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Lower Extremity Arterial Disease Treatment

Intro to PAD Treatment Options

Endovascular treatment is the guideline-recommended approach to lower extremity arterial disease when conservative approaches prove insufficient.
Endovascular treatment of lower extremity arterial disease using a minimally invasive catheter-based approach

For lower extremity arterial disease treatment, endovascular treatment is the guideline-recommended approach when conservative approaches prove insufficient. Peripheral artery disease (PAD) is treated most effectively by eliminating blockages in the arteries and restoring blood flow. Minimally invasive endovascular care is now the most common approach to revascularization.

In the hands of a dedicated Vascular Specialist, endovascular therapies can effectively restore blood flow to the lower extremities, reverse tissue loss, restore function, and salvage limbs on track for amputation. Here we provide a 101 on what options are available for lower extremity arterial disease treatment, with a focus on endovascular techniques and technology for the primary care physician.

You can use this quick navigation list to learn more about a specific type of treatment:

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Dr. Michael Lalezarian

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Conservative Therapy

Lifestyle Changes

Initial conservative therapy for the early stages of PAD involve lifestyle changes to reduce symptoms and to prevent the progression of disease. Ideally, every patient with PAD-related claudication should be started on a treatment to quit smoking and reduce weight, as cigarette smoking and morbid obesity are two major risk factors for PAD. Smoking cessation is especially important because studies show that most patients with claudication remain stable when they stop smoking. Other lifestyle changes such as healthy dieting can help prevent worsening of PAD and improve symptoms. Reducing PAD risk factors or controlling existing ones, such as diabetes or coronary heart disease, is strongly recommended.
Smoking cessation is a conservative therapy for lower extremity arterial disease

Exercise

An exercise program of walking on a treadmill or track for 45 to 60 minutes at least three times per week can also help reduce claudication. By allowing patients to increase the distance and time they can walk before developing symptoms, an exercise program can be a very effective treatment. Patients who respond well to an exercise program typically see improvements within 2 months, and the best results are seen when a trained professional is supervising. Supervised treadmill exercise for people with PAD is covered by Medicare and Medicaid. Importantly, more advanced disease can leave patients functionally deficient when exercise therapy is initiated, rendering them unable to participate. Patients with exercise-limiting claudication should be referred for specialty vascular care immediately.

Medication

In addition to lifestyle changes and exercise programs, patients with PAD symptoms may benefit from prescription blood pressure and/or cholesterol medications. Statins have been shown to slow progression of PAD and help with claudication symptoms, even in people who do not have high cholesterol. Aspirin and Plavix are medications that reduce blood clotting and are recommended for all patients with coronary heart disease equivalents, including PAD. These anticoagulating medicines may only modestly improve claudication symptoms, but they are important for preventing any adverse cardiovascular events or complications. Medicines that specifically target claudication symptoms include Cilostazol and Naftidrofuryl. Cilostazol is currently the most effective medication for the management of claudication symptoms, allowing some patients to traverse greater distances. Naftidrofuryl can also help you achieve pain-free walking. Importantly, neither of these medications attack the root cause of peripheral artery disease.
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The Endovascular Approach to Lower Extremity Arterial Disease Treatment

Lower extremity peripheral artery disease is treated most effectively by eliminating blockages in the arteries and restoring blood flow to tissues in the leg that aren’t receiving enough oxygen-rich blood. If medication, exercise, lifestyle changes, and risk factor modification are not sufficient to reduce PAD symptoms or progression, patients are usually good candidates for minimally invasive revascularization or bypass surgery.

The endovascular approach involves going directly into the blood vessel with catheter-based devices, such as balloons and stents, to treat the source of disease. Endovascular care is image-guided and can involve hybrid approaches. It may take place over multiple staged procedures with a multitude of techniques to ensure patient safety and optimal clinical outcomes. Endovascular treatments for PAD are provided by a Vascular Specialist trained in either minimally invasive revascularization therapy. When possible, catheter-based revascularization is typically recommended before surgery because it is less invasive and yields comparable or superior outcomes.

PAD can be categorized as above-the-knee (ATK) or below-the-knee (BTK) disease. The specific tools and devices used to accomplish minimally invasive revascularization will differ depending on the location of the obstructed artery, whether above or below the knee, with purpose-built devices for specific lesion morphology and anatomical location.

Vascular Specialist performing lower extremity arterial revascularization to treat peripheral artery disease

Above-the-Knee Revascularization

Pain in the butt, hips, or thighs can result from blockage of the main artery of the abdomen (the aorta) or its branches (the iliac arteries). Occlusive peripheral artery disease in the aortoiliac segment is typically treated with balloon angioplasty and/or stents. Thigh claudication and pain can also occur if arteries in the groin (the common femoral artery) or mid-thigh (the superficial femoral artery) are narrowed. Minimally invasive revascularization of these arteries in the femoropopliteal region of the leg usually involves treatment with balloon angioplasty and/or stents. The approach to stenting depends on the length of the obstructed segment. For shorter obstructions (less than 5 cm), balloon angioplasty alone often suffices. However, as the length and extent of the obstruction increases, so does the need for stenting.

