2 This guideline recognizes that: Individuals With PAD Present in Clinical Practice With Distinct SyndromesAsymptomatic: Without obvious symptomatic complaint (but usually with a functional impairment).Classic claudication: Lower extremity symptoms confined to the muscles with a consistent (reproducible) onset with exercise and relief with rest.“Atypical” leg pain: Lower extremity discomfort that is exertional but that does not consistently resolve with rest, consistently limit exercise at a reproducible distance, or meet all “Rose questionnaire” criteria.
3 This guideline recognizes that: Individuals With PAD Present in Clinical Practice With Distinct SyndromesCritical limb lschemia: Ischemic rest pain, nonhealing wound, or gangrene/Acute limb ischemia: The five “P”s, defined by the clinical symptoms and signs that suggest potential limb jeopardy:PainPulselessnessPallorParesthesiasParalysis (& polar, as a sixth “P”).
4 Clinical Presentations of PAD ~15%Classic (Typical) Claudication50%Asymptomatic~33%Atypical Leg Pain (functionally limited)1%-2%Critical Limb Ischemia
5 Claudication vs. Pseudoclaudication Characteristic of discomfortCramping, tightness, aching, fatigueSame as claudication plus tingling, burning, numbnessLocation ofdiscomfortButtock, hip, thigh,calf, footSame as claudicationExercise-inducedYesVariableDistanceConsistentOccurs with standingNoAction for reliefStandSit, change positionTime to relief<5 minutes30 minutesAlso see Table 4 of Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
6 Leg Pain Has a Differential Diagnosis Spinal canal stenosisPeripheral neuropathyPeripheral nerve painHerniated disc impinging on sciatic nerveOsteoarthritis of the hip or kneeVenous claudicationSymptomatic Baker’s cystChronic compartment syndromeMuscle spasms or crampsRestless leg syndromeAlso see Table 3 of Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
7 ABI and Functional Outcomes Proportion StoppingDuring 6-Minute WalkMean Distance Achievedin 6-Minute Walk7060501600401200Patients (%)30Feet8002040010<0.4<0.5ABIABIABI=ankle-brachial indexMcDermott MM, et al. Ann Intern Med. 2002;136:McDermott MM, Greenland P, Liu K, et al. The ankle brachial index is associated with leg function and physical activity: the Walking and Leg Circulation Study. Ann Intern Med. 2002;136:
8 Factors That Increase Risk of Limb Loss in Patients With Critical Limb Ischemia Factors that reduce blood flow to the microvascular bedDiabetesSevere renal failureSeverely decreased cardiac output (severe heart failure or shock)Vasospastic diseases or concomitant conditions (e.g., Raynaud’s phenomenon, prolonged cold exposure)Smoking and tobacco useFactors that increase demand for blood flow to the microvascular bedInfection (e.g., cellulitis, osteomyelitis)Skin breakdown or traumatic injuryAlso see Table 5 of Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
9 Objectives for Diagnostic Evaluation of Patients With Critical Limb Ischemia Localization of the responsible lesion(s) and measurement of relative severityAssessment of the hemodynamic requirements for successful revascularization (vis-à-vis proximal versus combined revascularization of multilevel disease)Assessment of individual patient endovascular or operative riskAlso see Table 6 of Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
10 Differential Diagnosis of Common Foot Ulcers Neuropathic UlcerNeuroischemic UlcerPainlessPainfulNormal pulsesAbsent pulsesTypically punches-out appearanceIrregular marginsOften located on sole or edge of foot or metatarsal headCommonly located on toesPresence of callusesCalluses absent or infrequentLoss of sensation, reflexes, and vibration senseVariable sensory findingsIncrease in blood flow(arteriovenous shunting)Decrease in blood flowDilated veinsCollapsed veinsDry, warm footCold footBone deformitiesNo bony deformitiesRed appearancePale, cyanoticReprinted with permission from Dormandy JA, Rutherford RB. J Vasc Surg. 2000;31:S1-S296.
