Guideline sources The following summarized guidelines for the evaluation and management of peripheral artery disease of lower extremities are prepared by our editorial team based on guidelines from the Canadian Cardiovascular Society (CCS 2022), the American College of Radiology (ACR 2022), the European Society of Cardiology (ESC/ESVS 2018), the U.S. Preventive Services Task Force (USPSTF 2018), the American Heart Association (AHA/ACC 2017), and the Society for Vascular Surgery (SVS 2015). 1 2 3 4 5 6 7 8 9 10 10 11 Definition PAD is a term that encompasses diseases characterized by narrowing of arteries distal to the aortic arch (i.e. non-cardiac and non-intracranial). 7 Epidemiology https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 1/16 6/29/23, 11:04 PM Peripheral artery disease of lower extremities Pathway Epidemiology The most common cause of PAD is atherosclerosis; less common causes include inflammatory disorders of the arterial wall (vasculitis) and noninflammatory arteriopathies, such as FMD. Athero-thrombosis due to hypercoagulable states may also lead to the development of PAD. 9 10 Pathophysiology In patients 40 years of age living in the United States, the incidence and prevalence of PAD are estimated at 2.35% and 10.69%, respectively. 8 Disease course The key clinical presentations of PAD are intermittent claudication and critical limb ischemia. Intermittent claudication refers to symptoms of pain in the muscles of the lower extremities that are brought on by physical activity and relieved by rest. Critical limb ischemia is a more severe manifestation of PAD that presents as rest pain, ischemic ulceration or gangrene of the foot. 10 Prognosis and risk of recurrence PAD is associated with increased mortality rates, with most deaths occurring due to coronary artery disease (40-60%) and cerebrovascular disease (10-20%). Critical limb ischemia is associated with an estimated 1-year mortality of 20-25%, and an estimated 5-year mortality of 40-50%. 11 Guidelines 1. Screening and diagnosis Indications for screening: As per CCS 2022 guidelines, consider obtaining ABI in asymptomatic adults > 50 years of age having risk factors for peripheral arterial disease (such as smoking or diabetes) to screen for peripheral arterial disease. C Show 2 more As per ESC 2018 guidelines, consider screening for PAD of lower extremities in patients with HF. C Show 2 more As per USPSTF 2018 guidelines, insufficient evidence to assess the risks and benefits of screening for PAD and cardiovascular risk with ABI in asymptomatic adults. I As per AHA 2017 guidelines, consider obtaining screening duplex ultrasound for AAA in patients with symptomatic PAD. C As per SVS 2015 guidelines: Avoid obtaining routine screening for lower extremity PAD in the absence of risk factors, history, signs, or symptoms of PAD. D Consider screening for lower extremity PAD in asymptomatic individuals with risk factors, such as age > 70 years, smoking, diabetes mellitus, abnormal pulse examination findings, https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 2/16 6/29/23, 11:04 PM Peripheral artery disease of lower extremities Pathway or other established CVD, if used to improve risk stratification, preventive care, and medical management. C 2. Diagnostic investigations Clinical history: elicit a comprehensive medical history in patients with increased risk of PAD and conduct a review of symptoms to assess for exertional leg symptoms, including claudication or other walking impairment, ischemic rest pain, and nonhealing wounds. B Physical examination: Perform vascular examination, including palpation of lower extremity pulses (femoral, popliteal, dorsalis pedis, and posterior tibial), auscultation for femoral bruits, and inspection of the legs and feet, in patients at increased risk of PAD. B Obtain noninvasive BP measurement in both arms at least once during the initial assessment in patients with PAD. B Ankle-brachial index: As per CCS 2022 guidelines, consider obtaining an ABI and/or toe-brachial index to confirm the diagnosis of peripheral arterial disease in patients with symptoms of peripheral arterial disease. B As per ESC 2018 guidelines, obtain ABI measurement as first-line noninvasive test for screening and diagnosis of lower extremity artery disease. B As per AHA 2017 guidelines, obtain resting ABI, with or without segmental pressures and waveforms, to establish the diagnosis in patients with history or physical examination findings suggestive of PAD. B Show 3 more As per SVS 2015 guidelines: Obtain ABI as the first-line noninvasive test in patients