European Society for Vascular Surgery (ESVS), and World Federation of Vascular Societies (WFVS). ^[18]

Definitions and nomenclature

Evaluate for ischemia and determine its severity using objective hemodynamic tests in all patients with suspected CLTI.

Grade wound extent, degree of ischemia, and infection severity with a lower-extremity threatened-limb classification staging system to guide clinical treatment in all patients with suspected CLTI.

Diagnosis and limb staging

A detailed history should be performed in all patients with suspected CLTI to determine symptoms, cardiovascular risk factors, and medical history .

A complete cardiovascular physical examination should be performed in all patients with suspected CLTI.

A complete foot examination should be performed in all patients with pedal tissue loss and suspected CLTI, including a neuropathy assessment and a probe-to-bone test of any open ulcers.

Ankle pressure (AP) and ABI should be measured as first-line noninvasive testing in all patients with suspected CLTI.

Toe pressure (TP) and TBI should be measured in all patients with tissue loss and suspected CLTI.

High-quality angiographic imaging of the lower limb (including the ankle and foot) should be performed in all patients with suspected CLTI who may be candidates for revascularization.

Medical management

Cardiovascular risk factors should be evaluated in all patients with suspected CLTI.

Modifiable risk factors should be managed in all patients with suspected CLTI.

Antiplatelet therapy should be administered to all patients with CLTI.

Systemic vitamin K antagonists should be avoided in the treatment of lower-extremity atherosclerosis in patients with CLTI.

Statin therapy (moderate- or high-intensity) should be administered to patients with CLTI to reduce the likelihood of all-cause and cardiovascular mortality.

Hypertension should be modified to target levels of < 140 mm Hg systolic and < 90 mm Hg diastolic in patients with CLTI.

Metformin is the primary hypoglycemic agent in patients with type 2 diabetes mellitus (DM) and CLTI.

Smoking-cessation interventions should be offered to all patients with CLTI who use tobacco products.

Smokers or former smokers with CLTI should be inquired about the status of tobacco use at every visit.

Analgesics should be prescribed to patients with CLTI who have ischemic rest pain of the lower extremity and foot until pain resolves following revascularization.

Chronic severe pain should be treated with acetaminophen in combination with opioids in patients with CLTI.

Global Limb Anatomic Staging System

An integrated limb-based anatomic staging system (eg, Global Limb Anatomic Staging System [GLASS]) should be used to define the complexity of a preferred target artery path (TAP) and to aid in revascularization (EBR) in patients with CLTI.

Strategies for evidence-based revascularization

A vascular specialist should be consulted in all cases of suspected CLTI to consider limb salvage except when major amputation is considered medically urgent.

Patients with a limited life expectancy, unsalvageable limb, or poor functional status should be offered primary amputation or palliation after shared decision-making.

The periprocedural risk should be assessed and life expectancy estimated in patients with CLTI who are candidates for revascularization.

All patients with CLTI who are candidates for limb salvage should be staged with an integrated threatened limb classification system.

Urgent surgical drainage and debridement (including minor amputation, if needed) should be performed and antibiotic therapy initiated in all patients with suspected CLTI who have wet gangrene or deep-space foot infection.

Limb staging should be repeated following surgical drainage, debridement, minor amputation, or correction of inflow disease (aortoiliac [AI], common and deep femoral artery disease) and before subsequent major treatment decisions.

Revascularization should not be performed in patients without significant ischemia (Wound, Ischemia, and foot Infection [WIfI] ischemia grade 0) unless an isolated region of poor perfusion in conjunction with major tissue loss (eg, WIfI wound grade 2 or 3) can be effectively targeted and the wound progresses or fails to decrease in size by 50% or more within 4 weeks despite appropriate infection control, wound care, and offloading.

Revascularization should be offered to all average-risk patients with advanced limb-threatening conditions (eg, WIfI stage 4) and significant perfusion deficits (eg, WIfI ischemia grades 2 and 3).

High-quality angiographic imaging with dedicated views of foot and ankle arteries should be performed for anatomic staging and procedural planning in all patients with CLTI who are candidates for revascularization.

The anatomic pattern of disease and preferred TAP should be defined with an integrated lib-based staging system in all patients with CLTI who are candidates for revascularization.