11 Etiologic Classification of Foot and Leg Ulcers Venous obstruction and insufficiencyArterial etiologiesLarger arteriesAtherosclerotic lower extremity PADThromboemboli, atheroemboliThromboangiitis obliteransMicrocirculatoryDiabetic microangiopathyVasculitisCollagen vascular diseasesNeuropathicDiabetes mellitusInfectiousLeprosyMycoticHematologicSickle cell anemiaPolycythemiaThrombocytosisMalignancySquamous cell carcinomaKaposi’s sarcomaArtifactual or factitiousAlso see Table 10 of Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
12 The Vascular History and Physical Examination IIaIIbIIIcIndividuals at risk for lower extremity PADshould undergo a vascular review ofsymptoms to assess walking impairment,claudication, ischemic rest pain, and/or thepresence of nonhealing wounds.should undergo comprehensive pulseexamination and inspection of the feet.IIIaIIbIIIc
13 Identification of the Asymptomatic Patient With PAD A history of walking impairment, claudication,and ischemic rest pain is recommended as arequired component of a standard review ofsystems for adults >50 years who haveatherosclerosis risk factors, or for adults >70 years.Individuals with asymptomatic PAD should beidentified in order to offer therapeuticinterventions known to diminish theirincreased risk of myocardial infarction, stroke,and death.IIIaIIbIIIcIIIaIIbIIIB
14 Identification of the Symptomatic Patient With Intermittent Claudication Patients with symptoms of intermittentclaudication should undergo a vascularphysical examination, including measurementof the ABI.In patients with symptoms of intermittentclaudication, the ABI should be measured afterexercise if the resting index is normal.IIIaIIbIIIBIIIaIIbIIIB
15 Identification of the Symptomatic Patient With Intermittent Claudication Patients with intermittent claudication shouldhave significant functional impairment with areasonable likelihood of symptomaticimprovement and absence of other disease thatwould comparably limit exercise even if theclaudication was improved (e.g., angina, heartfailure, chronic respiratory disease, ororthopedic limitations) before undergoing anevaluation for revascularization.IIIaIIbIIIc
16 Revascularization of the Patient With Intermittent Claudication IIaIIbIIIcIndividuals with intermittent claudication who are offered the option of endovascular or surgical therapies should:be provided information regarding supervised claudication exercise therapy and pharmacotherapy;receive comprehensive risk factor modification and antiplatelet therapy;have a significant disability, either being unable to perform normal work or having serious impairment of other activities important to the patient;have lower extremity PAD lesion anatomy such that the revascularization procedure would have low risk and a high probability of initial and long-term success.
17 Evaluation of the Patient With Critical Limb Ischemia Patients with CLI should undergo expeditedevaluation and treatment of factors that areknown to increase the risk of amputation.Patients with CLI in whom open surgical repair isanticipated should undergo assessment ofcardiovascular risk.IIIaIIbIIIcIIIaIIbIIIB
18 Evaluation of the Patient With Critical Limb Ischemia Patients at risk of CLI (ABI less than 0.4 in anondiabetic individual, or any diabeticindividual with known lower extremity PAD)should undergo regular inspection of the feetto detect objective signs of CLI.The feet should be examined directly, withshoes and socks removed, at regular intervalsafter successful treatment of CLI.IIIaIIbIIIBIIIaIIbIIIc
19 Evaluation of the Patient With Critical Limb Ischemia IIaIIbIIIBPatients with CLI and skin breakdown shouldbe referred to healthcare providers withspecialized expertise in wound care.Patients at risk for CLI (those with diabetes,neuropathy, chronic renal failure, or infection)who develop acute limb symptoms representpotential vascular emergencies and should beassessed immediately and treated by aspecialist competent in treating vasculardisease.IIIaIIbIIIc
20 Surveillance of the Patient With Prior Infra-inguinal Bypass Graft IIaIIbIIIBLong-term patency of infrainguinal bypassgrafts should be evaluated in a surveillanceprogram, which should include an intervalvascular history, resting ABIs, physicalexamination, and a Duplex ultrasound atregular intervals if a venous conduit has beenused.
21 The Clinical Approach to the Patient With, or at Risk for, PAD Clinicians who care for individuals with PAD should be able to provide:A vascular review of symptomsA vascular-focused physical examinationUse of the noninvasive vascular diagnostic laboratory (ABI and toe-brachial index [TBI], exercise ABI, Duplex ultrasound, magnetic resonance angiography [MRA], and computed tomographic angiography [CTA])When required, use of diagnostic catheter-based angiography
22 The Vascular Review of Symptoms: An Essential Component of the Vascular History Key components of the vascular review of systems (not usually included in the review of systems of the extremities) and family history include the following:Any exertional limitation of the lower extremity muscles or any history of walking impairment. The characteristics of this limitation may be described as fatigue, aching, numbness, or pain. The primary site(s) of discomfort in the buttock, thigh, calf, or foot should be recorded, along with the relation of such discomfort to rest or exertion.Any poorly healing or nonhealing wounds of the legs or feet.Any pain at rest localized to the lower leg or foot and its association with the upright or recumbent positions.Post-prandial abdominal pain that reproducibly is provoked by eating and is associated with weight loss.Family history of a first-degree relative with an abdominal aortic aneurysm.
