Peripheral arterial disease (PAD) is often asymptomatic, and is underdiagnosed, under-recognized, and undertreated. It is associated with significant cardiovascular (CV) and cerebrovascular morbidity and mortality. Since the 2005 Canadian Cardiovascular Congress Consensus Conference on PAD, newer data are available to inform clinicians on best practices to manage patients with PAD.
Section 1 of this guideline provides evidence-based recommendations on the diagnosis and screening of patients with PAD, with a focus primarily on lower-extremity PAD. We discuss the most accurate signs, symptoms, and tests for detecting PAD in symptomatic and asymptomatic individuals. We review whether routine screening of patients at high risk for, or with established atherosclerosis, benefit from routine screening for PAD to reduce limb ischemia and global CV outcomes. We also review the evidence for screening patients with PAD for coronary artery disease (CAD) or cerebrovascular disease, to determine if this improves prognosis. Section 2 provides evidence-based recommendations and highlights the recent substantial advancements in the medical management of patients with PAD. We provide recommendations for clinicians who care for PAD patients regarding smoking cessation and exercise therapy. We also review the key evidence that supports risk factor modification and drug therapy including: (1) blood pressure (BP) diagnosis, lowering, and targets, and selection of BP medications; (2) the use of glucose-lowering medications; (3) the effectiveness of lipid-lowering agents including statins, proprotein convertase subtilisin/Kexin-9 (PCSK-9) inhibitors, and the role of icosapent ethyl. A substantial body of literature regarding the efficacy and safety of antithrombotic therapy in patients with PAD is reviewed, integrating recent evidence for low-dose rivaroxaban and aspirin to reduce major adverse CV and major adverse limb events (MALE). Use of antithrombotics in a broad range of PAD patients is discussed, from outpatients to those with lower extremity revascularization, including endovascular and open surgical approaches.
Section 3 provides guidance on revascularization procedures for patients with PAD. Preoperative assessment and risk stratification, and indications for revascularization are also reviewed. Significant advancements in technology and techniques of revascularization, particularly for endovascular procedures, are discussed to inform the nonsurgeon clinician caring for the patient with PAD. For surgeons and interventionalists, evidence for choosing between open surgical and endovascular procedures are reviewed. Please refer to the Supplementary Material for expanded information on the topics that follow.
The topics and scope were chosen by the 3 co-chairs. Aortic diseases were explicitly excluded. The primary and secondary panelists were assigned to each of the topic areas on the basis of consideration of their research and clinical expertise, with consideration for geography and gender. Primary panelists were asked to develop the health care questions and outline Population, Intervention, Comparison, Outcome (PICO) questions, if applicable. Evidence reviews were led by the primary panelists and supported by a targeted scan for on-topic systematic reviews and meta-analyses from 2016 to 2021 for the topics, identified by the McMaster Evidence Review Synthesis Team (MERST). The search was conducted in PubMed using keywords: “peripheral artery disease” and “diagnosis,” and “meta-analysis.” This search resulted in 369 citations, which were reviewed for each of the guideline topics. This initial search was augmented for each PICO question, the results of which can be found on ccs.ca. For sections on lipid-lowering, glucose-lowering, and antithrombotic therapy, which were dominated by multiple recent randomized controlled trials (RCTs), MERST completed a more detailed literature review (see ccs.ca). The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) scale for rating the strength of recommendations and the quality of evidence was applied. When each section was complete, the primary panelists voted on the recommendations and if more than two-thirds of the members agreed, it was confirmed. Secondary panelists were then asked to read the entire document and provide comments. The recommendation discussions are prefaced by the PICO points we considered in their development.
1. Canadian Cardiovascular Society: Framework for Application of GRADE in CCS Guideline Development. Available at: https://ccs.ca/wp-content/uploads/2021/07/CCS_GRADE_Framework_April2020.pdf.
Accessed April 1, 2021.