AHA

Clinical Update
ADAPTED FROM:

2024 AHA/ACC Guideline on the

Management of Lower Extremity
Peripheral Artery Disease
Table 1. CLASS (STRENGTH) OF RECOMMENDATION LEVEL (QUALITY) OF EVIDENCE‡

Applying Class of CLASS 1 (STRONG)

Benefit >>> Risk
LEVEL A
• High-quality evidence‡ from more than 1 RCT
Recommendation Suggested phrases for writing recommendations:
• Is recommended
• Meta-analyses of high-quality RCTs
• One or more RCTs corroborated by high-quality

and Level of • Is indicated/useful/effective/beneficial

• Should be performed/administered/other
registry studies

LEVEL B-R
Evidence to
• Comparative-Effectiveness Phrases†:
− Treatment/strategy A is recommended/indicated in (Randomized)
preference to treatment B
Clinical
• Moderate-quality evidence‡ from 1 or more RCTs
− Treatment A should be chosen over treatment B
• Meta-analyses of moderate-quality RCTs
CLASS 2a (MODERATE)
Strategies, Benefit >> Risk
LEVEL B-NR
(Nonrandomized)

Interventions, Suggested phrases for writing recommendations:

• Is reasonable
• Can be useful/effective/beneficial
• Moderate-quality evidence‡ from 1 or more well-
designed, well-executed nonrandomized studies,

Treatments, or • Comparative-Effectiveness Phrases†:

− Treatment/strategy A is probably recommended/indicated
observational studies, or registry studies
• Meta-analyses of such studies

Diagnostic Testing in preference to treatment B

− It is reasonable to choose treatment A over treatment B
LEVEL C-LD
(Limited Data)

in Patient Care CLASS 2b (Weak)

Benefit ≥ Risk
• Randomized or nonrandomized observational or
registry studies with limitations of design or
execution
Suggested phrases for writing recommendations:
• Meta-analyses of such studies
• May/might be reasonable
• Physiological or mechanistic studies in human
• May/might be considered •COR and LOE are determined independently (any COR may be paired with any LOE).
subjects
• Usefulness/effectiveness is unknown/unclear/uncertain or not •A recommendation with LOE C does not imply that the recommendation is weak. Many
well-established important clinical questions addressed in guidelines do not lend themselves to clinical
LEVEL C-EO
trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a
CLASS 3: No Benefit (MODERATE) (Expert
particular test or therapy Opinion)
is useful or effective.

Benefit = Risk •*The outcome or result of the intervention should be specified (an improved clinical
• Consensus
outcome of expert
or increased diagnostic opinion
accuracy based
or incremental on clinical
prognostic information).
experience.
Suggested phrases for writing recommendations: • †For comparative-effectiveness recommendation (COR 1 and 2a; LOE A and B only),
• Is not recommended studies that support the use of comparator verbs should involve direct comparisons of the
treatments or strategies being evaluated.
• Is not indicated/useful/effective/beneficial
• Should not be performed/administered/other •‡The method of assessing quality is evolving, including the application of standardized,
widely-used, and preferably validated evidence grading tools; and for systematic reviews,
the incorporation of an Evidence Review Committee.
CLASS 3: Harm (STRONG)
•COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level
Risk > Benefit of Evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled trial.

Suggested phrases for writing recommendations:

• Potentially harmful
Gornik, H. L., et al. •(2024).
Causes2024
harm AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery
• Associated with excess Disease. Circulation.
morbidity/mortality
• Should not be performed/administered/other
Definitions
TERM DEFINITION
Acute (<2 week) hypoperfusion of the limb that may be characterized by
Acute limb ischemia
the following features: pain, pallor, pulselessness, poikilothermia,
(ALI) paresthesias, and/or paralysis.
A condition characterized by chronic (>2 wk.) ischemic rest pain,
nonhealing wounds/ulcers, or gangrene attributable to objectively proven
Chronic limb- arterial occlusive disease. Current nomenclature has evolved from the prior
threatening commonly used term of critical limb ischemia (CLI) to reflect the chronic
ischemia (CLTI) nature of this condition and its potentially limb-threatening nature with
associated risk for amputation and to distinguish it from acute limb
ischemia (ALI).