23 Comprehensive Vascular Examination Key components of the vascular physical examination include:Bilateral arm blood pressure (BP)Cardiac examinationPalpation of the abdomen for aneurysmal diseaseAuscultation for bruitsExamination of legs and feetPulse ExaminationCarotidRadial/ulnarFemoralPoplitealDorsalis pedisPosterior tibialScale:0=Absent1=Diminished2=Normal3=Bounding (aneurysm or AI)
24 The First Tool to Establish the PAD Diagnosis: A Standardized Physical Examination Pulse intensity should be assessed and should be recorded numerically as follows:0, absent1, diminished2, normal3, boundingUse of a standardexamination shouldfacilitate clinicalcommunicationIIIaIIbIIIc
25 Differential Diagnosis of PAD AtherosclerosisVasculitisFibromuscular dysplasiaAtheroembolic diseaseThrombotic disordersTraumaRadiationPopliteal aneurysmThromboangiitis obliterans (Buerger’s disease)Popliteal entrapmentCystic adventitial diseaseCoarctation of aortaVascular tumorIliac syndrome of the cyclistPseudoxanthoma elasticumPersistent sciatic artery (thrombosed)
26 ACC/AHA Guideline for the Management of PAD: Steps Toward the Diagnosis of PAD Recognizing the “at risk” groups leads to recognition of the five main PAD clinical syndromes:Obtain history of walking impairment and/or limb ischemic symptoms:Obtain a vascular review of symptoms:Leg discomfort with exertionLeg pain at rest; non-healing wound; gangreneNo leg pain“Atypical”leg painClassic claudicationChronic critical limb ischemia(CLI)Acute limb ischemia(ALI)Perform a resting ankle-brachial index measurement
27 How to Perform an ABI Exam Performed with the patient resting in the supine positionAll pressures are measured with an arterial Doppler and appropriately sized blood pressure cuff (edge 1-2 inches above the pulse; cuff width should be 40% of limb circumference).Systolic pressures will be measured in the right and left brachial arteries followed by the right and left ankle arteries.
28 ABI ProcedureStep 1: Apply the appropriately sized blood pressure cuff on the arm above the elbow (either arm).Step 2: Apply Doppler gel to skin surface.Step 3: Turn on the Doppler and place the probe in the area of the pulse at a 45-60° angle to the surface of the skin, pointing to the shoulder.Step 4: Move the probe around until the clearest arterial signal is heard.
30 ABI ProcedureStep 5: Inflate the blood pressure cuff to approximately 20 mmHg above the point where systolic sounds are no longer heard.Step 6: Gradually deflate until the arterial signal returns. Record the pressure reading.Step 7: Repeat the procedure for the right and left posterior tibial and dorsalis pedis arteries. Place the probe on the pulse and angle the probe at 45o toward the knee.Step 8: Record the systolic blood pressure of the contralateral arm.
31 Understanding the ABI ABI = Ankle systolic pressure The ratio of the higher brachial systolic pressure and the higher ankle systolic pressure for each leg:Ankle systolic pressureHigher brachial artery systolic pressureABI =
32 ≤ 0.90 is diagnostic of peripheral arterial disease Calculate the ABIFor the left side, divide the left ankle pressure by the highest brachial pressure and record the result.Repeat the steps for the right side.Record the ABIs and place the results in the medical record.Right Leg ABILeft Leg ABIRight Ankle PressureLeft Ankle PressureHighest Arm PressureHighest Arm PressureABI Interpretation≤ 0.90 is diagnostic of peripheral arterial diseaseHiatt WR. N Engl J Med. 2001;344: ; TASC Working Group. J Vasc Surg. 2000;31(1Suppl):S1-S296.