When available, ultrasonographic vein mapping should be performed in all patients with CLTI who are candidates for surgical bypass.

The ipsilateral great saphenous vein (GSV) and small saphenous vein (SSV) should be mapped to plan the surgical bypass.

Veins in the contralateral leg and both arms should be mapped if the ipsilateral vein is insufficient.

A patient with CLTI should not be considered as unsuitable for revascularization until imaging studies are reviewed and the patient is clinically evaluated by a qualified vascular specialist.

Inflow disease should be corrected first in patients with CLTI who have both inflow and outflow disease.

The decision for staged versus combined inflow and outflow revascularization should be based on risk and limb threat.

Inflow disease alone should be corrected in patients with CLTI who have multilevel disease and low-grade ischemia (eg, WIfI ischemia grade 1) or limited tissue loss (eg, WIfI wound grade 0 or 1) and whenever the risk-benefit of additional outflow reconstruction is high or initially unclear.

The limb should be restaged and hemodynamic assessment repeated following inflow correction in patients with CLTI who have both inflow and outflow disease.

An endovascular-first approach should be used to treat patients with CLTI who have moderate to severe (eg, GLASS stage IA) aortoiliac (AI) disease.

Open common femoral artery (CFA) endarterectomy with patch angioplasty should be performed, with or without extension into the profunda femoris artery (PFA), in patients with CLTI who have hemodynamically significant disease of the common and deep femoral arteries (>50% stenosis).

Endovascular treatment should be considered for significant CFA disease in patients who are deemed to be at high surgical risk or to have a hostile groin.

Stents should be avoided in the CFA, and they should not be placed across the origin of a patent deep femoral artery.

Hemodynamically significant disease of the proximal deep femoral artery should be corrected, when technically feasible.

Decisions concerning endovascular intervention versus open surgical bypass should be based on the severity of the limb threat (eg, WIfI grade), the anatomic disease pattern (eg, GLASS), and the availability of autologous vein in average-risk patients with CLTI.

The preferred conduit for infrainguinal bypass surgery is autologous vein in patients with CLTI.

Intraoperative imaging (angiography, duplex ultrasonography, or both) should be performed upon completion of open bypass surgery for CLTI and significant technical defects corrected, if feasible, during the index operation.

Nonrevascularization treatments

Vasoactive drugs and defibrinating agents (ancrod) should not be offered to patients in whom revascularization is not possible.

Hyperbaric oxygen therapy (HBOT) should not be offered to improve limb salvage in patients with CLTI who have severe uncorrected ischemia (eg, WIfI ischemia grade 2 or 3).

Optimal wound care should be continued until the lower extremity wound has completely healed or amputation is performed.

Biologic and regenerative medicine approaches

Therapeutic angiogenesis should be restricted for patients with CLTI who are enrolled in a registered clinical trial.

Minor and major amputations

After shared decision-making, primary amputation should be offered to patients with CLTI who have an unsalvageable or pre-existing dysfunctional limb, a short life expectancy, or poor functional status.

A multidisciplinary rehabilitation team should be involved from the time of decision to amputate through successful completion of rehabilitation.

Patients with CLTI who have undergone amputation should be monitored at least yearly to track disease progression in the contralateral limb, to maintain optimal medical therapy, and to manage risk factors.

Postprocedural care and surveillance following infrainguinal revascularization

Following lower-extremity revascularization, optimal medical therapy for PAD, including long-term antiplatelet and statin therapies, should be continued.

Smoking cessation should be promoted to all patients with CLTI who have undergone lower-extremity revascularization.

Patients who have undergone lower-extremity vein bypass for CLTI should be observed regularly for at least 2 years. The clinical surveillance program should include interval history, pulse examination, and assessment of resting APs and TPs. Duplex ultrasonography (DUS) should also be considered.

Patients who have undergone lower-extremity prosthetic bypass for CLTI should be observed regularly for at least 2 years, with interval history, pulse examination, and measurement of resting APs and TPs.

Patients who have undergone infrainguinal endovascular interventions for CLTI should be observed in a surveillance program that includes clinical visits, pulse examination, and noninvasive testing (resting APs and TPs).