Major adverse Variably defined but usually includes death (all-cause or cardiovascular),
myocardial infarction, acute coronary syndrome (acute MI, unstable
cardiovascular angina), and stroke. May also include heart failure, rehospitalization for
events (MACE) cardiovascular causes, and other cardiovascular endpoints.

Variably defined but usually includes major amputation and endovascular

Major adverse limb
or surgical lower extremity revascularization (initial or reintervention). May
events (MALE) also include ALI.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 3
Disease. Circulation.
Recognizing Clinical Subsets of PAD

Abbreviations: ALI indicates acute limb ischemia; CLTI, chronic limb-threatening ischemia; and PAD, peripheral artery disease.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 4
Disease. Circulation.
History and Physical Exam for PAD
HISTORY PHYSICAL EXAM
• Claudication • Abnormal lower extremity pulse palpation (femoral,
– Pain type: Aching, burning, cramping, discomfort, or popliteal, dorsalis pedis, or posterior tibial arteries)
fatigue
• Vascular bruit
– Location: Buttock, thigh, calf, or ankle
– Onset/offset: Distance, exercise, uphill, how long for • Nonhealing lower extremity wound
relief after rest (typically <10 min for typical
claudication) • Lower extremity gangrene
• Other non-joint-related exertional lower extremity • Other physical findings suggestive of ischemia like
symptoms (not typical of claudication) or asymmetric hair growth, nail bed changes, calf
symptoms of impaired walking function muscle atrophy, or elevation pallor/dependent
– Lower extremity muscular discomfort associated with rubor.
walking that requires >10 min rest to resolve
– Leg weakness, numbness, or fatigue during walking
without pain

• Ischemic rest pain

• History of nonhealing
or slow-healing lower
extremity wound
• Erectile dysfunction

Abbreviations: PAD indicates peripheral artery disease; and min, minute

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 5
Disease. Circulation.
Resting ABI
History or Patients not at
physical increased risk of
Patients at
examination PAD and without
increased risk of
findings history or physical
PAD
suggestive of examination findings
PAD suggestive of PAD
Screening for PAD
Resting ABI with or Screening for PAD with
with resting ABI with
without ankle the
or without ankle
PVR and/or Doppler ABI is not
PVR and/or Doppler
waveforms recommended.
waveforms is
(Class 1) (Class 3: No Benefit)
reasonable. (Class 2a)

Resting ABI should be reported as abnormal,

borderline, normal, or non-compressible (Class 1)

Non-
Abnormal: Borderline: Normal:
compressible:
ABI ≤0.90 ABI 0.91–0.99 ABI 1.00–1.40
ABI >1.40

Abbreviations: ABI indicates ankle-brachial index; CLTI, chronic limb-threatening ischemia; PAD, peripheral artery disease; PVR, pulse
volume recordings;
SPP, skin perfusion pressure; TBI, toe-brachial index; and TcPO2, transcutaneous oxygen pressure.
Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 6
Disease. Circulation.
 Exercise ABI and Additional Physiological Testing
Patients with
Patients Patients with CLTI with
suspected
with Patients chronic nonhealing
chronic Suspected CLTI
suspected with PAD symptomatic wounds or
symptomatic
PAD PAD gangrene
PAD
Segmental leg
Toe pressure/TBI
pressures with Toe pressure/TBI
Non- Normal or with waveforms,
Abnormal PVR and/or with waveforms,
compressible Borderline TcPO2, SPP,
Resting ABI Doppler TcPO2, and/or
Resting ABI Resting ABI and/or other
waveforms is SPP is
local perfusion
reasonable to reasonable to
measures to
perform in perform in
Exercise determine
Exercise addition to addition to
treadmill ABI likelihood of
TBI with treadmill ABI resting ABI to resting ABI to
testing to wound healing
waveforms testing to help delineate establish the
assess without or after
(Class 1) evaluate for anatomic level of diagnosis of CLTI
functional revascularization
PAD (Class 1) PAD (Class 2a)
status and (Class 2a)
(Class 2a)
walking
performance
(Class 2a)

