The diagnosis and current treatment of chronic lower extremity arterial disease.
Chronic lower extremity arterial disease (PAD) can be categorized into three subsets: Asymptomatic PAD, Chronic Symptomatic PAD, and Chronic Limb Threatening Ischemia (CLTI). Symptoms, signs and treatment of patients in each category are presented. Ankle Brachial Pressure index and Doppler ultrasound should be measured and individuals with chronic symptomatic PAD and CLTI should undergo computed tomographic angiography (CTA), magnetic resonance angiography (MRA), or contrast peripheral vascular angiography for arterial revascularization evaluation. Medical therapy is initial treatment for asymptomatic and symptomatic chronic PAD and CLTI and should include a statin, antihypertensive medications, antiplatelet and antithrombotic therapy, and management of diabetes. American and European Society of Cardiology guidelines for CLTI with endovascular or surgical arterial revascularization are reviewed. Guidelines provide a Class 1 (strong) recommendation for endovascular therapy for patients with symptomatic claudication with hemodynamically significant aortoiliac or femoral popliteal disease who fail medical therapy and a structured exercise program. A Class 2 recommendation (i.e. reasonable) is given to surgical revascularization if preoperative risk is acceptable, technical factors suggest specific advantages over endovascular procedures, and an autologous saphenous vein is available for grafting. Rivaroxaban + Aspirin or a purinergic receptor P2Y G-protein coupled inhibitor + ASA and an exercise program are recommended for patients with chronic PAD.