Additional imaging should be considered in patients with lower-extremity vein grafts whose ABI has decreased ≥0.15 and whose symptoms have recurred or pulse status changed to evaluate for vein graft stenosis.

Intervention should be offered if vein graft lesions are detected on duplex US in patients with an associated peak systolic velocity (PSV) of >300 cm/s and a PSV ratio >3.5 or grafts with low velocity (midgraft PSV < 45 cm/s) to maintain patency.

Long-term surveillance, including DUS graft scanning, should be maintained following surgical or catheter-based revision of a vein graft to evaluate for recurrent graft-threatening lesions.

Mechanical offloading should be provided as a primary component of care in all patients with CLTI who have pedal wounds.

Counseling on protection of the healed wound and foot should be provided, including appropriate shoes, insoles, and monitoring of inflammation.

In August 2017, the European Society for Cardiology (ESC), in collaboration with the ESVS, issued updated guidelines on the diagnosis and treatment of PAD ^[17] ; these guidelines were also endorsed by the European Stroke Organisation (ESO).

Recommendations regarding best medical therapy for PAD include the following:

• Smoking cessation is recommended in all patients with PAD (class I recommendation; evidence level B)
• Healthy diet and physical activity are recommended for all patients with PAD (class I recommendation; evidence level C)
• Statins are recommended in all patients with PAD (class I recommendation; evidence level A)
• In patients with PAD, it is recommended to reduce LDL-C to < 1.8 mmol/L (70 mg/dL) or decrease it by ≥50% if baseline values are 1.8-3.5 mmol/L (70-135 mg/dL) (class I recommendation; evidence level C)
• In diabetic patients with PAD, strict glycemic control is recommended (class I recommendation; evidence level C)
• Antiplatelet therapy is recommended in patients with symptomatic PAD (class I recommendation; evidence level C)
• In patients with PAD and hypertension, it is recommended to control blood pressure at < 140/90 mm Hg (class I recommendation; evidence level A)
• ACEIs or ARBs should be considered as first-line therapy in patients with PAD and hypertension (class I recommendation; evidence level B)

Recommendations related to screening and diagnosis of lower-extremity arterial disease (LEAD) include the following:

• ABI is indicated as a first-line noninvasive test for screening and diagnosis of lower-extremity arterial disease (LEAD) (class I recommendation; evidence level C)
• If ankle arteries are not compressible or ABI >1.40, alternative methods (eg, TBI, Doppler waveform analysis, or pulse volume recording) are indicated (class I recommendation; evidence level C)
• DUS is a first-line imaging modality for confirming LEAD (class I recommendation; evidence level C)
• DUS and/or computed tomography angiography (CTA) and/or magnetic resonance angiography (MRA) are indicated for characterizing anatomy in LEAD and guiding optimal revascularization (class I recommendation; evidence level C)
• Anatomic imaging data should always be analyzed in conjunction with symptoms and hemodynamic data for treatment is decided on (class I recommendation; evidence level C)
• DUS screening for abdominal aortic aneurysm (AAA) should be considered (class IIa recommendation; evidence level C)

Recommendations for patients with IC are as follows:

• On top of general prevention, statins are indicated to improve walking distance (class I recommendation; evidence level A)
• In patients with intermittent claudication, supervised exercise training is recommended (class I recommendation; evidence level A); unsupervised exercise training is recommended when supervised training is not feasible or available (class I recommendation; evidence level C)
• If daily life activities are compromised despite exercise therapy, revascularization should be considered (class IIa recommendation; evidence level C)
• If daily life activities are severely compromised, revascularization should be considered in association with exercise therapy (class IIa recommendation; evidence level B)

Recommendations for revascularization of aortoiliac occlusive lesions in patients with intermittent claudication and severe chronic limb ischemia are as follows:

