Peripheral Artery Disease

Smoking cessation (MOST IMPORTANT): smoking accelerates PAD progression, worsens symptoms, increases amputation risk 10x, increases cardiovascular death 3-4x—MUST QUIT (nicotine replacement, bupropion, varenicline, counseling, whatever it takes), symptom improvement often dramatic within weeks-months of quitting, Exercise therapy (MOST EFFECTIVE TREATMENT for claudication): supervised walking program 3x/week, 30-60 min—walk until claudication pain, rest, repeat (interval training), increases collateral circulation, improves endothelial function, increases walking distance 50-200% (better than angioplasty for claudication improvement), pain during walking is OK (mild-moderate—'hurt but not harm', not severe pain), home walking program if supervised not available (but supervised more effective), consistency critical (benefits take 3-6 months), Optimize cardiovascular risk factors: blood pressure control (<130/80), cholesterol management (LDL <70 if high risk, focus on reducing oxidized LDL and inflammation—not just statin to lower LDL number), diabetes control (HbA1c <6.5-7%—tight control reduces PAD progression), weight loss if overweight, Foot care CRITICAL (if PAD): inspect feet daily (poor circulation delays healing—minor cuts become infected, lead to ulcers, amputation), moisturize (prevent cracking), proper footwear (avoid blisters, pressure sores), report any wounds immediately (don't wait), control diabetes (high glucose impairs healing), Medications: antiplatelet therapy (aspirin 81-325mg or clopidogrel 75mg—reduces cardiovascular events), statin (if high cholesterol or cardiovascular risk—atorvastatin, rosuvastatin), cilostazol (vasodilator, antiplatelet—improves walking distance 40-60%, side effects—headache, diarrhea, palpitations, contraindicated if heart failure), ACE inhibitor or ARB (if hypertension or diabetes—cardiovascular protection), avoid beta-blockers (may worsen claudication—though less concern with newer selective agents), Revascularization (if critical limb ischemia, rest pain, non-healing ulcers, failed conservative treatment): angioplasty +/- stenting (percutaneous—catheter-based, opens blockage, 70-90% initial success, 50-60% stay open 1-2 years, may need repeat procedures, less invasive than surgery), bypass surgery (vein graft or synthetic graft bypasses blockage, more invasive but more durable than angioplasty, 70-80% patency at 5 years, risks—infection, graft failure, amputation if fails), choice depends on location and severity of blockage, patient factors, EDTA chelation therapy: IV infusions of EDTA (removes heavy metals, calcium—reduces plaque, improves endothelial function), TACT study (Trial to Assess Chelation Therapy) showed benefit in diabetics with previous MI (reduced cardiovascular events 40%—post-hoc analysis, PAD subset had significant benefit), controversial but evidence growing, series of 30-40 infusions, Critical limb ischemia (rest pain, non-healing ulcers, gangrene): EMERGENCY—needs urgent revascularization to save limb, high amputation risk without treatment, hyperbaric oxygen (adjunctive—improves wound healing), aggressive wound care, pain management.