Below-the-Knee Revascularization

Pain in the upper two thirds of the calf is usually due to the narrowing of the artery in the mid-thigh (the superficial femoral artery). Pain in the lower third of the calf is due to disease in the popliteal artery located behind the knee. Claudication in the foot can result from narrowing of the tibial or peroneal arteries. Minimally invasive revascularization can still be performed in the calf, ankle, and foot. However, any PAD below the popliteal artery in the knee (the infrapopliteal segment) isn’t typically treated with an intervention like balloon angioplasty if the only symptom is claudication. Rather, infrapopliteal interventions are usually reserved for patients with late-stage PAD that has progressed to chronic limb-threatening ischemia with visible tissue loss.
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Minimally Invasive Revascularization Technology

Minimally invasive revascularization involves a variety of techniques and procedures including balloon angioplasty, stenting, and atherectomy. Selection is based on factors such as symptom severity, anatomy and location of the blocked artery, extent of blockage, and the patient’s other pre-existing medical conditions.

Balloon Angioplasty

Balloon angioplasty involves threading a wire through the narrowed or blocked artery along the length of the blood vessel. A deflated balloon is placed over the wire and then inflated, opening the blockage and allowing blood to flow more freely. Balloon angioplasty can be performed with or without the assistance of a stent device. Angioplasty is most effective when treating single, short blockages.
Balloon-expanded stent placed along an arterial lesion to treat lower extremity arterial disease

Balloon-expanded stent placed along an arterial lesion.

Stenting

A stent is a wire mesh, tubular device that is inserted into the blood vessel containing the blockage. The stent is able to expand, so it is often used to prop open the blocked artery and hold the vessel open after balloon angioplasty. Stents stay in the body and are made of a special metal or polymer material. The goal of a stent is to prevent restenosis, which is when the vessel becomes narrowed again. Stents work better in some vessels than others. Like balloon angioplasty, stenting is most successful when treating single, short blockages. Although technology advancements allow for the treatment of multiple, longer, and even completely blocked segments of artery, restenosis is more common with these conditions.

Atherectomy

Atherectomy is a procedure that involves destroying plaque in the artery using a mechanical device that cuts, shaves, or burns away fatty deposits. Atherectomy is typically reserved for totally occluded arteries or arteries with hard, calcified plaques that are unsafe to open with balloon angioplasty alone.
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Surgical Approaches

Bypass Surgical Revascularization

Surgical bypass reroutes blood flow around blockages in the artery caused by PAD. This is accomplished by connecting a new piece of blood vessel above and below the area that is obstructed. The newly attached vessel provides an additional path for blood to flow so that it can avoid the plaque obstruction and get to the part of the leg that wasn’t receiving enough blood. The replacement blood vessel can be a graft taken from another part of the patient’s body or it can be a prosthetic man-made one.

Endarterectomy

Endarterectomy is the surgical removal of part of the inner lining of the artery along with any plaque deposits that may be obstructing the vessel. When minimally invasive revascularization is not possible, endarterectomy is an alternative procedure that can be performed on arteries supplying blood to the legs.
More Resources
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Los Angeles Vascular Specialist Dr. Michael Lalezarian

Vascular Specialist in Los Angeles

Learn more about Los Angeles Vascular Specialist Dr. Michael Lalezarian.

References

[1] Berger, JS., Davies, MG. Overview of lower extremity peripheral artery disease (Beyond the Basics). UptoDate. Accessed November 2020
[2] Dosluoglu, HH. Endovascular techniques for lower extremity revascularization. UpToDate. Accessed November 2020.
[3] Davies, MG. Management of claudication due to peripheral artery disease. UpToDate. Accessed November 2020.
[4] Patient education: Peripheral artery disease and claudication (The Basics). UpToDate. Accessed November 2020.
[5] Treatment of Peripheral Arterial Disease with Paclitaxel-Coated Balloons and Paclitaxel-Eluting Stents Potentially Associated with Increased Mortality – Letter to Health Care Providers. www.fda.gov. Accessed November 2020.
[6] Baerlocher (2015). Meta-Analysis of Drug-Eluting Balloon Angioplasty and Drug-Eluting Stent Placement for Infrainguinal Peripheral Arterial Disease. Journal of Vascular and Interventional Radiology, 26(4), 459–473.e4.
[7] Gerhard-Herman (2017). 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary. Journal of the American College of Cardiology, 69(11), 1465–1508.

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