Atherosclerotic Occlusive Disease of the Lower Extremities
Publication Date: March 2, 2015
Last Updated: September 2, 2022
Diagnosis
Table 1. Diagnosis of Peripheral Arterial Disease (PAD)
The SVS recommends using the ABI as the first-line noninvasive test to establish a diagnosis of PAD in individuals with symptoms or signs suggestive of disease. When the ABI is borderline or normal (>0.9) and symptoms of claudication are suggestive, the SVS recommends an exercise ABI. ( S , A )
681
The SVS suggests against routine screening for lower extremity PAD in the absence of risk factors, history, signs, or symptoms of PAD. ( W , A )
681
For asymptomatic individuals who are at elevated risk, such as those aged >70, smokers, diabetic patients, those with an abnormal pulse examination, or other established cardiovascular disease, screening for lower extremity PAD is reasonable if used to improve risk stratification, preventive care, and medical management. ( W , A )
681
In symptomatic patients who are being considered for revascularization, the SVS suggests using 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. ( W , A )
681
In symptomatic patients in whom revascularization treatment is being considered, the SVS recommends anatomic imaging studies, such as arterial duplex ultrasound, computed tomography angiography, magnetic resonance angiography, and contrast arteriography. ( S , B )
681
Treatment
Table 3. Management of Asymptomatic Disease
The SVS recommends multidisciplinary comprehensive smoking cessation interventions for patients with asymptomatic PAD who use tobacco (repeatedly until tobacco use has stopped). ( S , A )
681
The SVS recommends providing education about the signs and symptoms of PAD progression to asymptomatic patients with PAD. ( S , U )
681
The SVS recommends against invasive treatments for PAD in the absence of symptoms, regardless of hemodynamic measures or imaging findings demonstrating PAD. ( S , B )
681
Table 4. Medical Treatment for Intermittent Claudication
The SVS recommends multidisciplinary comprehensive smoking cessation interventions for patients with IC (repeatedly until tobacco use has stopped). ( S , A )
681
The SVS recommends statin therapy in patients with symptomatic PAD. ( S , A )
681
The SVS recommends optimizing diabetes control (hemoglobin A1c goal of <7.0%) in patients with IC if this goal can be achieved without hypoglycemia. ( S , B )
681
The SVS recommends the use of indicated β-blockers (eg, for hypertension, cardiac indications) in patients with IC. There is no evidence supporting concerns about worsening claudication symptoms. ( S , B )
681
In patients with IC due to atherosclerosis, the SVS recommends antiplatelet therapy with aspirin (75–325 mg daily). ( S , A )
681
The SVS recommends clopidogrel in doses of 75 mg daily as an effective alternative to aspirin for antiplatelet therapy in patients with IC. ( S , B )
681
In patients with IC due to atherosclerosis, the SVS suggests against using warfarin for the sole indication of reducing the risk of adverse cardiovascular events or vascular occlusions. ( S , C )
681
The SVS suggests against using folic acid and vitamin B12 supplements as a treatment of IC. ( W , C )
681
In patients with IC who do not have congestive heart failure, the SVS suggests a 3-month trial of cilostazol (100 mg twice daily) to improve pain-free walking. ( W , A )
681
In patients with IC who cannot tolerate or have contraindications for cilostazol, the SVS suggests a trial of pentoxifylline (400 mg thrice daily) to improve pain-free walking. ( W , B )
681
A recommendation for using ramipril in IC was originally made but subsequently deleted (see Supplementary Material on page 41S.e1, online only).
Table 5. Exercise Therapy
The SVS recommends as first-line therapy a supervised exercise program consisting of walking a minimum of three times per week (30–60 min/session) for ≥12 weeks for all suitable patients with IC. ( S , A )
681
The SVS recommends home-based exercise, with a goal of ≥30 minutes of walking three to five times per week when a supervised exercise program is unavailable or for long-term benefit after a supervised exercise program is completed. ( S , B )
681
In patients who have undergone revascularization therapy for IC, the SVS recommends exercise (either supervised or home-based) for adjunctive functional benefits. ( S , B )
681
The SVS recommends that patients with IC be followed up annually to assess compliance with lifestyle measures (smoking cessation, exercise) and medical therapies as well as to determine if there is evidence of progression in symptoms or signs of PAD. Yearly ABI testing may be of value to provide objective evidence of disease progression. ( S , C )
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Table 6. General Considerations on Invasive Treatment for Intermittent Claudication
The SVS recommends endovascular therapy (EVT) or surgical treatment of IC for patients with significant functional or lifestyle-limiting disability when there is a reasonable likelihood of symptomatic improvement with treatment, when pharmacologic or exercise therapy, or both, have failed, and when the benefits of treatment outweigh the potential risks. ( S , B )
681
The SVS recommends an individualized approach to select an invasive treatment for IC. The modality offered should provide a reasonable likelihood of sustained benefit to the patient (>50% likelihood of clinical efficacy for ≥2 years). For revascularization, anatomic patency (freedom from hemodynamically significant restenosis) is considered a prerequisite for sustained efficacy. ( S , C )
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Table 7. Interventions for Aortoiliac Occlusive Disease (AIOD) in Intermittent Claudication
The SVS recommends endovascular procedures over open surgery for focal AIOD causing IC. ( S , B )
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The SVS recommends endovascular interventions as first-line revascularization therapy for most patients with common iliac artery or external iliac artery occlusive disease causing IC. ( S , B )
681
The SVS recommends the selective use of BMS or covered stents for aortoiliac angioplasty for common iliac artery or external iliac artery occlusive disease, or both, due to improved technical success and patency. ( S , B )
681
The SVS recommends the use of covered stents for treatment of AIOD in the presence of severe calcification or aneurysmal changes where the risk of rupture may be increased after unprotected dilation. ( S , C )
681
For patients with diffuse AIOD (eg, extensive aortic disease, disease involving both common and external iliac arteries) undergoing revascularization, the SVS suggests either endovascular or surgical intervention as first-line approaches. Endovascular interventions that may impair the potential for subsequent aortofemoral bypass in surgical candidates should be avoided. ( W , B )
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Table 8. Interventions for Aortoiliac Occlusive Disease in Intermittent Claudication
EVT of AIOD in the presence of aneurysmal disease should be undertaken cautiously. The SVS recommends that the modality used should either achieve concomitant aneurysm exclusion or should not jeopardize the conduct of any future open or endovascular aneurysm repair. ( S , C )
681
In all patients undergoing revascularization for AIOD, the SVS recommends assessing the common femoral artery (CFA). If hemodynamically significant CFA disease is present, the SVS recommends surgical therapy (endarterectomy) as first-line treatment.
