Peripheral arterial disease and claudication — structured viva

Stem

Practice viva. The examiner asks how you diagnose PAD, which drugs every patient with PAD should take, how you manage claudication, and what you do when a patient presents with an acutely ischaemic leg.^[1]

Branch A — Making the diagnosis

Examiner: A 65-year-old smoker describes calf pain on walking. How do you confirm PAD?^[1]

Strong answer:

• ESC 2024 recommends the ABI as the first-line non-invasive test for screening and diagnosis, with ABI ≤0.90 as the diagnostic criterion (Class I, Level B), reported separately for each leg.^[1]
• If the ankle arteries are non-compressible or the ABI is >1.40, additional methods such as toe pressure, TBI or Doppler waveform analysis are recommended (Class I, Level B); the usual pathological TBI threshold is ≤0.70.^[1]
• With an ABI >0.90 and clinical suspicion of PAD, ESC 2024 text says post-exercise ABI measurements should be considered, along with imaging studies, preferably by treadmill (no class or level given), and a fall of >20% may serve as a diagnostic criterion.^[1]
• Duplex ultrasound is recommended as the first-line imaging method to confirm lesions (Class I, Level C).^[1]

Follow-up: His ABI is 1.48 and he has diabetes. What now?^[1]

• An ABI >1.40 reflects arterial stiffness, seen in diabetes, severe kidney failure or advanced age, and correlates with increased cardiovascular events and mortality.^[1]
• With an ABI >1.40, additional methods such as toe pressure, TBI or Doppler waveform analysis are recommended (Class I, Level B), and, separately, in patients with diabetes or renal failure, measuring toe pressure or TBI is recommended if the resting ABI is normal (Class I, Level C).^[1]

Branch B — What every patient with PAD takes

Examiner: List the drug treatment you would give a patient with symptomatic PAD.^[1]

Strong answer:

• A statin, recommended in all patients with PAD (ESC 2024, Class I, Level A), towards an ultimate LDL-C goal of <1.4 mmol/L with a >50% reduction from baseline (Class I, Level A).^[1]
• Ezetimibe is indicated if the target is not reached (Class I, Level B), and a PCSK9 inhibitor is recommended if it is still not reached on maximally tolerated statin and ezetimibe (Class I, Level A).^[1]
• With hypertension, an SBP target towards 120–129 mmHg if tolerated is recommended (Class I, Level A), and an ACE inhibitor or ARB should be considered as first-line antihypertensive therapy (Class IIa, Level B).^[1]
• In symptomatic PAD, aspirin alone (75–160 mg once daily) or clopidogrel alone (75 mg once daily) is recommended to reduce MACE (Class I, Level A).^[1]
• Rivaroxaban 2.5 mg twice daily with aspirin 100 mg once daily should be considered with high ischaemic risk and non-high bleeding risk (Class IIa, Level A).^[1]
• With type 2 diabetes, an SGLT2 inhibitor or a GLP-1 receptor agonist with proven cardiovascular benefit is recommended to reduce cardiovascular events, independent of baseline or target HbA1c and other glucose-lowering drugs (each Class I, Level A).^[1]

Follow-up: What evidence supports adding low-dose rivaroxaban?^[6][7]

• COMPASS (7470 patients with lower-extremity PAD, carotid disease, or coronary disease with ABI <0.90, randomised double-blind after a 30-day run-in; median duration of treatment 21 months): rivaroxaban 2.5 mg twice daily plus aspirin reduced cardiovascular death, MI or stroke against aspirin alone (5% vs. 7%; HR 0.72) and major adverse limb events including major amputation (1% vs. 2%; HR 0.54).^[6]
• Its abstract says major bleeding was increased but fatal or critical organ bleeding was not.^[6]
• VOYAGER PAD (6564 patients after lower-extremity revascularization, double-blind): the composite of acute limb ischaemia, major amputation for vascular causes, MI, ischaemic stroke or cardiovascular death had Kaplan-Meier estimates at 3 years of 17.3% with rivaroxaban plus aspirin vs. 19.9% with placebo plus aspirin (HR 0.85); ISTH major bleeding was significantly higher.^[7]

Branch C — Claudication

Examiner: He wants an angioplasty for his claudication. What do you advise?^[1]

Strong answer:

• Supervised exercise training is recommended in symptomatic PAD (ESC 2024, Class I, Level A), and at least three sessions a week of at least 30 min for at least 12 weeks should be considered (Class IIa, Level B).^[1]
• If supervised training is not available or feasible, a structured and monitored home-based programme should be considered (Class IIa, Level A).^[1]
• After 3 months of optimal medical treatment and exercise, PAD-related quality of life should be assessed (recommended, Class I, Level B), and revascularization may be considered if it remains impaired (Class IIb, Level B).^[1]
• Revascularization is not recommended solely to prevent progression to CLTI (Class III, Level B).^[1]
• If he does undergo endovascular revascularization, SET is recommended as adjuvant therapy (Class I, Level A).^[1]

Branch D — The acutely ischaemic leg

Examiner: A patient arrives with a 4-hour history of a cold, numb, weak leg. Walk me through it.^[1]

Strong answer:

• ESC 2024 calls ALI a medical emergency; skeletal muscle and nerves tolerate ischaemia for roughly 4–6 h, and sensory loss or, especially, motor deficit is a sign of limb threat.^[1]
• An urgent evaluation by a vascular clinician with sufficient experience to assess limb viability and implement appropriate therapy is recommended (Class I, Level C), with analgesia as soon as possible (Class I, Level C).^[1]
• ESC 2024 text says to start analgesia, anticoagulation and intravenous fluids on diagnosis, and its row says heparin may be considered once ALI is confirmed (Class IIb, Level C).^[1]
• With a neurological deficit, urgent revascularization is recommended, and diagnostic imaging is recommended to guide treatment, provided it does not delay treatment, or if the need for primary amputation is obvious (Class I, Level C).^[1]
• After revascularization, monitoring for compartment syndrome and treating it (fasciotomy) is recommended (Class I, Level C).^[1]
• Systemic thrombolysis has no role in ALI.^[1]