Chapter e35: Peripheral Arterial Disease

KEY CONCEPTS

• Peripheral arterial disease (PAD) is a form of atherosclerotic cardiovascular disease (ASCVD) that occurs in the peripheral arteries. Lower extremity PAD is the most common form of PAD.

• Lower extremity PAD is associated with an increased risk of limb loss and death.

• The most prevalent PAD risk factors are tobacco smoking, diabetes mellitus (DM), hypertension, and dyslipidemia. The risk of developing PAD increases with age.

• Symptoms of lower extremity PAD may include cramping or discomfort in the affected lower extremity(ies). A significant portion of those with PAD will be asymptomatic. Signs of lower extremity PAD include, but are not limited to, diminished or absent pedal pulses, nonhealing wounds, brittle and hypertrophic toenails, and/or cool skin. The presence of signs and/or symptoms in those at risk for PAD should prompt further evaluation.

• The ankle-brachial index (ABI) is the most common test used to diagnose lower extremity PAD. PAD is defined by an ABI score ≤0.9 for one or more of the pedal pulses (ie, dorsalis pedis, posterior tibial). A score >1.4 is indicative of noncompressible arteries which may be present in those with DM and/or chronic kidney disease (CKD).

• ASCVD risk reduction is prudent to lower the risk of cardiovascular (CV) complications associated with PAD. This includes acheiving good glycemic and blood pressure (BP) control. A high-intensity statin is recommended to reduce the risk of CV and limb-related events. Smoking cessation has been shown to reduce the risk of limb loss and death.

• Participation in a structured exercise training program has been shown to improve functional status and quality of life and to decrease lower extremity symptoms.

• Revascularization surgery is a potential therapeutic option for patients who have persistent lower extremity PAD symptoms despite pharmacological therapy, exercise, and smoking cessation.

• Low-dose aspirin or clopidogrel is recommended for patients with symptomatic lower extremity PAD to lower the risk of CV events and death.

• An antithrombotic regimen should be prescribed after revascularization surgery to lower the risk of CV events and limb-related events. Options include aspirin or clopidogrel monotherapy, dual antiplatelet therapy with aspirin and clopidogrel, or rivaroxaban 2.5 mg twice daily combined with low-dose aspirin.

• Cilostazol can be considered in those with lower extremity PAD symptoms despite other pharmacological therapy, exercise, and smoking cessation. This agent is not to be used in those with heart failure due to an increased risk of death.

BEYOND THE BOOK

Readers are encouraged to watch the following videos:

• Overview of the physical examination for peripheral arterial disease (PAD): https://youtu.be/sJ6YkxQeAbo (Duration: 10:08 minutes)

• Overview of Surgical Approaches for Peripheral Arterial Disease (PAD): https://www.youtube.com/watch?v=Y1WK6p0l80A&ab_channel=ColumbiaUniversityDepartmentofSurgery (Duration: 5:38 minutes)