Peripheral Vascular Disease Guidelines

Updated: Dec 13, 2016
  • Author: Everett Stephens, MD; Chief Editor: Erik D Schraga, MD  more...
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Guidelines

AHA/ACC Guideline on Lower-Extremity Peripheral Artery Disease

In November 2016, the American Heart Association (AHA) and the American College of Cardiology (ACC) published the following recommendations on lower-extremity peripheral artery disease (PAD) [19] :

  • 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 ankle-brachial index (ABI) as the initial test
  • Patients with confirmed diagnosis of PAD are at increased risk for subclavian artery stenosis; an inter-arm 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