with symptoms or signs suggestive of PAD. A Obtain exercise ABI when the ABI is borderline or normal (> 0.9) and symptoms of claudication are present. A Toe-brachial index: As per CCS 2022 guidelines: Consider obtaining an ABI and/or toe-brachial index to confirm the diagnosis of peripheral arterial disease in patients with symptoms of peripheral arterial disease. B Consider obtaining toe-brachial index with tibial waveforms and/or transcutaneous oxygen pressure as adjuncts in patients with symptoms of peripheral arterial disease with calcified arteries to confirm the diagnosis of PAD. C As per ESC 2018 guidelines, obtain toe-brachial index in case of incompressible ankle arteries or ABI > 1.40. B As per AHA 2017 guidelines, measure toe-brachial index in patients with suspected PAD if the ABI is > 1.40. B Diagnostic imaging: As per ESC 2018 guidelines: https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 3/16 6/29/23, 11:04 PM Peripheral artery disease of lower extremities Pathway Obtain duplex ultrasound as first-line imaging to confirm lower extremity artery disease lesions. B Obtain duplex ultrasound and/or CT angiography and/or MRA for anatomical characterization of lower extremity artery disease lesions and guidance for optimal revascularization strategy. Analyze imaging test findings always in conjunction with symptoms and hemodynamic tests before making treatment decisions. B As per AHA 2017 guidelines, obtain duplex ultrasound, CT angiography, or MRA of the lower extremities to diagnose anatomic location and severity of stenosis in patients with symptomatic PAD being considered for revascularization. B Show 3 more As per SVS 2015 guidelines, obtain anatomic imaging studies, such as arterial duplex ultrasound, CT angiography, MRA, or contrast arteriography in symptomatic patients considered for revascularization. B Other perfusion assessment modalities: As per ESC 2018 guidelines, obtain Doppler waveform analysis or pulse volume recording in case of incompressible ankle arteries or ABI > 1.40. B As per AHA 2017 guidelines: Consider obtaining toe-brachial index with waveforms, transcutaneous partial pressure of oxygen, or skin perfusion pressure to diagnose critical limb ischemia in patients with normal ABI of 1.00-1.40 or borderline ABI of 0.9-0.99, in the setting of nonhealing wounds or gangrene. C Consider obtaining toe-brachial index with waveforms, transcutaneous partial pressure of oxygen, or skin perfusion pressure to evaluate local perfusion in patients with PAD with an abnormal ABI of 0.90 or with noncompressible arteries having ABI of > 1.40 and toe- brachial index of 0.70, in the setting of nonhealing wounds or gangrene. C As per SVS 2015 guidelines, consider obtaining physiologic noninvasive studies, such as segmental pressures and pulse volume recordings, to aid in the quantification of arterial insufficiency and help localize the level of obstruction, in symptomatic patients considered for revascularization. C Screening for other arterial diseases: As per CCS 2022 guidelines, avoid obtaining routine screening for asymptomatic carotid artery stenosis or asymptomatic coronary artery disease in patients with documented peripheral arterial disease. D As per ESC 2018 guidelines, consider obtaining duplex ultrasound to screen for abdominal aorta aneurysm. C As per AHA 2017 guidelines, consider measuring resting ABI in patients at increased risk of PAD, but without history or physical examination findings suggestive of PAD. C Screening for heart failure: consider screening for HF with TTE and/or natriuretic peptides assessment in patients with symptomatic PADs. C 3. Medical management https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 4/16 6/29/23, 11:04 PM Peripheral artery disease of lower extremities Pathway Management of claudication: As per AHA 2017 guidelines: Consider offering cilostazol to improve symptoms and increase walking distance in patients with intermittent claudication. B Do not use pentoxifylline ot chelation therapy (such as with EDTA) for the treatment of claudication. D As per SVS 2015 guidelines, consider initiating a 3-month trial of cilostazol to improve pain- free walking in patients with intermittent claudication in the absence of congestive HF. B Management of hypertension: As per CCS 2022 guidelines, consider obtaining home BP monitoring measurement or 24- hour ambulatory BP monitoring over office BP measurement for the diagnosis and management of hypertension in patients with PAD. Use the higher value for diagnosis and treatment considerations if there is a difference in BP