• Endovascular-first strategy is recommended for short (< 5 cm) occlusive lesions (class I recommendation; evidence level C)
• In patients fit for surgery, aorto(bi)femoral bypass should be considered (class IIa recommendation; evidence level B)
• Endovascular-first strategy should be considered in long and/or bilateral lesions in patients with severe comorbidities (class IIa recommendation; evidence level B)
• Endovascular-first strategy may be considered for aortoiliac occlusive lesions if it is done by an experienced team and does not compromise subsequent surgical options (class IIb recommendation; evidence level B)
• Primary stent implantation rather than provisional stenting should be considered (class IIa recommendation; evidence level B)
• Open surgery should be considered in fit patients with an aortic occlusion extending up to the renal arteries (class IIa recommendation; evidence level C)
• For iliofemoral occlusive lesions, a hybrid procedure combining iliac stenting and femoral endarterectomy or bypass should be considered (class IIa recommendation; evidence level C)
• Extra-anatomic bypass may be indicated for patients with no other alternatives (class IIb recommendation; evidence level C)

Recommendations for revascularization of femoropopliteal occlusive lesions in patients with intermittent claudication and severe chronic limb ischemia are as follows:

• Endovascular-first strategy is recommended in short (< 25 cm) lesions (class I recommendation; evidence level C)
• Primary stent implantation should be considered in short (< 25 cm) lesions (class IIa recommendation; evidence level A)
• Drug-eluting balloons may be considered in short (< 25 cm) lesions (class IIb recommendation; evidence level A)
• Drug-eluting stents may be considered for short (< 25 cm) lesions (class IIb recommendation; evidence level B)
• Drug-eluting balloons may be considered for treatment of in-stent restenosis (class IIb recommendation; evidence level B)
• In patients not at high risk for surgery, bypass surgery is indicated for long (≥25 cm) superficial femoral artery (SFA) lesions when an autologous vein is available and life expectancy is >2 years (class I recommendation; evidence level B)
• The autologous saphenous vein is the conduit of choice for femoropopliteal bypass (class I recommendation; evidence level A)
• When above-the-knee bypass is indicated, the use of a prosthetic conduit should be considered in the absence of any autologous saphenous vein (class IIa recommendation; evidence level A)
• In patients unfit for surgery, endovascular therapy may be considered in long (≥25 cm) femoropopliteal lesions (class IIb recommendation; evidence level C)

Recommendations for revascularization of infrapopliteal occlusive lesions are as follows:

• In the case of CLTI, infrapopliteal revascularization is indicated for limb salvage (class I recommendation; evidence level C)
• For revascularization of infrapopliteal arteries, bypass using the GSV is indicated (class I recommendation; evidence level A); endovascular therapy should be considered (class IIa recommendation; evidence level B)

Recommendations for management of CLTI are as follows:

• Early recognition of tissue loss or infection and referral to the vascular team is mandatory to improve limb salvage (class I recommendation; evidence level C)
• Assessment of the risk of amputation is indicated (class I recommendation; evidence level C)
• In patients with CLTI and diabetes, optimal glycemic control is recommended (class I recommendation; evidence level C)
• For limb salvage, revascularization is indicated whenever feasible (class I recommendation; evidence level B)
• In CLTI patients with below-the-knee lesions, angiography (including foot runoff) should be considered before revascularization (class IIa recommendation; evidence level C)
• Stem cell or gene therapy is not indicated for CLTI (class III recommendation; evidence level B)

Recommendations for management of acute limb ischemia are as follows:

• In the case of neurologic deficit, urgent revascularization is indicated; imaging should not delay intervention (class I recommendation; evidence level C)
• In the absence of neurologic deficit, revascularization is indicated within hours after initial imaging on a case-by-case basis (class I recommendation; evidence level C)
• Heparin and analgesics are indicated as soon as possible (class I recommendation; evidence level C)

In November 2016, the American Heart Association (AHA) and the American College of Cardiology (ACC) published the following recommendations regarding lower-extremity PAD ^[16] :

