Management of asymptomatic lower limb peripheral arterial disease and intermittent claudication clinical practice guidelines 2024

Published by the European Society of Vascular Surgery, this document includes the main aspects to take into account for the management of patients with asymptomatic peripheral vascular disease and intermittent claudication. This is the first guideline that specifically covers the diagnosis and treatment of patients with atherosclerotic lower extremity peripheral arterial disease (PAD,) falling within the following clinical stages: (1) asymptomatic lower limb PAD (Rutherford grade0/Fontaine stage I); and (2) intermittent claudication (IC, Rutherford grade IeIII/Fontaine stage IIa and IIb)

In this document authors carry out a brief overview of differences between previous cardiovascular guideline recommendations and this guideline collected in a table that reflects the differences between the different recommendations and the reason for them.

Likewise, the epidemiological aspects of its incidence and prevalence as well as its natural history are reviewed, highlighting its possible association with vascular disease at other levels, both coronary and carotid, taking into account that Concomitant PAD (clinical or subclinical) is also associated with a worse outcome in patients undergoing coronary revascularization.

Besides, atherosclerotic vascular disease in the lower limbs is thus a predictor of stroke, thromboembolism, and death in subjects with AF. On the other hand, it is also remembered that clinical attention should thus be paid to the development of PAD symptoms and signs in people with any stage of chronic kidney disease, as establishing the PAD diagnosis in this high risk population could lead to improved medical management that may in turn impact on long term prognosis

Regarding diagnosis the ankle brachial index is recommended as the appropriate test to establish the diagnosis of lower limb peripheral arterial disease, level of recommendation IB.
The authors reflect in a table an overview of the measurement conditions, calculation, interpretation, and target populations for the ankle brachial index measurement and established a flow chart for describing the principal steps to establish the lower limb peripheral arterial disease (PAD) diagnosis.

Once diagnosis is established for patients with lower limb PAD in whom lower limb revascularization is indicated and being considered, pre-procedural vascular imaging is recommended, to evaluate the location(s) and extent of arterial lesions IC.

For patients with lower limb PAD in whom imaging is indicated, duplex ultrasound, magnetic resonance angiography, or computed tomography angiography are recommended as primary imaging modalities, at the discretion of the treating physician. IB

In the treatment and recommendations section, there is a very well-developed schematic illustration of best medical treatment strategies in PAD patients which includes strict control of cardiovascular risk factors. In the same way, all recommendations regarding revascularization are included as well specific considerations according to each case and type of revascularization procedure as well as the most appropriate antithrombotic therapy. At the end of the document there are three sections: 1.-Aspects on sex, socio-economic factors, ethnicity, and diabetes 2. Unresolved issues and future research 3. Plain language summary and information for patient
Without any doubt, this is an excellent document that is a must-read. 

The 2024 Guidelines of the ESC on Peripheral Arterial and Aortic Diseases are very much awaited and will be published in the scope of the ESC Congress in London.