Peripheral arterial disease of the lower limbs Risk stratification and management

Peripheral arterial disease (PAD) of the lower limbs is present in 3-10% of the total population of whom 1/4 to 1/3 has symptoms. Prevalence increases with age with a prevalence of 15 to 20% at age 70 plus. Risk factors are similar to those for cardiovascular and cerebrovascular diseases, with smoking and diabetes as the most prominent. PAD of the lower limbs is often associated with other vascular diseas of the heart, brain and kidneys. The cardiovascular morbidity and mortality is 20-25%. A thorough anamnesis and clinical examination of the whole vascular system are the base to diagnosis. The ankle-brachial index (ABI) is a useful screening method in the first line to detect asymptomatic PAD. Intermittent claudication, pain at walking and disappearing at rest, stays stable in 70-80% of the cases. Critical limb ischaemia, pain at rest with or without trophic lesions, occurs in 1-2%. Control of cardiovascular risk factors is crucial and contains lifestyle modifications (stop smoking!), physical activity and medication (antiplatelet, statins). In symptomatic PAD a supervised exercise program is the first choice treatment. Drug trial therapy (naftidrofuryl) during at least 3 to 6 months can be considered if persistent symptoms and/or if exercise therapy is impossible or insufficient. Endovascular or surgical open revascularization procedures are indicated in case of persistent or worsening symptoms. The choice between procedure types is determined by the patient, lesion characteristics and the cost.