• The vascular examination for PAD includes pulse palpation, auscultation for femoral bruits, and inspection of the legs and feet. Lower extremity pulses are assessed and rated as follows: 0, absent; 1, diminished; 2, normal; or 3, bounding
• To confirm the diagnosis of PAD, abnormal physical examination findings must be confirmed with diagnostic testing, generally with the ABI as the initial test
• Patients with a confirmed diagnosis of PAD are at increased risk for subclavian artery stenosis; an interarm blood pressure difference of >15 to 20 mm Hg is abnormal and suggestive of subclavian (or innominate) artery stenosis; measuring blood pressure in both arms identifies the arm with the highest systolic pressure, a requirement for accurate measurement of the ABI
• Resting ABI results should be reported as abnormal (ABI ≤ 0.90), borderline (ABI 0.91-0.99), normal (1.00-1.40), or noncompressible (ABI >1.40)
• ABI is not recommended in patients who are not at increased risk of PAD and who do not have a  history or physical examination findings suggestive of PAD
• TBI should be measured to diagnose patients with suspected PAD when the ABI is >1.40
• Patients with exertional non-joint-related leg symptoms and normal or borderline resting ABI (>0.90 and ≤ 1.40) should undergo exercise treadmill ABI testing to evaluate for PAD
• Patients with PAD should receive a comprehensive program of guideline-directed medical therapy, including structured exercise and lifestyle modification, to reduce cardiovascular ischemic events and improve functional status
• Antiplatelet therapy with aspirin alone (range, 75-325 mg/day) or clopidogrel alone (75 mg/day) is recommended to reduce myocardial infarction (MI), stroke, and vascular death in patients with symptomatic PAD
• Treatment with a statin medication is indicated for all patients with PAD
• Patients with PAD who smoke cigarettes or use other forms of tobacco should be advised at every visit to quit
• Cilostazol is an effective therapy to improve symptoms and increase walking distance in patients with claudication
• Endovascular procedures are effective as a revascularization option for patients with lifestyle-limiting claudication and hemodynamically significant aortoiliac occlusive disease
• When surgical revascularization is performed, bypass to the popliteal artery with autogenous vein is recommended in preference to prosthetic graft material 

In 2015, the SVS issued practice guidelines for management of atherosclerotic disease of the lower extremities. ^[15]

Recommendations for diagnosis of PAD include the following:

• ABI is recommended as the first-line noninvasive test to establish a diagnosis of PAD in individuals with symptoms or signs suggestive of disease. If the ABI is borderline or normal (>0.9) and symptoms of claudication are suggestive, an exercise ABI is recommended (grade 1 recommendation; evidence level A).
• Routine screening is not suggested for lower-extremity PAD in the absence of risk factors, history, signs, or symptoms of PAD (grade 2 recommendation; evidence level C).
• For asymptomatic individuals at elevated risk (eg, those aged >70 years, smokers, diabetic patients, those with an abnormal pulse examination, and those with other established cardiovascular disease), screening for lower-extremity PAD is reasonable if used to improve risk stratification, preventive care, and medical management (grade 2 recommendation; evidence level C).
• In symptomatic patients being considered for revascularization, physiologic noninvasive studies (eg, segmental pressures and pulse volume recordings) are suggested to aid in quantification of arterial insufficiency and help localize the level of obstruction (grade 2 recommendation; evidence level C).
• In symptomatic patients being considered for revascularization treatment, anatomic imaging studies (eg, arterial DUS, CTA, MRA, and contrast arteriography) are recommended (grade 1 recommendation; evidence level B).

Recommendations for management of asymptomatic PAD include the following:

• Multidisciplinary comprehensive smoking cessation interventions are recommended for patients with asymptomatic PAD who use tobacco (repeatedly until tobacco use has stopped) (grade 1 recommendation; evidence level A).
• Provision of education about the signs and symptoms of PAD progression to asymptomatic patients with PAD is recommended (grade 1 recommendation; evidence ungraded).
• Invasive treatments for PAD are not recommended in the absence of symptoms, regardless of hemodynamic measures or imaging findings demonstrating PAD (grade 1 recommendation; evidence level B).

Recommendations for medical treatment of intermittent claudication (IC) include the following:

