37  Peripheral Vascular Disease

37.1 Note

PAD
- Consider ABI if not already completed
- Lifestyle modification: diet, exercise
  - Encourage ≥ 30-45 mins of exercise at least 3 days/wk
- Tobacco cessation therapies: behavioral, pharmacologic
- BP control
  - Preference for ACEi
- Cholesterol control: statin +/- ezetimibe and/or PCSK9i
  - for LDL-C/Lp(a) lowering
- DM control (if indicated)
  - Consider SGLT2i, GLP-1
- Exercise therapy, Supervised exercise training
- Antiplatelet therapy
  - Options:
    - ASA or clopidogrel monotherapy
    - if prior PI/CAD and *low* bleeding risk:
      - ASA + rivaroxaban 2.5 mg BID
      - ASA + ticagrelor 60 mg BID (prior MI or other need for DAPT)
      - ASA and/or clopidogrel with vorapaxar
    - if prior peripheral revascularization and *low* bleeding risk
      - ASA + rivaroxaban 2.5 mg BID (only option shown efficacious in immediate post-revasc setting)
      - ASA + ticagrelor 60 mg BID (prior MI or other need for DAPT) - chronic PAD
      - ASA and/or clopidogrelwith vorapaxar - chronic PAD
- If claudication, cilostazol 100 mg BID
  - avoid if pt has NYHA Class 3 or 4 HF d/t ↑ mortality w/ PDE inhibitors in these pts

37.2 History

  • History: pain relieved w/ sitting down or standing still
    • By contrast, in pts with spinal stenosis, pain is only by sitting down (i.e. Sx persist even if standing still)
    • does not cause nocturnal leg cramps (neither does lumbar stenosis)
  • Intermittent claudication
    • supervised exercise program is part of the initial Tx regiman in all pts w/ intermittent claudication

37.3 Diagnosis

  • Ankle-Brachial Index (ABI) interpretation:
    • normal ABI: 0.91-1.30
    • mild-to-moderate PAD: 0.41-0.90
    • severe PAD: 0.00-0.40

Interpretation of the ankle-brachial index (ABI).

  • Duplex (ultrasound + Doppler) waveform interpretation in PVD:
    • normal → TRIphasic
    • moderate occlusion → BIphasic
    • severe occlusion → MONOphasic

37.4 Management

  • Encourage ≥ 30-45 mins of exercise at least 3 days/wk
  • ⚠️ Avoid cilostazol for Tx of PAD in pts w/ NYHA Class 3 or 4 HF
    • d/t ↑ mortality w/ PDE inhibitors in these pts
  • Patients with symptomatic PAD (claudication with ABI < 0.85, or previous revascularization or amputation) are considered a ‘high-risk’ ASCVD group and are recommended to be on high-intensity statin (See Chapter 61)
  • Anti-thrombotic therapy (Hussain et al. 2018)
    • Asymptomatic:
      • AHA/ACC PAD guideline recommends antiplatelet therapy as reasonable if ABI ≤ 0.90
      • European Society of Cardiology guideline recommends against routine antiplatelet therapy in asymptomatic pts
    • Symptomatic
      • Tx w/ antithrombotic - monotherapy with either ASA or clopidogrel
    • s/p revascularization (See Figure 37.1 and Figure 37.2)
  • Indications for surgical intervention for PVD:
    • rest pain
    • intractable claudication
    • non-healing infection
    • tissue necrosis

Figure 37.1: Algorithm for Rx of anti-thrombotic therapy in Peripheral Arterial Disease (Source: Hussain et al., 2018)

Figure 37.2: Source: Bonaca et al., Circ Res 2021