Peripheral Vascular Disease Guidelines

Guidelines on peripheral arterial disease (PAD) were published in May 2022 by the Canadian Cardiovascular Society in the Canadian Journal of Cardiology. ^[13] They include approaches to the diagnosis, risk stratification, and medical and intervention treatments for patients with PAD. Strong recommendations are outlined below.

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 counselling; 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 with 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 is 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:

• 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 chronic limb-threatening ischemia.

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 chronic limb-threatening 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.

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) ^[12] :

• 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