Peripheral Artery Disease (PAD) Guidelines
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Because early detection of peripheral artery disease (PAD) in asymptomatic patients and subsequent treatment may reduce cardiovascular disease (CVD) in a potentially large group of individuals, screening guidelines have been addressed by a number of organizations, including the following:
Currently, no organization recommends routine screening for PAD in asymptomatic patients. In 2013, the USPSTF changed its recommendation against screening to an indeterminate recommendation, due to insufficient evidence to assess the balance of benefits and harms. However, for individuals with known CVD or diabetes, the USPSTF recommends risk reduction interventions (eg, antiplatelet or lipid-lowering therapies). [1]
Recommendations for PAD screening are listed in Table 1, below.
Table 1. Recommendations for peripheral artery disease screening in adults. (Open Table in a new window)
Issuing organization
Year
Recommendation
U.S. Preventive Services Task Force [1]
2013
Insufficient evidence that screening for PAD in asymptomatic adults leads to clinically important benefits. Risk reduction interventions (such as antiplatelet or lipid-lowering therapies) are recommended for high- risk individuals with known CVD or diabetes.
American College of Preventive Medicine [2]
2011
No routine screening is recommended but clinicians should be alert to symptoms of PAD in patients with risk factors (eg, age ≥50 years, history of smoking, diabetes mellitus)
American College of Cardiology/American Heart Association [3, 4]
2005/2011
Screen with ankle-brachial index (ABI) in patients at increased risk, including adults ≥65 years old, adults ≥50 years old with a history of smoking or diabetes, and adults of any age with exertional leg symptoms or nonhealing wounds
Society for Vascular Surgery [5]
2015
Screening is reasonable if used to improve risk stratification, preventive care, and medical management in asymptomatic patients at increased risk, (eg, adults >70 years old, smokers, individuals with diabetes, those with an abnormal pulse examination, or other established CVD)
European Society of Cardiology [6]
2011
Consider screening with ABI in patients with coronary artery disease (CAD)
American Diabetes Association [7]
2015
Screen with ABI in patients with diabetes who are symptomatic or are asymptomatic and >50 years old or have at least one other risk factor (eg, smoking, hypertension, hyperlipidemia, or duration of diabetes >10 years)
The following organizations have released guidelines for the management of peripheral artery disease (PAD) in the lower extremities:
The ACC/AHA identifies the following as the most common risk factors for lower-extremity PAD [3] :
The SVS and ESC guidelines concur that older age, smoking, and diabetes are associated with the highest relative risk of developing lower-extremity PAD. [5, 6]
All three guidelines recommend ankle-brachial index (ABI) determination as the first-line noninvasive test to establish a diagnosis of PAD, because of its high sensitivity and specificity. [3, 5, 6] The ACC/AHA recommends using the resting ABI in patients with any of the following:
ABI diagnostic values are as follows: [4]
ACC/AHA and SVS recommend exercise ABI testing in patients with claudication or other risk factors whose ABI is borderline or normal. [3, 5] For patients with ABI >140, the ACC/AHA and ESC recommended toe-brachial index or pulse volume recording as alternative tests. [3, 6]
For symptomatic patients who may undergo revascularization, all three guidelines recommend imaging studies such as duplex ultrasound, computed tomography angiography, magnetic resonance angiography, and contrast arteriography. The use of segmental pressures and pulse volume recordings to assess localization and severity is also recommended. [3, 5, 6]
Treatment of asymptomatic disease is directed at risk factor reduction. The following measures are recommended by the ACC/AHA and ESC [3, 4, 6] :
Intermittent claudication (IC) is managed with exercise and medication to improve symptoms and impede progression of the disease. Endovascular and surgical revascularization are generally recommended when exercise and medication have failed. [3, 5, 6]
In addition to lifestyle modification for risk reduction, similar to those outlined above, the 2015 SVS guidelines for treatment of IC recommend the following first-line interventions [5] :
In general, the ACC/AHA and ESC recommendations are in agreement but include the following variations:
ACC/AHA guidelines recommend endovascular revascularization as second-line therapy for patients with lifestyle- or vocation-limiting disability when there is a reasonable likelihood of symptomatic improvement with treatment, and pharmacologic or exercise therapy, or both, have failed.
