Clinical Quick Reference — Management of Lower Extremity PAD
Normal: ABI 1.00-1.40
Borderline: ABI 0.91-0.99 (requires additional testing)
Abnormal (PAD): ABI ≤0.90
Noncompressible (Calcified): ABI >1.40 (need toe-brachial index or TBI)
| Stage | Clinical Presentation |
|---|---|
| I | Asymptomatic |
| II | Claudication (pain with walking, relief with rest) |
| III | Rest pain (nocturnal leg pain) |
| IV | Tissue loss (ulcers, gangrene) |
Integrates Wound extent, Ischemia severity, and foot Infection to stratify amputation risk
Class 1 Single antiplatelet therapy for symptomatic PAD to reduce MACE
Class 1 Low-dose rivaroxaban 2.5mg BID + aspirin (COMPASS) reduces MACE and MALE in stable CAD/PAD
Class 1 Antiplatelet therapy after endovascular or surgical revascularization
Class 1 High-intensity statin therapy to achieve ≥50% LDL-C reduction in all PAD patients
Class 2a Add PCSK9 inhibitor or ezetimibe if LDL-C not at goal on maximal tolerated statin
Class 1 Antihypertensive therapy for BP control (goal <130/80 mmHg)
Class 1 ACE inhibitor or ARB preferred for hypertensive PAD patients
Class 1 SGLT2 inhibitors for PAD + type 2 diabetes to reduce MACE
Class 1 GLP-1 receptor agonists for MACE reduction in PAD with diabetes
Class 1 Counsel all PAD patients to quit smoking at every visit
Class 1 Pharmacotherapy (varenicline, bupropion, NRT) + behavioral counseling
Class 1 Cilostazol 100mg twice daily for leg symptom improvement in claudication
Class 2b Cilostazol may reduce restenosis after endovascular femoropopliteal therapy
Class 3 Pentoxifylline and chelation therapy NOT recommended
CLTI represents advanced PAD with rest pain or tissue loss. Risk stratification via WIfI classification based on wound size, ischemia severity, and foot infection presence.
Class 1 Multispecialty team evaluation for comprehensive CLTI care
Class 1 Surgical bypass preferred for infrapopliteal disease; autogenous vein preferred
Class 1 Endovascular approach reasonable for proximal disease
Sudden onset
Pale appearance
Absent pulses
Numbness/tingling
Muscle weakness
Cold limb
Class 1 Immediate vascular specialist evaluation
Class 1 Unfractionated heparin anticoagulation unless contraindicated
Class 1 Revascularization (catheter-directed thrombolysis, mechanical thrombectomy, or surgical thromboembolectomy) for salvageable limbs
Class 1 SET recommended for all patients with chronic symptomatic PAD
Class 1 Structured community-based exercise program effective alternative
Class 1 SET offered as initial treatment for functionally limiting claudication
Endovascular Revascularization: Preferred for proximal disease (iliac, proximal femoral); lower periprocedural morbidity.
Surgical Bypass: Preferred for infrapopliteal disease; autogenous vein superior to prosthetic; superior long-term durability.
Class 1 Preventive foot self-care education for all PAD patients
Class 1 Foot inspection by clinician at every office visit
Class 1 Therapeutic footwear for high-risk patients
Class 1 Comprehensive annual foot evaluation
Class 2a Referral to foot care specialist for ongoing surveillance
Integrated tools to support evidence-based PAD management:
10-year cardiovascular risk estimation
Next-generation CVD risk prediction
Glomerular filtration rate
Kidney function for dosing
Coronary heart disease risk
Fatal & nonfatal CVD events
Stroke risk in AFib
Bleeding risk with anticoagulation
Statin efficacy
Pulmonary embolism probability