A. Medical and Exercise Therapy
The cornerstones of PAD treatment are cardiovascular risk factor reduction and a supervised or structured exercise program. Essential elements include smoking cessation, antiplatelet therapy, lipid and blood pressure management, and weight loss. Nicotine replacement therapy, bupropion, and varenicline have established benefits in smoking cessation (see Chapter 1). Antiplatelet agents (aspirin, 81 mg orally daily, or clopidogrel, 75 mg orally daily) reduce overall cardiovascular morbidity and are recommended for all symptomatic patients. All patients with PAD should receive high-dose statin (eg, atorvastatin 80 mg daily if tolerated) to treat hypercholesterolemia and inflammation. A trial of cilostazol 100 mg orally twice a day, may improve walking distance in approximately two-thirds of patients.
Supervised exercise programs for PAD provide significant improvements in pain, walking distance, and quality of life and may be more effective than an endovascular treatment alone. A minimum training goal is a walking session of 30–45 minutes at least 3 days per week for a minimum of 12 weeks. Structured community or home-based exercise programs as well as alternative exercises (cycling, upper-body ergometry) may also be effective.
When the atherosclerotic lesions are focal, they can be effectively treated with angioplasty and stenting. This approach matches the results of surgery for single stenoses but both effectiveness and durability decrease with longer or multiple stenoses.
A prosthetic aorto-femoral bypass graft that bypasses the diseased artery segments is a highly effective and durable treatment for this disease. Patients may also be treated with a graft from the axillary artery to the femoral arteries (axillo-femoral bypass graft) or with a graft from the contralateral femoral artery (femoral-femoral bypass) when iliac disease is limited to one side. The operative risk of axillo-femoral and femoral-to-femoral bypass grafts is lower because the abdominal cavity is not entered and the aorta is not cross-clamped, but the grafts are less durable.