measurements between arms. C Show 3 more As per ESC 2018 guidelines: Target controlling BP at < 140/90 mmHg in patients with PAD and hypertension. A Consider initiating ACEIs as first-line therapy in patients with PAD and hypertension. C As per AHA 2017 guidelines: Initiate antihypertensive therapy to reduce the risk of myocardial infarction, stroke, HF, and cardiovascular death in patients PAD and hypertension. A Consider initiating ACEIs or ARBs to reduce the risk of cardiovascular ischemic events in patients with PAD. B As per SVS 2015 guidelines: Consider initiating ramipril (10 mg PO once daily) to improve pain-free and maximal walking times in patients with intermittent claudication. C Initiate -blocker therapy, if indicated (such as for the management of cardiac disease), in patients with intermittent claudication. B Management of diabetes mellitus: As per CCS 2022 guidelines, consider ensuring tight glycemic control in patients with PAD and diabetes for preventing major adverse limb events or need for revascularization. C Show 2 more As per ESC 2018 guidelines, ensure strict glycemic control in patients with diabetes mellitus and PAD. B As per AHA 2017 guidelines, coordinate the management of diabetes mellitus in patients with peripheral aretry disease between members of the healthcare team. B As per SVS 2015 guidelines, optimize diabetes control (HbA1c goal of < 7.0%) in patients with intermittent claudication if this goal can be achieved without hypoglycemia. B Antiplatelet therapy: As per CCS 2022 guidelines, do not initiate routine antiplatelet therapy in patients with isolated asymptomatic lower extremity PAD. D Show 4 more https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 5/16 6/29/23, 11:04 PM Peripheral artery disease of lower extremities Pathway As per ESC 2018 guidelines, initiate long-term single antiplatelet therapy in symptomatic patients with PAD of lower extremities. A Show 2 more As per AHA 2017 guidelines, initiate antiplatelet monotherapy with aspirin or clopidogrel to reduce the risk of myocardial infarction, stroke, and vascular death in patients with symptomatic PAD. A Show 4 more As per SVS 2015 guidelines, initiate aspirin (75-325 mg PO once daily) as first-line antiplatelet therapy in patients with intermittent claudication due to atherosclerosis. A Show 3 more Updated evidence: EUCLID In patients with symptomatic PAD who had an ABI of 0.80 or had undergone previous revascularization of the lower limbs, ticagrelor was not superior to clopidogrel with respect to cardiovascular death, myocardial infarction, or ischemic stroke. Hiatt WR et al. N Engl J Med. 2017 Jan 5. Anticoagulation therapy: As per CCS 2022 guidelines, do not initiate routine anticoagulation therapy in patients with isolated asymptomatic lower extremity PAD. D Show 3 more As per AHA 2017 guidelines, do not use anticoagulation to reduce the risk of cardiovascular ischemic events in patients with PAD. D As per SVS 2015 guidelines, avoid using warfarin for the sole indication of reducing the risk of adverse cardiovascular events or vascular occlusions in patients with intermittent claudication due to atherosclerosis. D Lipid-lowering therapy: As per CCS 2022 guidelines: View patients with PAD as statin-indicated patients and initiate lipid-modifying therapy for the reduction of death, cardiovascular death, nonfatal myocardial infarction, nonfatal stroke (major adverse cardiovascular events) and major adverse limb events: maximally tolerated dose of statin therapy statin add-on therapies (ezetimibe and/or PCSK9 inhibitors) if receiving maximally tolerated dose of statin therapy and the LDL cholesterol is 1.8 mmol/L, non-HDL cholesterol 2.4 mmol/L or ApoB100 0.7 mg/dL. A Consider initiating icosapent ethyl for the reduction of cardiovascular death, nonfatal myocardial infarction and nonfatal stroke in patients with PAD having a triglyceride level of 1.5-5.6 mmol/L despite maximally tolerated dose of statin therapy. B As per ESC 2018 guidelines: Initiate statins in all patients with PADs, also for improving walking distance. A https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 6/16 6/29/23, 11:04 PM Peripheral artery disease of lower extremities Pathway Target reducing LDL cholesterol to < 1.8 mmol/L (< 70 mg/dL) or decreasing it by 50% if baseline values are 1.8-3.5 mmol/L (70-135 mg/dL). B As per AHA 2017 guidelines, initiate statin therapy in all patients with PAD. A As per SVS 2015 guidelines, initiate statin therapy in all patients with symptomatic PAD. A 4. Nonpharmacologic interventions Exercise therapy: As per CCS 2022 