Abbreviations: ABI indicates ankle-brachial index; CLTI, chronic. limb-threatening ischemia; PAD, peripheral artery disease; PVR,
pulse volume recordings;
SPP, skin perfusion pressure; TBI, toe-brachial index; and TcPO2, transcutaneous oxygen pressure.
Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 7
Disease. Circulation.
Imaging for PAD
Anatomic Assessment
(Class 1)
Functional limiting • Duplex ultrasound
claudication despite • Computed tomography
GDMT angiography
Revascularization • Magnetic resonance
angiography
planning
• Catheter angiography
Patients with CLTI
To determine revascularization
strategy
Imaging to establish
diagnosis
Suspected PAD with (Class 2b)
• Duplex ultrasound
inconclusive ABI and • Computed tomography
physiological testing angiography
• Magnetic resonance
angiography

Confirmed diagnosis Invasive or noninvasive

imaging should not be
of PAD in whom
performed solely for
revascularization is anatomic assessment
not being considered (Class 3: Harm)

Abbreviations: CLTI indicates chronic. limb-threatening ischemia; CTA, computed tomography angiography; GDMT, guideline-directed
medical therapy;
MRA, magnetic resonance angiography; and PAD, peripheral artery disease.
Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 8
Disease. Circulation.
PAD-Related Risk Amplifiers and Health Disparities
Increase Risk of MACE and MALE
PAD Risk Amplifiers Health Disparities
Contributors
• Older Age (e.g., > 75 years) and
Geriatric Syndromes (e.g., frailty, • Geography (i.e., rural location with less
mobility impairment) access to health care)
• Diabetes • Race and Ethnicity (especially Black,
• Ongoing Smoking and Other Tobacco Hispanic, American Indian individuals)
Use • Structural Racism and Implicit Bias
• Chronic Kidney Disease and End-Stage • Social Determinants of Health
Kidney Disease
• Polyvascular Disease (i.e., coexisting
atherosclerotic heart-brain-leg
cardiovascular disease)
• Microvascular Disease (retinopathy,
neuropathy, nephropathy)
• Depression
• Chronic Stress Exercise
Social Determinants • Lower Quality Education and Poor Health • Inadequate Health Insurance
Literacy • Poor Access to Health Care (preventative
of Health • Lower Income and Less Access to Quality care, diagnosis, treatment,
Housing revascularizations)
Abbreviations: PAD indicates peripheral• artery
Limited Access
disease; tomajor
MACE, Quality Foodcardiovascular
adverse and •events;
Impact
andof Health
MALE, onadverse
major Jobs/Workplace
limb
events.
Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 9
Disease. Circulation.
Consideration for PAD in Older Patients
In older patients with PAD (i.e., age ≥75 years), assessment for geriatric syndromes can be useful
to identify high-risk patients, including before revascularization, and to provide safe and goal-
concordant care. (Class 2a)

Frailty Impact of amputation

Sarcopenia Mobility impairment

Malnutrition Revascularization considerations

Polypharmacy

Encourage shared decision making to evaluate the utility of endovascular, surgical, or

hybrid revascularization procedures to balance risk of complications or loss of
independence against the potential for improved quality-of-life and palliation of symptoms
with a limited life span.
Abbreviations: PAD indicates peripheral artery disease.
Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 10
Disease. Circulation.
Overview of Medical Therapy and
Preventive Footcare for Patients with PAD
Medications for Diabetes
Leg Symptoms Management

Structured Lipid-Lowering
Exercise Program Therapy
Medical
Therapy
Preventi of PAD Antihypertensive
ve Foot Therapy
Care