Aortobifemoral bypass is appropriate for patients who are unsuitable for endovascular repair; iliac endarterectomy and aortoiliac or iliofemoral bypass for surgical treatment of unilateral disease may be considered if aortobifemoral bypass is not possible. Axillofemoral-femoral bypass should not be considered except in very limited settings. [3]
SVS guidelines recommend an individualized approach to selection of invasive treatment. The SVS advises, however, that endovascular procedures are generally preferred over open surgery. [5]
ESC guidelines recommend an endovascular approach. An experienced team is required in patients with multi-vessel disease and severe comorbidities. Stent implementation should be considered for femoropopliteal lesions classified as type B according to the Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC B lesions). [6]
In its 2014 consensus statement on femoral-popliteal arterial intervention, the Society for Cardiac Angiography and Interventions (SCAI) advised that endovascular treatment is appropriate care for patients who have any of the following [8] :
The SCAI advises that endovascular treatment may be appropriate care for CTO with severe claudication or CLI, but is rarely appropriate care for most mildly symptomatic or asymptomatic blockages.
The ACC/AHA guideline includes the following recommendations for management of CLI [3, 4] :
The ACC/AHA guideline recommends evaluation for primary amputation of the leg in patients with any of the following:
The ESC recommends revascularization whenever feasible for limb salvage. Endovascular therapy is preferred, if technically possible. [6]
In 2014, the Society for Cardiac Angiography and Interventions (SCAI) issued a consensus statement on the treatment of infrapopliteal arterial disease. The statement provided the following recommendations [9] :
The following organizations have released guidelines for the management of renal artery stenosis (RAS):
The 2003 ACC/AHA and 2014 ESC guidelines recommend performing diagnostic studies to identify RAS in patients with any of the following [3, 6] :
The ACC/AHA guidelines also include patients with sudden, unexplained pulmonary edema in its class I recommendations. [3] In its 2014 SCAI Expert Consensus Statement for Renal Artery Stenting Appropriate Use, the SCAI utilized the ACC/AHA recommendations. [10]
The ESC has additional recommendation for patients with hypertension and abdominal bruit as well as those with hypertension and hypokalemia in particular when receiving thiazide diuretics. [6]
Class I recommendations for establishing a diagnosis of RAS generally concur and include the following [3, 6] :
When the clinical index of suspicion is high and the results of noninvasive tests are inconclusive, ACC/AHA recommends catheter angiography, [3] while ESC recommends digital subtraction angiography. [6]
Both guidelines are in agreement that captopril renal scintigraphy, selective renal vein renin measurements, plasma renin activity, and the captopril test are not recommended as useful screening tests for RAS (class III). [3, 6]
SCAI recommends renal angiography as the gold standard for invasive assessment of hemodynamically significant RAS and categorizes stenosis severity as follows [10] :
Severe angiographic stenosis is considered hemodynamically significant. Moderate angiographic stenosis is considered hemodynamically significant only when the patient also has a resting mean pressure gradient >10 mm Hg or systolic hyperemic pressure gradient >20 mm Hg or renal fractional flow reserve (FFR) ≤0.8. Mild and moderate stenosis that is not hemodynamically significant should only rarely be considered for revascularization. [10]
ACC/AHA, ESC and SCAI all prefer medical therapy as the first-line treatment for RAS. [3, 6, 10] ACC/AHA and ESC recommend ACE inhibitors, ARBs, and calcium channel blockers for unilateral RAS, [3, 6] but ESC considers ACE inhibitors and ARBs contraindicated for the treatment of bilateral severe RAS and in the case of a single functional kidney. [6] ACC/AHA also recommends beta-blockers for treatment of hypertension associated with RAS.