guidelines, offer supervised exercise programs as first-line therapy in patients with peripheral arterial disease and intermittent claudication with the aim of improving maximal and pain-free walking distance and time and quality of life. A Show 4 more Landmark trials: MOSAIC In adults with PAD and intermittent claudication, motivating structured walking activity treatment was superior to usual care with respect to mean improvement in 6MWD at 3- month follow-up. Lindsay M Bearne et al. JAMA. 2022 Apr 12. As per ESC 2018 guidelines: Advise physical activity in all patients with PADs. B Offer supervised exercise training in patients with intermittent claudication. A Offer unsupervised exercise training when supervised exercise training is not feasible or available. B As per AHA 2017 guidelines, offer supervised exercise programs to improve functional status and quality of life and to reduce leg symptoms in patients with claudication. A Show 3 more As per SVS 2015 guidelines, offer supervised exercise programs consisting of walking a minimum of 3 times/week (30-60 min/session) for at least 12 weeks as first-line therapy in all suitable patients with intermittent claudication. A Show 2 more Smoking cessation: As per CCS 2022 guidelines: Advise smoking cessation to prevent peripheral arterial disease, major adverse cardiovascular and major adverse limb events in patients with peripheral arterial disease. B Offer smoking cessation interventions ranging from intensive counseling, nicotine replacement therapy, bupropion, varenicline and sometimes nicotine e-cigarettes. A As per ESC 2018 guidelines, advise smoking cessation in all patients with PADs. B As per AHA 2017 guidelines, advise smoking cessation at every visit in patients with PAD using cigarettes or other forms of tobacco. A https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 7/16 6/29/23, 11:04 PM Peripheral artery disease of lower extremities Pathway Show 2 more As per SVS 2015 guidelines, provide multidisciplinary smoking cessation interventions in patients with asymptomatic PAD or intermittent claudication using tobacco. Support the patient until tobacco use has stopped. A Dietary changes: advise healthy diet in all patients with PADs. B Supplements: As per AHA 2017 guidelines, do not use B-complex vitamin supplements to lower homocysteine levels for the prevention of cardiovascular events in patients with PAD. D As per SVS 2015 guidelines, avoid using folic acid and vitamin B12 supplements for the treatment of intermittent claudication. D 5. Therapeutic procedures Indications for revascularization: As per CCS 2022 guidelines: Consider performing revascularization in patients with intermittent claudication affecting vocational, recreational, or daily living activities having an acceptable risk profile, reasonable expectation for function and life expectancy and if a trial of nonoperative therapy with an exercise program and optimal medical therapy has failed. C Do not perform revascularization in patients with asymptomatic peripheral arterial disease. D As per ESC 2018 guidelines: Consider performing revascularization when daily life activities are compromised despite exercise therapy. C Consider performing revascularization in association with exercise therapy when daily life activities are is severely compromised. C As per AHA 2017 guidelines, consider performing revascularization in patients with lifestyle- limiting claudication with an inadequate response to guideline-directed medical therapy. B As per SVS 2015 guidelines: Perform revascularization in patients with intermittent claudication and significant functional or lifestyle-limiting disability, if there is a reasonable likelihood of symptomatic improvement with treatment and when pharmacologic or exercise therapy, or both, have failed, and the benefits of treatment outweigh the potential risks. B Do not perform invasive treatments for PAD in the absence of symptoms, regardless of hemodynamic measures or imaging findings demonstrating PAD. D Choice of revascularization: As per CCS 2022 guidelines: Take into account anatomic, patient, and procedural factors in addition to operator expertise and resource availability when selecting endovascular versus open revascularization strategies for peripheral arterial disease. B Individualize the choice of revascularization procedure for intermittent claudication based on the expectation of low perioperative morbidity and reasonable likelihood of providing https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 8/16 6/29/23, 11:04 PM Peripheral artery disease of lower