Antiplatelet and Smoking

Antithrombotic Cessation
Therapy
Abbreviations: PAD indicates peripheral artery disease.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 11
Disease. Circulation.
Anti-platelet therapy in Patients with PAD
Asymptomatic PAD Revascularized PAD
COR RECOMMENDATIONS COR RECOMMENDATIONS
Single antiplatelet therapy is reasonable Endovascular or surgical: antiplatelet therapy is
2a to reduce the risk of MACE recommended.
1
1 Endovascular or surgical: rivaroxaban (not caps) 2.5
mg BID + low dose aspirin is recommended to reduce
risk of MACE and MALE
Symptomatic PAD
Endovascular: DAPT with P2Y12 antagonist and low
2a dose aspirin for 1-6 months is reasonable
COR RECOMMENDATIONS
If on full-intensity anticoagulation for other indication
Single agent antiplatelet therapy with
2a and are not at a high risk of bleeding, adding single
1 aspirin alone (75-325 mg) or clopidogrel
antiplatelet therapy is reasonable
alone is recommended
If post prosthetic graft, DAPT with P2Y12 antagonist &
Rivaroxaban 2.5 mg BID + low dose
1 2b low dose aspirin for at least one month may be
aspirin is recommended
DAPT without recent revascularization in
ALL PAD
reasonable
2b symptomatic PAD has uncertain benefit
COR RECOMMENDATIONS
Adding vorapaxar to existing therapy is
2b of uncertain benefit
In PAD, without another indication, full intensity oral
3: Harm anticoagulation should not be used to reduce the risk
of MACE and MALE
Abbreviations: BID indicates twice a day; DAPT, dual anti-platelet therapy; MACE, major adverse cardiac events;
MALE, major adverse limb events; P2Y12, purinergic receptor P2Y; PAD, peripheral arterial disease.
Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 12
Disease. Circulation.
Medical Therapy in Patients with PAD
Lipid Lowering
Smoking Cessation
Therapy
COR RECOMMENDATIONS COR RECOMMENDATIONS
High intensity statin to lower LDL-C by Remind patients at every visit to quit or maintain
1 ≥ 50% 1 cessation
of tobacco use
If LDL-C remains ≥ 70 mg/dL on
maximally tolerated statin, adding Pharmacotherapy should be included in tobacco
2a ezetimibe or a PCSK9 inhibitor is 1 cessation plans combined with counseling and referral
reasonable to smoking cessation program
1 Advise patients to avoid secondhand smoke exposure
Antihypertensive
Therapy Diabetes
COR RECOMMENDATIONS COR RECOMMENDATIONS
Antihypertensive therapy to reduce the
1 1 Multidisciplinary team approach
risk of MACE
SBP goal <130 mmHg DBP Glycemic control with GLP1-receptor agonist and
1 1 SGLT2i to reduce risk of MACE
goal <80
Use ACEI or ARBs to reduce the risk of Glycemic control may be beneficial to improve limb
1 2b outcomes
MACE
Abbreviations: ACEI indicates angiotensin converting enzyme inhibitor; ARB, angiotensin II receptor blocker; DBP,
diastolic blood pressure; GLP1-a, glucagon-like peptide-1 agonist; LDL, low-density lipoprotein; MACE, major adverse limb
events; mmHg, millimeters of mercury; PCSK9i, proprotein convertase subtilsin-kexin type 9; PAD, peripheral artery
diseases; SBP, systolic blook pressure; and SGLT2i, sodium-glucose transporter 2 inhibitor.
Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 13
Disease. Circulation.
Preventive Foot Care and Leg Symptom
Management in Patients with PAD

Preventive Foot
Leg Symptoms
Care
COR RECOMMENDATIONS COR RECOMMENDATIONS
Educating patients & family on preventive foot Cilostazol is recommended to increase walking
1 care 1 distance and reduce symptoms

1 Foot inspection by clinician at every visit Cilostazol may help reduce restenosis after
2b endovascular therapy in femoropopliteal disease
Therapeutic footwear for those at high risk for
1 ulcers/amputation In chronic symptomatic PAD pentoxifylline and
3: No
Comprehensive foot evaluation annually to chelation therapy are not recommended for
1 identify risk factors for ulcers and amputation
Benefit treatment of claudication.
Referral to a foot care specialist for preventive 3: In patients with PAD and congestive heart failure
2a care and longitudinal surveillance is reasonable
Harm cilostazol is not recommended