The ACC/AHA guidelines recommend percutaneous revascularization in patients with hemodynamically significant RAS and any of the following [3] :
In addition, percutaneous revascularization is reasonable for patients with progressive chronic kidney disease (CKD) and bilateral RAS or a RAS to a single functioning kidney and can be considered for unilateral RAS with chronic renal insufficiency. [3]
ACC/AHA and ESC recommend renal stent placement for ostial atherosclerotic RAS (class I). [3]
ACC/AHA gives a class I recommendation for balloon angioplasty with bailout stent placement if necessary for fibromuscular dysplasia lesions, [3] whereas ESC recommends considering balloon angioplasty with or without stenting for patients with RAS and recurrent congestive heart failure or sudden pulmonary edema and preserved left ventricular systolic function (class IIb). [6]
Based on an expert panel review of scientific data, the SCAI concluded that patients with the following are most likely to benefit from renal artery stenting [10] :
The SCAI concluded that patients with any of the following are typically not good candidates for renal artery stenting [10] :
ACC/AHA gives class I recommendations to surgical revascularization for the following indications [3] :
ESC gives a class IIb recommendation to consider surgical revascularization in patients undergoing repair of the aorta or with complex anatomy of renal arteries or after failure of endovascular treatment. [6]
Screening guidelines for abdominal aortic aneurysms (AAA) have been released by the following organizations:
Because most AAA are asymptomatic until they rupture but the risk for death with AAA rupture is as high as 75-90%, all the organizations recommend a one-time screening with ultrasound for high-risk men >65 years old. Because of the relatively low risk in women, including those who have smoked, the guidelines vary from recommending against screening to recommending it for in specific higher-risk populations. A comparison of all screening recommendations for AAA is outlined in Table 2, below.
Table 2. Abdominal aortic aneurysm screening recommendations (Open Table in a new window)
One-time abdominal screening with ultrasound
USPSTF (2014) [11]
ACPM (2011) [2]
SVS (2009) [12]
ESC (2014) [13]
ESVS (2011) [14]
All men
65-74 years old (offer selectively)
≥65 years old
>65 years old
≥65 years old
Men who have smoked
65-74 years old
65-74 years old
65-74 years old
Consider < 65 years old
Men with family history of AAA
≥60 years old
≥55 years old
Consider < 65 years old
All women
Recommend against in women who have never smoked
Recommend against
Recommend against in absence of family history or smoking
Not beneficial
Women who have smoked
Insufficient evidence
≥65 years old
>65 years old (consider)
Requires further investigation
Women with a family history of AAA
≥65 years old
SVS guidelines do not recommend rescreening patients for AAA if an initial ultrasound scan performed on patients 65 years of age or older demonstrates an aortic diameter of < 2.6 cm. [12] ESVS guidelines recommend considering rescreening in those initially screened at a younger age or at higher risk for AAA. [14]
ACC/AHA, SVS, ESC and ESVS guidelines agree that in asymptomatic patients with AAA < 5.5 cm, surveillance and smoking cessation are recommended; surgical repair is indicated for AAA ≥5.5 cm or if growth exceeds 1.0 cm/year. [3, 12, 13, 14] In addition, for patients with AAA < 5.5 cm, ACC/AHA and ESC recommend monitoring and controlling blood pressure and serum lipids. [3, 13] However, the SVS guidelines find doxycycline, roxithromycin, ACE inhibitors, and ARBs of uncertain benefit in reducing the risk of AAA expansion and rupture, and that use of beta- blockers is not recommended. [12]
All the guidelines recommend that the interval for monitoring by ultrasound for expansion of AAAs should shorten as the AAA enlarges. ACC/AHA guidelines recommend that with AAA < 4.0 cm, monitoring should take place every 2 to 3 years and with AAA 4.0-5.4cm, every 6 to 12 months. [3] A comparison of the intervals recommended by the other three guidelines is shown in Table 3, below.