extremities Pathway sustained symptomatic benefit. B As per SVS 2015 guidelines, individualize the decision on choosing an invasive treatment for intermittent claudication. Ensure that the offered modality provides a reasonable likelihood of sustained benefit to the patient (> 50% likelihood of clinical efficacy for at least 2 years). Recognize that anatomic patency (freedom from hemodynamically significant restenosis) is a prerequisite for sustained efficacy of revascularization. B Show 2 more Endovascular interventions: As per CCS 2022 guidelines, perform endovascular therapy in appropriately selected patients with claudication or chronic limb-threatening ischemia. B Show 2 more As per ESC 2018 guidelines, perform endovascular therapy as the first choice of treatment in patients with short (< 5 cm) aortoiliac occlusive lesions. B Show 7 more As per AHA 2017 guidelines, perform endovascular therapy in patients with lifestyle-limiting claudication and hemodynamically significant aortoiliac or femoropopliteal occlusive disease. A Show 2 more As per SVS 2015 guidelines, perform endovascular procedures over open surgery in patients with focal aortoiliac occlusive disease causing intermittent claudication. B Show 9 more 6. Perioperative care Preoperative risk assessment: do not use the RCRI for preoperative assessment of cardiac risk in patients undergoing peripheral arterial surgery. D Show 4 more 7. Surgical interventions Surgical bypass: As per CCS 2022 guidelines: Perform surgical bypass to the popliteal artery (when indicated) with an autogenous vein in preference to prosthetic graft material in patients with intermittent claudication. A Do not perform femoral-tibial artery bypasses in patients with intermittent claudication. D As per ESC 2018 guidelines, consider performing aorto-(bi)femoral bypass in patients with aortoiliac occlusions fit for surgery. C Show 5 more As per AHA 2017 guidelines, consider performing surgical revascularization in patients with lifestyle-limiting claudication with inadequate response to guideline-directed medical therapy, acceptable perioperative risk, and technical factors suggesting advantages over endovascular procedures. C Show 3 more https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 9/16 6/29/23, 11:04 PM Peripheral artery disease of lower extremities Pathway As per SVS 2015 guidelines: Perform surgical reconstruction (bypass, endarterectomy) in patients with reasonable surgical risk meeting one of the following criteria: diffuse aortoiliac disease not amenable to an endovascular approach 1 failed attempts at endovascular therapy combined occlusive and aneurysmal disease. B Perform surgical bypass as an initial revascularization strategy in patients with diffuse femoropopliteal disease, small caliber (< 5 mm), or extensive calcification of the superficial femoral artery, in the presence of favorable anatomy for bypass (popliteal artery target, good runoff) and with an average or low operative risk. B Endarterectomy: As per ESC 2018 guidelines, consider performing a hybrid procedure combining iliac stenting and femoral endarterectomy or bypass in patients with iliofemoral occlusive lesions. C As per SVS 2015 guidelines, assess the common femoral artery in all patients undergoing revascularization for aortoiliac occlusive disease. Perform endarterectomy as first-line treatment in patients with hemodynamically significant common femoral artery disease. B Show 2 more 8. Specific circumstances Patients with acute limb ischemia: perform urgent revascularization in patients with neurological deficits. B Show 2 more Patients with chronic limb-threatening ischemia: As per CCS 2022 guidelines, refer all patients with chronic limb-threatening ischemia urgently to vascular specialists for consideration of revascularization. B Show 6 more As per ESC 2018 guidelines, ensure early recognition of tissue loss and/or infection and referral to the vascular team to improve limb salvage. B Show 6 more As per AHA 2017 guidelines, evaluate and provide comprehensive care with the help of an interdisciplinary care team in patients with critical limb ischemia and tissue loss to achieve complete wound healing and a functional foot. B Show 4 more As per AHA 2017 guidelines, perform revascularization when possible to minimize tissue loss in patients with critical limb ischemia. B Show 9 more Patients with foot infection: Diagnose and treat foot infection promptly to avoid amputation in patients with PAD. B Consider referring patients with PAD and signs of foot infection promptly to an interdisciplinary care team. C