Peripheral arterial disease and claudication — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 67-year-old man who smokes 20 cigarettes a day has had cramping calf pain on walking 200 m for 6 months, relieved by rest. His resting ABI is 0.72 on the right and 0.95 on the left. His BP averages 146/88 mmHg, his LDL-C is 3.1 mmol/L, and he has no diabetes, no wounds and no history of revascularization, stroke, TIA, bleeding or acute coronary syndrome.^[1]

1. What does his ABI show, and which ESC 2024 row supports using it? Give class and level. (2)^[1]
2. Give two ESC 2024 risk-factor rows that apply to him, with class and level. (2)^[1]
3. Which antithrombotic therapy is recommended for him under ESC 2024, and which drug is not recommended for routine use? Give class and level. (2)^[1]
4. Describe the exercise programme ESC 2024 recommends or says should be considered for him. (2)^[1]
5. When may revascularization be considered for his claudication under ESC 2024? Give class and level. (2)^[1]

Model answers — SAQ 1

1. An ABI ≤0.90 confirms PAD, so the right leg is diagnostic and the left (0.95) is not (1 mark).^[1] ESC 2024 recommends ABI measurement as the first-line non-invasive test for screening and diagnosis of PAD, using an ABI ≤0.90 as a diagnostic criterion (Class I, Level B) (1 mark).^[1]
2. Stopping and abstaining from smoking of any kind is recommended to reduce the risk of aortic dissection, MI, death and limb ischaemia (Class I, Level A) (1 mark).^[1] Any one of: with hypertension, an SBP target towards 120–129 mmHg, if tolerated, is recommended (Class I, Level A); statins are recommended in all patients with PAD (Class I, Level A); an ultimate LDL-C goal of <1.4 mmol/L with a >50% reduction from baseline is recommended (Class I, Level A) (1 mark).^[1]
3. Aspirin alone (75–160 mg once daily) or clopidogrel alone (75 mg once daily) is recommended to reduce MACE in symptomatic PAD (Class I, Level A) (1 mark).^[1] Routine ticagrelor is not recommended in PAD (Class III, Level A) (1 mark).^[1]
4. Supervised exercise training is recommended in symptomatic PAD (Class I, Level A) (1 mark).^[1] At least three sessions a week of at least 30 min for at least 12 weeks should be considered (Class IIa, Level B) (1 mark).^[1]
5. In symptomatic PAD, after a 3-month period of optimal medical treatment and exercise therapy, PAD-related quality-of-life assessment is recommended (Class I, Level B) (1 mark).^[1] In symptomatic PAD with impaired PAD-related quality of life after that 3-month period, revascularization may be considered (Class IIb, Level B) (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 76-year-old woman with type 2 diabetes and known PAD has rest pain in the right forefoot that eases when she hangs her leg over the bed, and an ulcer on the right great toe that has not healed for 6 weeks. Her right ABI is 1.45 and her right toe pressure is 24 mmHg. There is cellulitis around the ulcer. She lives independently.^[1]

1. What is the diagnosis, and which clinical and haemodynamic features in the ESC 2024 text support it? (2)^[1]
2. Why is her ABI unreliable, and what does ESC 2024 recommend instead? Give class and level. (2)^[1]
3. Give two ESC 2024 Class I rows on her medical and wound management. (2)^[1]
4. Give the ESC 2024 Class I rows on the timing of revascularization and the preferred bypass conduit. (2)^[1]
5. Summarise one randomised trial comparing surgical and endovascular strategies in CLTI: population, design and main result. (2)^[10][11]

Model answers — SAQ 2

1. Chronic limb-threatening ischaemia: ESC 2024 says CLTI should be considered with ischaemic rest pain, a non-healing lower-limb wound of ≥2 weeks or lower-limb gangrene, and she has the first two (1 mark).^[1] A toe pressure <30 mmHg is one of the haemodynamic criteria that may be used to guide the diagnosis (1 mark).^[1]
2. In CLTI the standard ABI may be normal or falsely elevated because of non-compressible arteries from medial sclerosis, common in diabetes or CKD (1 mark).^[1] With non-compressible ankle arteries or an ABI >1.40, additional methods such as toe pressure, TBI or Doppler waveform analysis are recommended (Class I, Level B) (1 mark).^[1]
3. Any two (1 mark each): management by a vascular team is recommended (Class I, Level C); offloading mechanical tissue stress is recommended to allow wound healing (Class I, Level C); treating infection with antibiotics is recommended (Class I, Level C).^[1] Lower-limb exercise training is not recommended in CLTI with wounds (Class III, Level C) (no mark; context).^[1]
4. Revascularization is recommended as soon as possible (Class I, Level B) (1 mark).^[1] Autologous vein is recommended as the preferred conduit for infra-inguinal bypass (Class I, Level B) (1 mark).^[1]
5. BEST-CLI: 1830 patients with CLTI and infrainguinal PAD randomised to surgery or endovascular therapy in two parallel cohorts by availability of a single-segment great saphenous vein (1 mark); in cohort 1 (adequate vein), major adverse limb event or death occurred in 42.6% with surgery and 57.4% with endovascular therapy (HR 0.68; 95% CI 0.59–0.79) over a median 2.7 years (1 mark).^[10] Or BASIL-2: 345 patients with CLTI needing infra-popliteal revascularization, randomised open-label at 41 vascular surgery units in the UK, Sweden and Denmark to vein bypass first or best endovascular treatment first, and followed up for a minimum of 2 years; major amputation or death 63% vs. 53% (adjusted HR 1.35; 95% CI 1.02–1.80) (2 marks).^[11]