Peripheral Arterial Occlusive Disease Guidelines

Updated: Sep 14, 2017
  • Author: Josefina A Dominguez, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
  • Print
Guidelines

SVS Guidelines on Atherosclerotic Occlusive Disease of Lower Extremities

In 2015, the Society for Vascular Surgery (SVS) issued practice guidelines for management of atherosclerotic disease of the lower extremities. [14]

Recommendations for diagnosis of peripheral arterial disease (PAD) include the following:

  • Ankle-brachial index (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 duplex ultrasonography [DUS], computed tomography [CT] angiography [CTA], magnetic resonance angiography [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 superficial femoral artery (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).
Next:

AHA/ACC Guideline on Lower-Extremity Peripheral Arterial Disease

In November 2016, the American Heart Association (AHA) and the American College of Cardiology (ACC) published the following recommendations regarding lower-extremity peripheral artery disease (PAD) [15] :

  • 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
  • Toe-brachial index (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 
Previous
Next:

ESC/ESVS Guidelines on Lower-Extremity Arterial Disease

In August 2017, the European Society for Cardiology (ESC), in collaboration with the European Society for Vascular Surgery (ESVS), issued updated guidelines on the diagnosis and treatment of PAD [16] ; 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)
  • Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-receptor blockers (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, toe-brachial index [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 CTA and/or 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) 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 chronic limb-threatening ischemia (CLTI), infrapopliteal revascularization is indicated for limb salvage (class I recommendation; evidence level C)
  • For revascularization of infrapopliteal arteries, bypass using the great saphenous vein 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)
Previous