Table 3. Recommendations for monitoring of abdominal aortic aneurysms (Open Table in a new window)
Monitoring Interval
Aneurysm size (cm)
SVS (2009) [12]
ESC (2014) [13]
ESVS (2011) [14]
5 years
2.6 to < 3.0
4 years
2.5 to < 3.0
3 years
3.0 to < 3.5
3.0 to < 4.0
2 years
4.0 to ≤4.5
3.0 to < 4.0
12 months
3.5 to < 4.5
>4.5
4.0 to < 4.5
6 months
≥4.5
4.5 to ≤5.0
According to the ESVS guidelines, surgery may be indicated for AAA ≥5.0 cm in women or in men at higher risk of rupture due to smoking, hypertension, or chronic airway disease. Patients should be referred to a vascular surgeon for risk assessment when the AAA reaches 5.0 cm. [14]
The ACC/AHA and ESC guidelines recommend endovascular or open aortic repair for patients with large aneurysms who are good surgical candidates. [4, 13] ACC/AHA further recommends that for patients who have undergone endovascular repair, long-term imaging surveillance should be performed to monitor for endoleak, document shrinkage or stability of excluded aneurysm sac, and to determine if further intervention is needed. Open repair is a reasonable option for those patients who cannot comply with long-term surveillance. [4]
Symptomatic AAA
ACC/AHA guidelines recommend immediate surgical evaluation of patients presenting with abdominal and/or back pain, pulsatile abdominal mass and hypotension. Surgical repair is indicated for all symptomatic AAAs regardless of size. [3]
ESC and ESVS guidelines recommend emergency repair for ruptured AAA and urgent repair for non-ruptured symptomatic AAA. [13, 14] In addition, ESVS finds no evidence to support endovascular repair of ruptured AAA. However, SVS guidelines recommend considering emergent endovascular repair if anatomically feasible. [12]
[Guideline] Moyer VA, U.S. Preventive Services Task Force. Screening for peripheral artery disease and cardiovascular disease risk assessment with the ankle-brachial index in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013 Sep 3. 159 (5):342-8. [Medline]. [Full Text].
[Guideline] Lim LS, Haq N, Mahmood S, Hoeksema L, ACPM Prevention Practice Committee, American College of Preventive Medicine. Atherosclerotic cardiovascular disease screening in adults: American College Of Preventive Medicine position statement on preventive practice. Am J Prev Med. 2011 Mar. 40 (3):381.e1-10. [Medline]. [Full Text].
[Guideline] Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the… Circulation. 2006 Mar 21. 113 (11):e463-654. [Medline]. [Full Text].
[Guideline] 2011 WRITING GROUP MEMBERS, 2005 WRITING COMMITTEE MEMBERS, ACCF/AHA TASK FORCE MEMBERS. 2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2011 Nov 1. 124 (18):2020-45. [Medline]. [Full Text].
[Guideline] Society for Vascular Surgery Lower Extremity Guidelines Writing Group, Conte MS, Pomposelli FB, Clair DG, Geraghty PJ, McKinsey JF, et al. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication. J Vasc Surg. 2015 Mar. 61 (3 Suppl):2S-41S. [Medline]. [Full Text].
[Guideline] European Stroke Organisation, et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011 Nov. 32 (22):2851-906. [Medline]. [Full Text].
[Guideline] American Diabetes Association. Standards of medical care in diabetes-2015 abridged for primary care providers. Clin Diabetes. 2015 Apr. 33 (2):97-111. [Medline]. [Full Text].
[Guideline] Klein AJ, Pinto DS, Gray BH, Jaff MR, White CJ, Drachman DE, et al. SCAI expert consensus statement for femoral-popliteal arterial intervention appropriate use. Catheter Cardiovasc Interv. 2014 Oct 1. 84 (4):529-38. [Medline]. [Full Text].
[Guideline] Gray BH, Diaz-Sandoval LJ, Dieter RS, Jaff MR, White CJ, Peripheral Vascular Disease Committee for the Society for Cardiovascular Angiography and Interventions. SCAI expert consensus statement for infrapopliteal arterial intervention appropriate use. Catheter Cardiovasc Interv. 2014 Oct 1. 84 (4):539-45. [Medline]. [Full Text].