• Multidisciplinary comprehensive smoking cessation interventions are recommended for patients with IC (repeatedly until tobacco use has stopped) (grade 1 recommendation; evidence level A).
• Statin therapy is recommended for symptomatic PAD (grade 1 recommendation; evidence level A).
• Optimized diabetes control (hemoglobin A1c goal of < 7.0%) is recommended in patients with IC if this goal can be achieved without hypoglycemia (grade 1 recommendation; evidence level B).
• Indicated beta blockers (eg, for hypertension, cardiac indications) are recommended in patients with IC; no evidence supports concerns about worsening claudication (grade 1 recommendation; evidence level B).
• In patients with IC due to atherosclerosis, antiplatelet therapy with aspirin (75-325 mg daily) is recommended (grade 1 recommendation; evidence level A).
• Clopidogrel 75 mg/day is recommended as an effective alternative to aspirin for antiplatelet therapy in patients with IC (grade 1 recommendation; evidence level B).
• In patients with IC due to atherosclerosis, it is suggested that warfarin not be used solely to reduce the risk of adverse cardiovascular events or vascular occlusions (grade 1 recommendation; evidence level C).
• It is suggested that folic acid and vitamin B12 supplements not be used to treat IC (grade 2 recommendation; evidence level C).
• In patients with IC who do not have congestive heart failure (CHF), a 3-month trial of cilostazol (100 mg bid) is suggested to improve pain-free walking (grade 2 recommendation; evidence level A).
• In patients with IC who cannot tolerate or have contraindications for cilostazol, a trial of pentoxifylline (400 mg tid) is suggested to improve pain-free walking (grade 2 recommendation; evidence level B).

Recommendations for exercise therapy for IC include the following:

• A supervised exercise program consisting of walking a minimum of three times per week (30-60 min/session) for at least 12 weeks is recommended as first-line therapy for all suitable patients with IC (grade 1 recommendation; evidence level A).
• Home-based exercise is recommended, with a goal of at least 30 minutes of walking three to five times per week when a supervised exercise program is unavailable or for long-term benefit after a supervised program is completed (grade 1 recommendation; evidence level B).
• After revascularization therapy for IC, exercise (either supervised or home-based) is recommended for adjunctive functional benefits (grade 1 recommendation; evidence level B).
• Patients with IC should be be followed up annually to assess compliance with lifestyle measures (smoking cessation, exercise) and medical therapies and to look for evidence of progression in symptoms or signs of PAD. Yearly ABI testing may be of value to provide objective evidence of disease progression (grade 1 recommendation; evidence level C).

General recommendations for interventions for IC include the following:

• Endovascular therapy (EVT) or surgical treatment of IC is recommended for patients with significant functional or lifestyle-limiting disability when it is reasonably likely to yield symptomatic improvement, when pharmacologic or exercise therapy or both have failed, and when the benefits outweigh the potential risks (grade 1 recommendation; evidence level B).
• Selection of an invasive treatment for IC should be individualized. The modality offered should provide a reasonable likelihood of sustained benefit to the patient (>50% likelihood of clinical efficacy for at least 2 years). For revascularization, anatomic patency (freedom from hemodynamically significant restenosis) is considered a prerequisite for sustained efficacy (grade 1 recommendation; evidence level C).

Recommendations for interventions for aortoiliac occlusive disease (AIOD) in IC include the following:

• EVT is preferred to open surgery for focal AIOD causing IC (grade 1 recommendation; evidence level B).
• EVT is recommended as first-line revascularization therapy for most patients with common iliac artery or external iliac artery occlusive disease causing IC (grade 1 recommendation; evidence level B).
• Selective use of bare-metal stents or covered stents for aortoiliac angioplasty is recommended for common iliac artery or external iliac artery occlusive disease, because of improved technical success and patency (grade 1 recommendation; evidence level B).
• Covered stents are recommended for AIOD in the presence of severe calcification or aneurysmal changes where the risk of rupture may be increased after unprotected dilation (grade 1 recommendation; evidence level C).
• For patients with diffuse AIOD undergoing revascularization, either EVT or surgical intervention is suggested as first-line therapy. Endovascular interventions that may impair the potential for subsequent aortofemoral bypass AFB in surgical candidates should be avoided (grade 2 recommendation; evidence level B).
• EVT for AIOD in the presence of aneurysmal disease should be undertaken cautiously. The modality used either should achieve concomitant aneurysm exclusion or should not jeopardize the conduct of any future open or endovascular aneurysm repair (grade 1 recommendation; evidence level C).
• In all patients undergoing revascularization for AIOD, the common femoral artery (CFA) should be assessed. If hemodynamically significant CFA disease is present, surgery (endarterectomy) is recommended as first-line treatment (grade 1 recommendation; evidence level B).
• In patients with iliac artery disease and CFA involvement, hybrid procedures combining femoral endarterectomy with iliac inflow correction are recommended (grade 1 recommendation; evidence level B).
• Direct surgical reconstruction (bypass, endarterectomy) is recommended in patients with reasonable surgical risk and diffuse AIOD not amenable to EVT, after one or more failed attempts at EVT, or in patients with combined occlusive and aneurysmal disease (grade 1 recommendation; evidence level B).
• In younger patients (< 50 years) with IC, a shared decision-making approach is recommended to engage patients and inform them of the possibility of inferior outcomes with either EVT or surgery (grade 2 recommendation; evidence level C).
• Either axial imaging (eg, CT or magnetic resonance imaging [MRI]) or catheter-based angiography is recommended for evaluation and planning of surgical revascularization for AIOD (grade 1 recommendation; evidence ungraded).
• When surgical bypass is performed for AIOD, concomitant aneurysmal disease of the aorta or iliac arteries should be treated as appropriate (exclusion) and is a contraindication for end-to-side proximal anastomoses (grade 1 recommendation; evidence ungraded).
• For any bypass graft originating from the CFA, the donor iliac artery must be free of hemodynamically significant disease or any preexisting disease should be corrected before the bypass procedure is performed (grade 1 recommendation; evidence ungraded).