33 The Ankle-Brachial Index Lower extremity systolic pressureBrachial artery systolic pressureABI =The ankle-brachial index is 95% sensitive and 99% specific for PADEstablishes the PAD diagnosisIdentifies a population at high risk of CV ischemic eventsThe “population at risk” can be clinically and epidemiologically defined:Age less than 50 years with diabetes, and one additional risk factor Age 50 to 69 years and history of smoking or diabetesAge 70 years and olderLeg symptoms with exertion (suggestive of claudication) or ischemic rest painAbnormal lower extremity pulse examinationKnown atherosclerotic coronary, carotid, or renal artery diseaseToe-brachial index (TBI) useful in individuals with non-compressible pedal pulsesLijmer JG. Ultrasound Med Biol 1996;22:391-8; Feigelson HS. Am J Epidemiol 1994;140:526-34;Baker JD. Surgery 1981;89:134-7; Ouriel K. Arch Surg 1982;117: ; Carter SA. J Vasc Surg 2001;33:708-14
34 Interpreting the Ankle-Brachial Index ABIInterpretation1.00–1.29Normal0.91–0.99Borderline0.41–0.90Mild-to-moderate disease≤0.40Severe disease≥1.30NoncompressibleAdapted from Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192. Figure 6.
35 Using the ABI: An Example Right ABI80/160=0.50Brachial SBP160 mm HgPT SBP 120 mm HgDP SBP 80 mm Hg150 mm HgPT SBP 40 mm HgLeft ABI120/160=0.75Highest brachial SBPHighest of PT or DP SBPABI(Normal >0.90)ABI=ankle-brachial index; DP=dorsalis pedis; PT=posterior tibial; SBP=systolic blood pressure.
36 ABI LimitationsIncompressible arteries (elderly patients, patients with diabetes, renal failure, etc.)Resting ABI may be insensitive for detecting mild aorto-iliac occlusive diseaseNot designed to define degree of functional limitationNormal resting values in symptomatic patients may become abnormal after exerciseNote: “Non-compressible” pedal arteries is a physiologic term and such arteries need not be “calcified”
37 Toe-Brachial Index Measurement The toe-brachial index (TBI) is calculated by dividing the toe pressure by the higher of the two brachial pressures.TBI values remain accurate when ABI values are not possible due to non-compressible pedal pulses.TBI values ≤ 0.7 are usually considered diagnostic for lower extremity PAD.
38 Hemodynamic Noninvasive Tests Resting Ankle-Brachial Index (ABI)Exercise ABISegmental pressure examinationPulse volume recordingsThese traditional tests continue to provide a simple, risk-free,and cost-effective approach to establishing the PAD diagnosisas well as to follow PAD status after procedures.
41 Exercise ABI Testing Confirms the PAD diagnosis Assesses the functional severity of claudicationMay “unmask” PAD when resting the ABI is normalAids differentiation of intermittent claudication vs. pseudoclaudication diagnoses
42 Exercise ABI Testing: Treadmill Indicated when the ABI is normal or borderline but symptoms are consistent with claudication;An ABI fall post-exercise supports a PAD diagnosis;Assesses functional capacity (patient symptoms may be discordant with objective exercise capacity)..
43 The Plantar Flexion Exercise ABI Benefits:Reproduces treadmill-derived fall in ABICan be performed anywhereInexpensiveLimitation:Does not measure functional capacityReprinted with permission from McPhail, IR et al. J Am Coll Cardiol. 2001;37:1381.
45 Arterial Duplex Ultrasound Testing Duplex ultrasound of the extremities is useful to diagnose anatomic location and degree of stenosis of peripheral arterial disease.Duplex ultrasound is useful to provide surveillance following femoral-popliteal bypass using venous conduit (but not prosthetic grafts).Duplex ultrasound of the extremities can be used to select candidates for:endovascular interventionsurgical bypass, andto select the sites of surgical anastomosis.However, the data that might support use of duplex ultrasound to assess long-term patency of PTA is not robust.PTA=percutaneous transluminal angioplasty.
46 Noninvasive Imaging Tests Duplex UltrasoundDuplex ultrasound of the extremities is useful to diagnose the anatomic location and degree of stenosis of PAD.Duplex ultrasound is recommended for routinesurveillance after femoral-popliteal or femoral-tibial-pedal bypass with a venous conduit.Minimum surveillance intervals are approximately 3, 6, and 12 months, and then yearly after graft placement.