https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 10/16 6/29/23, 11:04 PM Peripheral artery disease of lower extremities Pathway Patients requiring oral anticoagulants: initiate oral anticoagulation in patients with PAD and AF with a CHA2DS2-VASc score of 2. A Consider initiating OACs also in all other patients. B Show 4 more Patients undergoing coronary artery intervention: Use radial artery access as the first option for coronary angiography/intervention in patients with PAD of lower extremities. B Consider sparing the autologous great saphenous vein for potential future use for surgical peripheral revascularization in patients with PAD of lower extremities undergoing CABG. C 9. Patient education Counseling on foot care: Counsel patients with PAD and diabetes mellitus about self-foot examination and healthy foot behaviors. B Consider counseling patients with PAD without diabetes mellitus on self-foot examination and healthy foot behaviors. C 10. Preventative measures Influenza vaccination: provide annual immunization against influenza in patients with PAD. B 11. Follow-up and surveillance Serial clinical assessment: As per AHA 2017 guidelines: Obtain periodic clinical evaluation, including assessment of cardiovascular risk factors, limb symptoms, and functional status in patients with PAD. B Consider performing biannual foot examinations in patients with PAD and diabetes mellitus. C As per SVS 2015 guidelines, obtain annual follow-ups in patients with intermittent claudication to assess compliance with lifestyle measures (smoking cessation, exercise) and medical therapies as well as to assess for the evidence of progression in symptoms or signs of PAD. Consider obtaining yearly ABI testing to provide objective evidence of disease progression. B Post-revascularization assessment, clinical: As per ACC/AHA 2017 guidelines, obtain periodic clinical evaluation and ABI measurement in patients with PAD after surgical or endovascular revascularization. B As per SVS 2015 guidelines, consider obtaining serial clinical assessments, including an interval medical history (to detect new symptoms, ensure compliance with medical therapies, and record subjective functional improvements), examination of pulses, and measurement of https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 11/16 6/29/23, 11:04 PM Peripheral artery disease of lower extremities Pathway resting and, if possible, post-exercise ankle-brachial indices, in patients treated with open or endovascular interventions for intermittent claudication. C Post-revascularization assessment, imaging: As per ACR 2022 guidelines, consider obtaining duplex ultrasound or arteriography of the lower extremity or MRA or CT angiography of the abdomen and pelvis with bilateral lower extremity runoff with IV contrast for the initial imaging assessment for revascularization in patients with lower extremity arterial claudication. C As per ACC/AHA 2017 guidelines, consider obtaining duplex ultrasound for routine surveillance of infrainguinal, autogenous vein bypass grafts in patients with PAD. C Show 2 more As per SVS 2015 guidelines, consider monitoring patients treated with lower extremity vein grafts for intermittent claudication with a surveillance program consisting of clinical follow-up and duplex scanning. C Post-revascularization antithrombotic therapy: As per CCS 2022 guidelines, initiate rivaroxaban 2.5 mg BID in combination with aspirin (80- 100 mg daily) with or without short-term clopidogrel use in patients with lower extremity peripheral arterial disease after elective endovascular revascularization. B Show 4 more As per ESC 2018 guidelines, initiate single antiplatelet therapy in patients with PAD after revascularization. B Initiate single antiplatelet therapy in patients after infra-inguinal bypass surgery. A Show 4 more As per AHA 2017 guidelines: Consider initiating dual antiplatelet therapy with aspirin and clopidogrel to reduce the risk of limb-related events in patients with symptomatic PAD after lower extremity revascularization. C Insufficient evidence to support the use of anticoagulation to improve patency after lower extremity autogenous vein or prosthetic bypass. I Management of restenosis: As per ESC 2018 guidelines, consider using drug-eluting balloons for the treatment of in- stent restenosis. C As per SVS 2015 guidelines, consider performing prophylactic open or endovascular reintervention to promote long-term bypass graft patency in patients previously undergone vein bypass surgery for intermittent claudication and have developed a significant graft stenosis on duplex