Recommendations for interventions for femoropopliteal occlusive disease (FPOD) in IC include the following:

• EVT is preferred to open surgery for focal occlusive disease of the SFA that does not involve the origin at the femoral bifurcation (grade 1 recommendation; evidence level C).
• Selective stenting is suggested for focal lesions (< 5 cm) in the SFA that have unsatisfactory technical results with balloon angioplasty (grade 2 recommendation; evidence level C).
• Adjunctive use of self-expanding nitinol stents (with or without paclitaxel) is recommended for intermediate-length (5-15 cm) SFA lesions to improve the midterm patency of angioplasty (grade 1 recommendation; evidence level B).
• Preoperative ultrasonographic vein mapping is suggested to establish the availability and quality of autogenous vein conduit in patients being considered for infrainguinal bypass to treat IC (grade 2 recommendation; evidence level C).
• EVT is not recommended for isolated infrapopliteal disease in IC, because it is of unproven benefit and may be harmful (grade 1 recommendation; evidence level C).
• Surgical bypass is recommended as an initial revascularization strategy for patients with diffuse FPOD, small vessel caliber (< 5 mm), or extensive SFA calcification if their anatomy is favorable for bypass (popliteal artery target, good runoff) and their operative risk is average or low (grade 1 recommendation; evidence level B).
• The saphenous vein is the preferred conduit for infrainguinal bypass grafts (grade 1 recommendation; evidence level A).
• In the absence of suitable vein, a prosthetic conduit is suggested for femoropopliteal bypass in claudicant patients if the above-knee popliteal artery is the target vessel and good runoff is present (grade 2 recommendation; evidence level C).

Recommendations for postinvervention therapy in IC include the following:

• After EVT or open surgical intervention for claudication, optimal medical therapy (antiplatelet agents, statins, antihypertensives, control of glycemia, smoking cessation) is recommended for all patients (grade 1 recommendation; evidence level A).
• After lower-extremity bypass (venous or prosthetic), antiplatelet therapy (aspirin, clopidogrel, or aspirin plus clopidogrel) is suggested (grade 2 recommendation; evidence level B).
• After infrainguinal endovascular intervention for claudication, treatment with aspirin and clopidogrel for at least 30 days is suggested (grade 2 recommendation; evidence level B).

Recommendations for surveillance after intervention for IC include the following:

• Patients treated with open surgery or EVT for IC should be monitored with a clinical surveillance program that consists of an interval history to detect new symptoms, ensure compliance with medical therapies, and record subjective functional improvements; pulse examination; and measurement of resting and, if possible, postexercise ABIs (grade 2 recommendation; evidence level C).
• Patients treated with lower-extremity vein grafts for IC should be monitored with a surveillance program consisting of clinical follow-up and DUS (grade 2 recommendation; evidence level C).
• Patients who have previously undergone vein bypass surgery for IC and have developed a significant graft stenosis on DUS should be considered for prophylactic reintervention (open or endovascular) to promote long-term bypass graft patency (grade 1 recommendation; evidence level C).