47 Magnetic Resonance Angiography (MRA) MRA has virtually replaced contrast arteriography for PAD diagnosisExcellent arterial pictureNo ionizing radiationNoniodine–based intravenous contrast medium rarely causes renal insufficiency or allergic reaction~10% of patients cannot utilize MRA because of:ClaustrophobiaPacemaker/implantable cardioverter-defibrillatorObesityGadolinium use in individuals with an eGFR <60 mL/min has been associated with nephrogenic systemic fibrosis (NSF)/nephrogenic fibrosing dermopathyMRA has virtually replaced contrast arteriography in helping to establish the diagnosis of PAD.MRA not only provides an excellent picture of the arteries but also has the advantage of not using ionizing radiation.Instead, MRA uses a noniodine-based intravenous contrast medium that rarely causes renal insufficiency or allergic reaction.However, approximately 10% of patients cannot be assessed by using MRA because of claustrophobia, a pacemaker or implantable cardioverter-defibrillator, or obesity.Keywords: PAD
48 Noninvasive Imaging Tests Magnetic Resonance Angiography (MRA)MRA of the extremities is useful to diagnoseanatomic location and degree of stenosis ofPAD.MRA of the extremities should be performedwith gadolinium enhancement.MRA of the extremities is useful in selectingpatients with lower extremity PAD as candidates for endovascular intervention.IIIaIIbIIIB
51 Noninvasive Imaging Tests Computed Tomographic Angiography (CTA)CTA of the extremities may be consideredto diagnose anatomic location andpresence of significant stenosis inpatients with lower extremity PAD.as a substitute for MRA for those patientswith contraindications to MRA.
52 The PAD Guideline Provides Steps Toward Ideal PAD Care Take strides to improve the standard of PAD care …
53 ACC/AHA Guideline for the Management of PAD: Steps Toward the Diagnosis of PAD Individuals“at risk”for PADAge 50 to 69 years and history of smoking or diabetesAge ≥ 70 yearsAbnormal lower extremity pulse examinationKnown atherosclerotic coronary, carotid, or renal arterial diseaseObtain history of walking impairment and/or limb ischemic symptoms: Obtain a vascular review of symptoms:Leg discomfort with exertionLeg pain at rest; nonhealing wound; gangreneNo leg pain“Atypical” leg painClassic claudicationChronic critical limb ischemia(CLI)Acute limb ischemia(ALI)Perform a resting ankle-brachial index measurementDiagnosis and Treatment of Asymptomatic PAD and Atypical Leg PainDiagnosis and Treatment of Asymptomatic PAD and Atypical Leg PainDiagnosis and Treatment of ClaudicationDiagnosis and Treatment of Critical Limb IschemiaDiagnosis and Treatment of Acute Limb IschemiaHirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
54 ACC/AHA Guideline for the Management of PAD: Diagnosis and Treatment of Asymptomatic PAD Individual at PAD risk: No leg symptoms or atypical leg symptomsConsider use of the San Diego Walking Impairment QuestionnairePerform a resting ankle-brachial index measurementABI ≥ 1.30(abnormal)ABI 0.91 to 1.30(borderline & normal)ABI ≤ 0.90(abnormal)Pulse volume recordingToe-brachial index(Duplex ultrasonography)Measure ABI afterexercise testNormal results:No PADAbnormal resultsNormal post-exercise ABI:No PADDecreased post-exercise ABIConfirmation of PAD diagnosisEvaluate other causes of leg symptomsHirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
55 ACC/AHA Guideline for the Management of PAD: Diagnosis and Treatment of Asymptomatic PAD Confirmation of PAD diagnosisRisk factor normalization:Immediate smoking cessationTreat hypertension: JNC-7 guidelinesTreat lipids: NCEP ATP III guidelinesTreat diabetes mellitus: HbA1c less than 7%Pharmacological Risk Reduction:Antiplatelet therapy (ACE inhibition; Class IIb, LOE C)ACE=angiotensin-converting enzyme; JNC-7=Joint National Committee on Prevention ;NCEP=National Cholesterol Education Program – Adult Treatment Panel III.Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
56 ACC/AHA Guideline for the Management of PAD: Diagnosis of Claudication and Systemic Risk Treatment Classic Claudication Symptoms:Muscle fatigue, cramping, or pain that reproducibly begins during exercise and that promptly resolves with restChart document the history of walking impairment (pain-free and total walking distance) and specific lifestyle limitationsDocument pulse examinationExercise ABI(TBI, segmental pressure, or Duplex ultrasound examination)ABI greater than 0.90ABIABI less than or equal to 0.90AbnormalresultsNormalresultsConfirmed PAD diagnosisNo PAD or consider arterial entrapment syndromesCont’dABI=ankle-brachial index; TBI=toe-brachial index.Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