( S , B )681
In patients with iliac artery disease and involvement of the CFA, the SVS recommends hybrid procedures combining femoral endarterectomy with iliac inflow correction. ( S , B )
681
The SVS recommends direct surgical reconstruction (bypass, endarterectomy) in patients with reasonable surgical risk and diffuse AIOD not amenable to an endovascular approach, after one or more failed attempts at EVT, or in patients with combined occlusive and aneurysmal disease. ( S , B )
681
In younger patients (age <50 years) with IC, the SVS recommends a shared decision-making approach to engage patients and inform them of the possibility of inferior outcomes with either endovascular or surgical interventions. ( W , C )
681
The SVS recommends either axial imaging (eg, computed tomography, magnetic resonance) or catheter-based angiography for evaluation and planning of surgical revascularization for AIOD. ( S , U )
681
When performing surgical bypass for aortoiliac disease, concomitant aneurysmal disease of the aorta or iliac arteries should be treated as appropriate (exclusion) and is a contraindication to end-to-side proximal anastomoses. ( S , U )
681
For any bypass graft originating from the CFA, the donor iliac artery must be free of hemodynamically significant disease, or any pre-existing disease should be corrected before performing the bypass graft. ( S , U )
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Table 9. Intervention For Femoropopliteal Occlusive Disease (FPOD) in Intermittent Claudication
The SVS recommends endovascular procedures over open surgery for focal occlusive disease of the superficial femoral artery (SFA) artery not involving the origin at the femoral bifurcation. ( S , C )
681
For focal lesions (<5 cm) in the SFA that have unsatisfactory technical results with balloon angioplasty, the SVS suggests selective stenting. ( W , C )
681
For intermediate-length lesions (5–15 cm) in the SFA, the SVS recommends the adjunctive use of self-expanding nitinol stents (with or without paclitaxel) to improve the midterm patency of angioplasty. ( S , B )
681
The SVS suggests the use of preoperative ultrasound vein mapping to establish the availability and quality of autogenous vein conduit in patients being considered for infrainguinal bypass for the treatment of IC. ( W , C )
681
The SVS recommends against EVT of isolated infrapopliteal disease for IC because this treatment is of unproven benefit and possibly harmful. ( S , C )
681
The SVS recommends surgical bypass as an initial revascularization strategy for patients with diffuse femoropopliteal (FP) disease, small caliber (<5 mm), or extensive calcification of the SFA, if they have favorable anatomy for bypass (popliteal artery target, good runoff) and have average or low operative risk. ( S , B )
681
The SVS recommends using the saphenous vein as the preferred conduit for infrainguinal bypass grafts. ( S , A )
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In the absence of a suitable vein, the SVS suggests using prosthetic conduit for FP bypass in claudicant patients if the above-knee popliteal artery is the target vessel and good runoff is present. ( W , C )
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Table 10. Postinterventional Medical Therapy in Intermittent Claudication
In all patients after endovascular or open surgical intervention for claudication, the SVS recommends optimal medical therapy (antiplatelets agents, statins, antihypertensives, control of glycemia, smoking cessation). ( S , A )
681
In patients undergoing lower extremity bypass (venous or prosthetic), the SVS suggests treatment with antiplatelet therapy (aspirin, clopidogrel, or aspirin plus clopidogrel). ( W , B )
681
In patients undergoing infrainguinal endovascular intervention for claudication, the SVS suggests treatment with aspirin and clopidogrel for ≥30 days. ( W , B )
681
Table 11. Surveillance After Interventions for Intermittent Claudication
The SVS suggests that patients treated with open or endovascular interventions for IC be monitored with a clinical surveillance program that consists of an interval history to detect new symptoms, ensure compliance with medical therapies, record subjective functional improvements, pulse examination, and measurement of resting and, if possible, postexercise ABIs. ( W , C )
681
The SVS suggests that patients treated with lower extremity vein grafts for IC be monitored with a surveillance program that consists of clinical follow-up and duplex scanning. ( W , C )
681
The SVS suggests that patients who have previously undergone vein bypass surgery for IC and have developed a significant graft stenosis on duplex ultrasound be considered for prophylactic reintervention (open or endovascular) to promote long-term bypass graft patency. ( S , C )
681
Recommendation Grading
Overview
Title
Atherosclerotic Occlusive Disease of the Lower Extremities
Authoring Organization
Society for Vascular Surgery
Publication Month/Year
March 2, 2015
Last Updated Month/Year
October 16, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Treatment, Management
Diseases/Conditions (MeSH)
D058729 - Peripheral Arterial Disease
Keywords
peripheral artery disease (P.A.D.), PAD, Peripheral artery disease