[Guideline] Parikh SA, Shishehbor MH, Gray BH, White CJ, Jaff MR. SCAI expert consensus statement for renal artery stenting appropriate use. Catheter Cardiovasc Interv. 2014 Dec 1. 84 (7):1163-71. [Medline]. [Full Text].
[Guideline] LeFevre ML, U.S. Preventive Services Task Force. Screening for abdominal aortic aneurysm: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014 Aug 19. 161 (4):281-90. [Medline]. [Full Text].
[Guideline] Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg. 2009 Oct. 50 (4 Suppl):S2-49. [Medline]. [Full Text].
[Guideline] Erbel R, et al; ESC Committee for Practice Guidelines. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014 Nov 1. 35 (41):2873-926. [Medline]. [Full Text].
Issuing organization
Year
Recommendation
U.S. Preventive Services Task Force [1]
2013
Insufficient evidence that screening for PAD in asymptomatic adults leads to clinically important benefits. Risk reduction interventions (such as antiplatelet or lipid-lowering therapies) are recommended for high- risk individuals with known CVD or diabetes.
American College of Preventive Medicine [2]
2011
No routine screening is recommended but clinicians should be alert to symptoms of PAD in patients with risk factors (eg, age ≥50 years, history of smoking, diabetes mellitus)
American College of Cardiology/American Heart Association [3, 4]
2005/2011
Screen with ankle-brachial index (ABI) in patients at increased risk, including adults ≥65 years old, adults ≥50 years old with a history of smoking or diabetes, and adults of any age with exertional leg symptoms or nonhealing wounds
Society for Vascular Surgery [5]
2015
Screening is reasonable if used to improve risk stratification, preventive care, and medical management in asymptomatic patients at increased risk, (eg, adults >70 years old, smokers, individuals with diabetes, those with an abnormal pulse examination, or other established CVD)
European Society of Cardiology [6]
2011
Consider screening with ABI in patients with coronary artery disease (CAD)
American Diabetes Association [7]
2015
Screen with ABI in patients with diabetes who are symptomatic or are asymptomatic and >50 years old or have at least one other risk factor (eg, smoking, hypertension, hyperlipidemia, or duration of diabetes >10 years)
One-time abdominal screening with ultrasound
USPSTF (2014) [11]
ACPM (2011) [2]
SVS (2009) [12]
ESC (2014) [13]
ESVS (2011) [14]
All men
65-74 years old (offer selectively)
≥65 years old
>65 years old
≥65 years old
Men who have smoked
65-74 years old
65-74 years old
65-74 years old
Consider < 65 years old
Men with family history of AAA
≥60 years old
≥55 years old
Consider < 65 years old
All women
Recommend against in women who have never smoked
Recommend against
Recommend against in absence of family history or smoking
Not beneficial
Women who have smoked
Insufficient evidence
≥65 years old
>65 years old (consider)
Requires further investigation
Women with a family history of AAA
≥65 years old
Monitoring Interval
Aneurysm size (cm)
SVS (2009) [12]
ESC (2014) [13]
ESVS (2011) [14]
5 years
2.6 to < 3.0
4 years
2.5 to < 3.0
3 years
3.0 to < 3.5
3.0 to < 4.0
2 years
4.0 to ≤4.5
3.0 to < 4.0
12 months
3.5 to < 4.5
>4.5
4.0 to < 4.5
6 months
≥4.5
4.5 to ≤5.0
Eric H Yang, MD Associate Professor of Medicine, Director of Cardiac Catherization Laboratory and Interventional Cardiology, Mayo Clinic Arizona
Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Nothing to disclose.
Mariclaire Cloutier Freelance editor, Medscape Drugs & Diseases
Disclosure: Nothing to disclose.
Peripheral Artery Disease (PAD) Guidelines
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