The worldwide prevalence of peripheral artery disease (PAD) is estimated to be in the range of 3-10%

The main symptom of PAD is intermittent claudication (IC). The prevalence of IC is approximately 3% in patients aged 40 years and rises to 6% in 60-year-old patients

A number of modifiable risk factors for PAD have been identified. These risk factors include smoking, diabetes mellitus, and hypertension

Incidence of amputation in patients with PAD:
Only 1-3.3% of patients with IC require amputation over a 5-year period
Amputation is used as the primary treatment for approximately 25% of patients with critical limb ischemia

PAD, coronary artery disease (CAD), and cerebral artery disease all commonly occur together:
40-60% of patients with PAD have concurrent CAD and cerebrovascular disease

The 15-year mortality rate for patients with IC is approximately 70%. Most of these deaths are attributable to CAD

Recommended therapeutic strategies for the management of atherosclerotic risk factors:
Smoking: a program of physician advice, group counseling sessions, and nicotine replacement is recommended for all patients with peripheral artery diesease who smoke

Hyperlipidemia: dietary modification should be initially used to control abnormal lipid levels

Hypertension: thiazides and angiotensin-converting enzyme inhibitors should be used as first-line pharmacological treatments for patients with PAD

Diabetes: the main aim of treatment in patients with co-morbid diabetes and PAD is to reduce their glycosylated hemoglobin (HbA1c) level to <7.0%

Homocysteine: the use of folate supplements is not recommended in patients with PAD

Antiplatelet drug therapy: all symptomatic PAD patients should receive long-term antiplatelet drug therapy with a drug such as aspirin/acetylsalicylic acid or clopidogrel

Coronary artery disease (CAD): current clinical guidelines should be adopted to manage PAD patients with clinical evidence of CAD

Beta-adrenergic blockers: patients with PAD undergoing vascular surgery should receive beta-blocking agents perioperatively

Carotid artery disease: current guidelines should be implemented to manage symptomatic carotid artery disease in patients with PAD

Renal artery disease:patients with suspected renal artery disease should be referred to a cardiovascular physician and treated according to current treatment guidelines 

Recommended treatment options for patients with intermittent claudication (IC):

The vascular history of patients with risk factors for peripheral artery disease (PAD) should be ascertained in order to investigate whether the patient has any claudication symptoms that limit their walking ability

The ankle-brachial index should be measured in all patients with suspected PAD

The success of IC treatment should primarily be evaluated using patient-based outcome assessment

Supervised exercise therapy should form the cornerstone of the initial treatment for patients with IC

Cilostazol should be used as the first-line pharmacotherapy agent in patients with IC

Key point summary

Clinical definition of critical limb ischemia (CLI):

Patients are defined as having CLI if they have chronic ischemic pain at rest, ulcers or gangrene that can be directly attributed to arterial occlusive disease

Recommended treatment options for patients with CLI:

Daily foot examination and referral to a foot specialist are vital in order to identify patients at risk of developing CLI

A multidisciplinary treatment approach is required in order to control patients' pain, manage concomitant cardiovascular risk factors, and avoid limb loss

Revascularization is the preferred treatment option for patients with CLI

The decision to use amputation as a potential treatment option depends on the potential for healing, rehabilitation, and return of quality of life

Ambiguous results have been obtained in clinical trials investigating the potential of prostanoids to treat patients with CLI; no other pharmacotherapy treatments are currently recommended

Key point summary
Diagnosis and treatment of acute limb ischemia (ALI)

A Doppler assessment should be used to confirm a diagnosis of ALI

A vascular specialist should evaluate all patients with suspected ALI to determine the therapeutic approach

All patients with ALI should receive parenteral anticoagulation therapy. The standard treatment is unfractionated heparin

After initial surgical or endovascular treatment, intraoperative angiography should be performed to identify any residual occlusion or critical arterial lesions

The recommended treatment for patients with compartment syndrome is fasciotomy

Key point summary

Recommendations for revascularization:

Endovascular techniques should be primarily used to treat conditions where the same level of symptomatic improvement will be obtained as using open repair/bypass procedures

Recommended treatment options for aortoiliac and femoral popliteal lesions vary depending on the severity of the patient's disease. In general, endovascular procedures are recommended for comparatively mild lesions, whereas surgical intervention is recommended for patients with severe occlusions or stenoses

Inflow and outflow arteries:

Inflow: provided that the origin of the graft and the flow of the artery are not compromised, any artery can be used as an inflow artery for a femoro-distal bypass

Outflow: the least diseased distal artery should be used as the outflow vessel in a femoro-tibial bypass

The ideal conduit for a femoral below-knee popliteal and distal bypass is the long saphenous vein

Patients undergoing revascularization should receive antiplatelet treatment both before and after their procedure. This therapy should continue indefinitely unless the patient develops any contraindications

A clinical surveillance program should be initiated for all patients undergoing a lower extremity bypass graft procedure

Key point summary

A variety of vascular imaging and laboratory techniques are available for the diagnosis of patients with peripheral artery disease (PAD):

Vascular laboratory techniques can be used to provide an assessment of the location and the severity of a patient's arterial disease. These techniques include:

Segmental limb pressure measurement
Pulse volume recording
Toe-brachial index assessment
Velocity wave form analysis

Investigating the severity of patients' disease with vascular imaging is recommended for all those undergoing revascularization. The different imaging methods used to assess patients with PAD include:

Digital subtraction angiography
Color-assisted duplex ultrasonography
Magnetic resonance angiography
Computed tomography angiography