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  • Review Article
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Peripheral artery disease. Part 2: medical and endovascular treatment

Nature Reviews Cardiology volume 8, pages 429–441 (2011)Cite this article

Subjects

Abstract

The treatment of peripheral artery disease (PAD) focuses on risk factor modification, cardiovascular event reduction, limb viability, and symptom improvement. Hypertension, hyperlipidemia, and diabetes mellitus should all be controlled to recommended target levels, and smoking cessation is vital. Antiplatelet therapies, such as aspirin or clopidogrel, should be administered in all patients unless contraindicated. Whenever possible, patients who present with claudication should be offered a regimen comprised of both medical and exercise therapy, which often results in substantial improvement in symptoms. For patients presenting with more-advanced disease, such as acute limb ischemia, critical limb ischemia, and severely-limiting symptoms of PAD, revascularization is often necessary. As a result of the rapid evolution in endovascular revascularization technology and expertise, many patients with PAD can be treated percutaneously. Therefore, in this Review, we will focus on medical therapy and endovascular revascularization of patients with PAD, with reference to surgical bypass in specific clinical scenarios.

Key Points

  • The three major objectives in the treatment of peripheral artery disease are to reduce cardiovascular morbidity and mortality, prevent amputation, and improve the symptom of claudication

  • In patients with peripheral artery disease, hypertension, hyperlipidemia, and diabetes must be controlled to recommended goals and smoking cessation is vital

  • Management of symptoms in patients with claudication starts with a combination of exercise therapy and cilostazol

  • Revascularization should be considered in patients with acute limb ischemia, chronic critical limb ischemia, iliac artery stenosis, or infrainguinal disease with lifestyle-interfering claudication nonresponsive to a trial of exercise and cilostazol

  • Endovascular intervention is the preferred method of revascularization in many scenarios; surgical revascularization is reserved for specific clinical scenarios and for cases where percutaneous therapy is not feasible or durable

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Figure 1: Approach for the patient who presents with claudication that interferes with their lifestyle.
Figure 2: CT and catheter-based angiograms from a 62-year-old man with diabetes who experienced 'one-half block' bilateral calf claudication.
Figure 3: Femoropopliteal intervention.

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Acknowledgements

C. P. Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape, LLC-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. The Zena and Michael A. Wiener Cardiovascular Institute & Marie-Josée and Henry R. Kravis Cardiovascular Health Center, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, Box 1033, 10029, NY, USA

    Mitchell D. Weinberg, Joe F. Lau & Jeffrey W. Olin

  2. Division of Cardiology, Section of Vascular Medicine and Intervention, Massachusetts General Hospital, 55 Fruit Street, Boston, 02114, MA, USA

    Kenneth Rosenfield

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  1. Mitchell D. Weinberg
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All authors contributed equally to discussion of content, writing the manuscript, and review/editing of the manuscript before submission and after peer-review. M. D. Weinberg and J. W. Olin also researched data for the article.

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Correspondence to Jeffrey W. Olin.

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Competing interests

K. Rosenfield has received research support as an investigator for Abbott Vascular, Atrium Medical Corporation, Bard Peripheral Vascular, Baxter Healthcare, IDev Technologies, Inc., Invatec/Medtronic, and Lutonix. He is a consultant/advisory board member for Abbott Vascular, Baxter Healthcare, Becker Venture Services Group LLC, Boston Biomedical, Inc., Cordis, Complete Conference Management, and HCRI. He is a member of the data safety and monitoring board for Boston Scientific. He has equity and/or stock options in CardioMEMS, Contego Medical LLC, Icon Plc, Lumen Biomedical, Medical Simulation Corporation, Micell Technologies, and Primacea. He received honoraria as a member of the board of governors of VIVA Physicians. J. W. Olin has acted as a consultant for Bristol-Myers Squibb, Merck & Co., Inc., and Sanofi-Aventis, and has received research support from Merck & Co., Inc. M. D. Weinberg and J. F. Lau declare no competing interests.

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Weinberg, M., Lau, J., Rosenfield, K. et al. Peripheral artery disease. Part 2: medical and endovascular treatment. Nat Rev Cardiol 8, 429–441 (2011). https://doi.org/10.1038/nrcardio.2011.81

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