ultrasound. B 12. Quality improvement Hospital requirements: set up a multidisciplinary vascular team in healthcare centers to make decisions for the management of patients with PADs. B Public health measures: implement and support initiatives to improve medical and public awareness of PADs, especially cerebrovascular and lower extremity artery diseases. B https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 12/16 6/29/23, 11:04 PM Peripheral artery disease of lower extremities Pathway Clinical findings Patient demographics Symptoms Age > 50 Calf pain Cold leg Past medical history Difficulty walking Erectile dysfunction Acute mesenteric ischemia Foot pain Aortic aneurysm Hip pain Atherosclerotic disease Intermittent claudication Carotid artery stenosis Leg cramping Coronary artery disease Leg fatigue Diabetes mellitus Leg pain Dyslipidemia Thigh pain Obesity Weakness in the legs Renal artery stenosis Stroke Social history Vital signs Cigarette smoking Hypertension Vascular exam Musculoskeletal exam Acute arterial occlusion Femoral bruit Muscle atrophy Lower extremity bruit Imaging findings Palpable pulse abnormality capillary refill time Arterial stenosis ABI Buerger's test Integument exam Brittle nails Nonhealing skin wounds Skin discoloration Skin wounds Thick toenails Likelihood Ratios Pertinent positives The following findings increase the probability of peripheral artery disease of lower extremities in adults. 11 13 Finding LR+ Value Presence of arterial stenosis 23.7 https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 13/16 6/29/23, 11:04 PM Peripheral artery disease of lower extremities Pathway Decreased PAD score (< 6) History of intermittent claudication 7.8 3 Increased capillary refill time (> 5 seconds) 1.9 Pertinent positives The following findings increase the probability of peripheral artery disease in symptomatic patients. 12 Finding LR+ Value Presence of skin wounds 5.9 (2.6-13.4) History of cold leg 5.9 (4.1-8.6) Presence of femoral bruit 5.7 (4.7-7.0) Presence of lower extremity bruit 5.6 (4.7-6.7) Show 2 more Pertinent negatives The following findings decrease the probability of peripheral artery disease of lower extremities in adults. 11 13 Finding LR- Value Absence of arterial stenosis 0.05 PAD score not decreased ( 6) 0.2 capillary refill time not increased ( 5 seconds) 0.8 No history of intermittent claudication 0.9 Pertinent negatives The following findings decrease the probability of peripheral artery disease in symptomatic patients. 12 Finding LR- Value Absence of palpable pulse abnormality 0.38 (0.23-0.64) Absence of lower extremity bruit 0.39 (0.34-0.45) Absence of skin discoloration 0.74 (0.69-0.79) Absence of femoral bruit 0.74 (0.70-0.78) Show 2 more Studies 2022 OCEAN(a)-DOSE (olpasiran 225 mg every 24 weeks) In patients with established ASCVD and a lipoprotein(a) concentration > 150 nmol/L, olpasiran was superior to placebo with respect to percent reduction in lipoprotein(a) concentration at week 36. Michelle L O'Donoghue et al. N Engl J Med. 2022 Nov 17. 2022 OCEAN(a)-DOSE (olpasiran 225 mg every 12 weeks) In patients with established ASCVD and a lipoprotein(a) concentration > 150 nmol/L, olpasiran was superior to placebo with respect to percent reduction in lipoprotein(a) concentration at week https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 14/16 6/29/23, 11:04 PM Peripheral artery disease of lower extremities Pathway 36. Michelle L O'Donoghue et al. N Engl J Med. 2022 Nov 17. Show 12 more References 1. Society for Vascular Surgery Lower Extremity Guidelines Writing Group, Conte MS, Pomposelli FB et al. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication. J Vasc Surg. 2015 Mar;61 3 Suppl):2S 41S. Open 2. 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Victor Aboyans, Jean-Baptiste Ricco, Marie-Louise E L Bartelink et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery ESVS Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization ESO The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology ESC and of the European Society for Vascular Surgery ESVS . Eur Heart J. 2018 Mar 1;39 9 763 816. Open 5. Expert Panel on Vascular Imaging, Ezana M Azene, Michael L Steigner et al. ACR Appropriateness Criteria Lower Extremity Arterial Claudication-Imaging Assessment for Revascularization: 2022 Update. J Am Coll Radiol. 2022 Nov;19 11S S364 S373. Open 6. US Preventive Services Task Force, Curry SJ, Krist AH et al. 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Chest. 2012 Feb;141 2 Suppl):e669S- e690S. Open https://web.pathway.md/diseases/recWWWlFX8N4KL8Wz 16/16