Peripheral Arterial Disease (PAD)

Management

Peripheral arterial disease (PAD) is strongly linked to smoking. Patients who still smoke should be given help to quit smoking.

Comorbidities should be treated, including

• hypertension
• diabetes mellitus
• obesity

As with any patient who has established cardiovascular disease, all patients should be taking a statin. Atorvastatin 80 mg is currently recommended. In 2010 NICE published guidance suggesting that clopidogrel should be used first-line in patients with peripheral arterial disease in preference to aspirin.

Exercise training has been shown to have significant benefits. NICE recommend a supervised exercise programme for all patients with peripheral arterial disease prior to other interventions.

Severe PAD or critical limb ischaemia may be treated by:

• endovascular revascularization
  • percutaenous transluminal angioplasty +/- stent placement
  • endovascular techniques are typically used for short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients
• surgical revascularization
  • surgical bypass with an autologous vein or prosthetic material
  • endarterectomy
  • open surgical techniques are typically used for long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease

Amputation should be reserved for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty of bypass surgery.

Drugs licensed for use in peripheral arterial disease (PAD) include:

• naftidrofuryl oxalate (Praxilene®️): vasodilator, sometimes used for patients with a poor quality of life
  • 100-200 mg PO TDS; re-assess in 3-6 months for improvement
• cilostazol: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects - not recommended by NICE