57 ACC/AHA Guideline for the Management of PAD: Diagnosis of Claudication and Systemic Risk Treatment Confirmed PAD diagnosisRisk factor normalization:Immediate smoking cessationTreat hypertension: JNC-7 guidelinesTreat lipids: NCEP ATP III guidelinesTreat diabetes mellitus: HbA1c less than 7%Pharmacological risk reduction:Antiplatelet therapy(ACE inhibition; Class IIa)Treatment of ClaudicationACE=angiotensin-converting enzyme; JNC-7=Joint National Committee on Prevention ;NCEP=National Cholesterol Education Program – Adult Treatment Panel III.Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
58 ACC/AHA Guideline for the Management of PAD: Treatment of Claudication Confirmed PAD DiagnosisLifestyle-limiting symptomsNo significant functional disabilityLifestyle-limiting symptoms with evidence of inflow diseasePharmacological therapy:Cilostazol(Pentoxifylline)No claudication treatment required.Follow-up visits at least annually to monitor for development of leg, coronary, or cerebrovascular ischemic symptoms.Supervisedexercise programFurther anatomic definition by more extensive noninvasive or angiographic diagnostic techniquesThree-month trialThree-month trialPreprogram and postprogram exercise testing for efficacyEndovasculartherapy or surgical bypass per anatomySignificant disability despite medical therapy and/or inflow endovascular therapy, with documentation of outflow PAD, with favorable procedural anatomy and procedural risk-benefit ratioClinical improvement:Follow-up visitsat least annuallyEvaluation for additional endovascular or surgical revascularizationHirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
59 ACC/AHA Guideline for the Management of PAD: Diagnosis and Treatment of Critical Limb Ischemia Chronic CLI symptoms: Ischemic rest pain, gangrene, nonhealing woundIschemic etiology must be established promptly by examination and objective vascular studiesImplication: Impending limb lossHistory and physical examination:Document lower extremity pulses;Document presence of ulcers or infectionAssess factors that may contribute to limb risk:diabetes, neuropathy, chronic renal failure, infectionNo or minimal atherosclerotic arterial occlusive diseaseABI, TBI, or Duplex USEvaluation of source(ECG or Holter monitor; TEE; and/or abdominal US, MRA, or CTA);or venous DuplexSevere lower extremity PAD documented:ABI less than 0.4; flat PVR waveform; absent pedal flowCont’dConsider atheroembolism, thromboembolism, or phlegmasia cerulea dolensABI=ankle-brachial index; CLI=critical limb ischemia; CTA=computed tomographic angiography; ECG=electrocardiogram; MRA=magnetic resonance angiography; PVR=pulse volume recording; TEE=transesophageal echocardiogram; TBI=toe-brachial index; US= ultrasound.Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
60 ACC/AHA Guideline for the Management of PAD: Diagnosis and Treatment of Critical Limb Ischemia (1) Severe lower extremity PAD documented:ABI less than 0.4; flat PVR waveform; absent pedal flowSystemic antibiotics if skin ulceration and limb infection are presentObtain prompt vascular specialist consultation:Diagnostic testing strategyCreation of therapeutic intervention planPatient is not a candidate for revascularizationPatient is a candidate for revascularizationMedical therapyor amputation (when necessary)Cont’dOngoing vascular surveillanceWritten instructions forself-surveillanceABI=ankle-brachial index; PVR=pulse volume recording.Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.
61 ACC/AHA Guideline for the Management of PAD: Diagnosis and Treatment of Critical Limb Ischemia (2) Patient is a candidate for revascularizationDefine limb arterial anatomyAssess clinical and objective severity of ischemiaImaging of relevant arterial circulation (noninvasive and angiographic)Revascularization possible(see treatment text, with application ofthrombolytic, endovascular, and surgical therapies)Revascularization not possible:medical therapy;amputation (when necessary)Ongoing vascular surveillanceWritten instructions for self-surveillanceHirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.