Management of peripheral arterial disease

Management is dependent on the severity of the symptoms and the extent to which they affect the patient's life. Options range from little or no active intervention in mild claudication to amputation in critical ischaemia.

Management is dependent on the severity of the symptoms and the extent to which they affect the patient's life. Options range from little or no active intervention in mild claudication to amputation in critical ischaemia.

Summary of NICE guidance re: management of peripheral arterial disease (PAD): (1)

Secondary prevention of cardiovascular disease in people with peripheral arterial disease

• all people with peripheral arterial disease should be offered information, advice, support and treatment regarding the secondary prevention of cardiovascular disease
  • smoking cessation
  • diet, weight management and exercise
  • lipid modification and statin therapy
  • the prevention, diagnosis and management of diabetes
  • the prevention, diagnosis and management of high blood pressure
  • antiplatelet therapy (3)
    
    
• management of intermittent claudication
  • offer a supervised exercise programme to all people with intermittent claudication (2)
    
    
  • angioplasty and stenting
    • should be offered if intermittent claudication only when:
      • advice on the benefits of modifying risk factors has been reinforced and
      • a supervised exercise programme has not led to a satisfactory improvement in symptoms and
      • imaging has confirmed that angioplasty is suitable for the person
      • primary stent placement should not be offered for treating people with intermittent claudication caused by aorto-iliac disease (except complete occlusion) or femoro-popliteal disease
      • primary stent placement should be considered for treating people with intermittent claudication caused by complete aorto-iliac occlusion (rather than stenosis)
      • bare metal stents should be used when stenting is used for treating people with intermittent claudication
        
        
  • bypass surgery and graft types
    • bypass surgery should be offered if severe lifestyle-limiting intermittent claudication only when:
      • angioplasty has been unsuccessful or is unsuitable and
      • imaging has confirmed that bypass surgery is appropriate for the person
    • use an autologous vein whenever possible for people with intermittent claudication having infra-inguinal bypass surgery
      
      
  • medication if intermittent claudication:
    • naftidrofuryl oxalate
      • consider naftidrofuryl oxalate for treating people with intermittent claudication only when:
        • supervised exercise has not led to satisfactory improvement and
        • the person prefers not to be referred for consideration of angioplasty or bypass surgery
      • review progress after 3-6 months and discontinue naftidrofuryl oxalate if there has been no symptomatic benefit
        
        
• management of critical limb ischaemia
  • if critical limb ischaemia ensure patients are assessed by a vascular multidisciplinary team before treatment decisions are made
  • major amputation should not be undertaken in people with critical limb ischaemia unless all options for revascularisation have been considered by a vascular multidisciplinary team
  • revascularisation
    • offer angioplasty or bypass surgery for treating people with critical limb ischaemia who require revascularisation, taking into account factors including:
      • comorbidities
      • pattern of disease
      • availability of a vein
      • patient preference
    • do not offer primary stent placement for treating people with critical limb ischaemia caused by aorto-iliac disease (except complete occlusion) or femoro-popliteal disease
    • primary stent placement should be considered for treating people with critical limb ischaemia caused by complete aorto-iliac occlusion (rather than stenosis)
    • use bare metal stents when stenting is used for treating people with critical limb ischaemia
    • use an autologous vein whenever possible for people with critical limb ischaemia having infra-inguinal bypass surgery

Reference:

1. Lower limb peripheral arterial disease. NICE Clinical Guideline (August 2012, updated December 2020)
2. Lane R, Harwood A, Watson L, et al. Exercise for intermittent claudication. Cochrane Database Syst Rev. 2017;(12):CD000990.
3. Aboyans V, Ricco JB, Bartelink MEL, 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. 2017 Aug 26.