Host/Editor: Dr. Alla Turshudzhyan, Chief Medical Resident at UCONN.
Majority of peripheral disease (PAD) cases are asymptomatic with only about 25% of patients presenting with claudication, rest pain, gangrene, and limb ulcerations. Ankle-brachial index (ABI) is a first-line diagnostic test. ABI of less than 0.9 is consistent with PAD. ABI greater than 1.3 is a sign of noncompressible calcified vessels. If patient’s story and exam are highly concerning for PAD, but ABI is normal, consider post-exercise ABI or a toe-brachial index. Use duplex US to help you identify location and severity of PAD. More advanced imaging may be warranted if non-invasive modalities are non-diagnostic or if patient needs an intervention. For symptomatic PAD patients, it is reasonable to consider clopidogrel over aspirin or low-dose rivaroxaban plus aspirin (while keeping in mind that rivaroxaban + ASA carries an increased risk of bleeding when compared to ASA alone). Antiplatelet therapy use in asymptomatic PAD is not routinely recommended. Treat claudication with supervised exercise program, followed by cilostazol or naftidrofuryl. If your patient progressed to the point that their symptoms are constant, disabling, and no longer responsive to lifestyle modification and pharmacotherapy, revascularization may be indicated. There are two options for revascularization – percutaneous and surgical. Most cases can be done percutaneously. Surgery is reserved for patient with long segment stenosis, multifocal stenosis, eccentric, calcified stenosis, or long segment occlusions.
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