Treatment

• Intermittent claudication

  • First-line therapy [23][24]

    • Structured exercise therapy

      • Patients repeatedly walk or exercise until the onset of claudication and then rest until the pain subsides

      • This cycle is repeated for 30-45 minutes, three times a week, for a minimum of 12 weeks.

      • Structured exercise therapy has been shown to improve patients' functional status and quality of life.

    • Cardiovascular risk factor modification

  • Persistent claudication despite first-line measures: Consider cilostazol (for symptomatic improvement) OR revascularization.

• CLI: Consider revascularization in addition to structured exercise therapy and cardiovascular risk factor modification.

As patients with PAD are at an increased risk of atherosclerotic cardiovascular disease (ASCVD) events such as MI or stroke, secondary prevention strategies for ASCVD should be initiated in all patients.

• Smoking cessation

• Treatment of dyslipidemia

  • Consider high-intensity statin therapy in all patients with PAD.

• Glycemic control (in patients with type 2 diabetes)

  • Consider metformin as a first-line oral hypoglycemic agent. [27]

• Antihypertensive treatment

• Single-agent antiplatelet therapy : aspirin OR clopidogrel (ticagrelor may also be considered) [3][7][28]

  • Recommended in all patients with symptomatic PAD (reduces morbidity and mortality from cardiovascular events)

• Recommended first-line therapy for claudication

• Involves repetitive exercise until the onset of claudication with intervening periods of rest until the pain subsides

Exercise therapy may improve claudication symptoms but not the ABI, as it primarily promotes collateral blood circulation.

• Indications

  • Consider in patients with persistent life-limiting claudication despite exercise therapy and risk factor modification.

  • Consider in patients with moderate to severe claudication who are not candidates for revascularization.

• Preferred agent: cilostazol (a phosphodiesterase III (PDE3) inhibitor with vasodilatory, antiplatelet, and antithrombotic properties)

Cilostazol improves claudication symptoms and walking distance but has not been shown to decrease major cardiovascular events.

The primary goal of revascularization is to improve blood flow in at least one artery to the foot to prevent pain and tissue loss.

• Indications

  • CLI, if the limb is viable

  • Lifestyle-limiting claudication despite optimal medical therapy and exercise

• Modalities [10][33][34]

  • Endovascular or surgical revascularization

  • The choice of procedure depends on the location and morphology of the arterial disease and the patient's comorbidities

• Wet gangrene, unsalvageable limb: Urgent amputation may be required, especially in patients with sepsis.

• Dry gangrene: Consult vascular surgery to evaluate for revascularization prior to amputation.