When patients present with symptoms of peripheral arterial disease (PAD), evaluation and treatment cannot wait. Delays can result in serious complications, including infections, leg and/or foot amputations or premature death (in 2019, 11,753 people in the United States died from PAD‑related causes, the journal Circulation Research reports).

Primary care providers often have the first opportunity to address PAD symptoms. An early indicator is claudication in the hip, thigh, buttocks or calf, but as PAD progresses it can result in ischemic rest pain and/or non-healing foot wounds, said Leo J. Daab, M.D., RPVI, FACS, a vascular surgeon with OHSU’s Knight Cardiovascular Institute. Daab recommends screening all at-risk patients regularly — even those who don’t appear symptomatic — with an ankle-brachial index test (at times, claudication pain from PAD can be confused with neurogenic or spinal claudication, so the ABI test is imperative). Risk is greatest among men with diabetes, high cholesterol and a history of smoking.

An ABI ratio below .9 is indicative of PAD; anything between .9 and 1.2 is normal.

“Any patient with a ratio below .9 should be referred to a specialist for further evaluation,” Daab said.

Vascular surgeons are best equipped to treat PAD

Though the ABI is the gold standard when it comes to diagnosing PAD, a vascular surgeon can provide additional testing (an arterial duplex ultrasound or diagnostic angiogram, for example) to help determine the severity and exact location of the disease, as well as a targeted treatment plan. Treatment will depend on findings and can vary significantly from patient to patient. Some require lifestyle modification only (smoking cessation and exercise); others need to take statins or antiplatelet medications. For many, though, surgery paired with lifestyle modification is the most appropriate intervention, especially in patients with disabling or lifestyle-limiting claudication, or PAD that evolves into a severe infection or unresolvable ischemic rest pain, Daab said.

Depending on the patient, surgical recommendations can range from endovascular therapy (balloon angioplasty, laser angioplasty, atherectomy or stent placement) to surgical bypass or even a hybrid approach. Amputation is, of course, the worst-case scenario — the preference is to avoid it whenever possible — but in cases of life-threatening infection it is sometimes the only option.

Clinical outcomes for PAD patients

Even after treatment, patients can continue to struggle with PAD. They also face increased risk of heart attack or stroke. However, those that embrace the recommended lifestyle modifications (whether they had surgery or not) fare consistently better than those who do not, said Daab. Outcomes improve even further for patients who manage their comorbidities well.

“Patients who are in good control of their diabetes and high cholesterol do better with this disease than those who are not in good control,” Daab said.

When to refer

Any patient with clinical signs of PAD (claudication, ischemic rest pain or non-healing wounds) and/or an ABI ratio below .9 should receive a referral to a vascular surgeon for further evaluation and treatment. We process referrals urgently for patients with ischemic rest pain or non-healing wounds.

PAD risk factors

In the United States, PAD affects an estimated 6.5 million adults over the age of 40. It is most common among people who have diabetes, high cholesterol and a history of smoking. Black men in particular face the highest lifetime risk of a PAD diagnosis (30%). In comparison, Black women have a 27.6% risk and Hispanic men and women have a 22% lifetime risk. For white men and women, it is 19%. People without the standard risk factors are unlikely to experience PAD, said Dr. Daab.

Sources

• Circulation Research (volume 128, no. 12)
• Centers for Disease Control
• NIH National Heart, Lung, and Blood Institute
• Cardiovascular Research Foundation