Abbreviations: PAD indicates peripheral artery disease.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 14
Disease. Circulation.
Exercise Therapy for Patients with PAD

Chronic symptomatic Post revascularization for chronic

PAD symptomatic PAD
COR RECOMMENDATIONS COR RECOMMENDATIONS
Supervised exercise therapy is 1 Supervised exercise therapy is effective
1 recommended
A structured community-based program
1 with behavioral change techniques is
Functionally limiting
effective claudication
Non-walking structured exercise COR RECOMMENDATIONS
2a programs can be beneficial Supervised exercise therapy or structured community-
Usefulness of unstructured exercise 1 based exercise therapy should be the initial treatment
2b programs is uncertain option

Abbreviations: PAD indicates peripheral artery disease.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 15
Disease. Circulation.
Revascularization for Asymptomatic PAD

CO
RECOMMENDATIONS
R
In patients with asymptomatic PAD, it is
reasonable to perform procedures to
2a reconstruct diseased arteries if needed for the
safety, feasibility, or effectiveness of other
procedures.

3: In patients with asymptomatic PAD,

revascularization should NOT be
Har performed to prevent the progression of
m disease.

Abbreviations: PAD indicates peripheral artery disease.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 16
Disease. Circulation.
Patient-centered Approach to Revascularization

Start GDMT and Revascularization Patient-centered discussion

assess response Functionally consideration • Clinical presentation
limiting Hemodynami • Severity of symptoms
• Functional claudication • History and cally • Anticipated natural history
status despite physical significant • Degree of functional limitation
• Walking GDMT • Physiological PAD
• Response to GDMT (including
performance testing structured exercise) thus far
• Quality-of-life • Imaging studies • Revascularization strategy
• Likelihood of short and long-
term benefit
• Potential short and long-term
procedural risk

Abbreviations: GDMT indicates guideline-directed management and therapy.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 17
Disease. Circulation.
 Algorithm for Revascularization for Claudication,
Chronic Symptomatic PAD
Revascularization not
Symptoms are recommended (3: No
functionally limiting No benefit)
and response to Risk/benefit assessment: do No Revascularizatio
GDMT (including Yes potential benefits of n is a
structured exercise) revascularization (QOL, walking Yes reasonable
performance, functional status) treatment
is inadequate? outweigh risks? (1) option (2a)

Hemodynamically significant Hemodynamically Hemodynamically

aortoiliac or femoropopliteal significant common significant isolated
disease femoral artery disease
Endovascular infrapopliteal disease
Effectivenes
Surgical Endarterect approaches s of Effectivenes
revascularization is Endovascula Continue
omy is may be endovascula s of surgical
reasonable if r GDMT
reasonable, considered if r revasculariz
perioperative risk is revasculariz including
particularly patient is revasculariz ation is
acceptable and ation is structure
to preserve high risk for ation is unknown
technical factors effective (1) d
profunda surgery unknown (2b)
suggest advantages femoris and/or (2b) exercise
of endovascular artery anatomic (1)
approaches (2a) pathways factors are
Fem-pop
bypass (2a) favorable
autogenous (2b)
vein
preferred (1)
Abbreviations: GDMT indicates guideline-directed management and therapy; PAD, peripheral artery disease; and
QOL, quality of life.
Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 18
Disease. Circulation.
Revascularization for Functionally Limiting
Claudication, Recommendations based on Location
of Disease
Aortoiliac Femoropopliteal
CO CO
RECOMMENDATIONS RECOMMENDATIONS
R R
Endovascular revascularization is Endovascular revascularization is
1 effective
1 effective
Surgical revascularization is reasonable Surgical revascularization is reasonable
2a based on perioperative risk and 2a based on perioperative risk and
technical factors technical factors
Common Femoral Infrapopliteal
CO CO
RECOMMENDATIONS RECOMMENDATIONS
R R
2a Surgical endarterectomy is reasonable Effectiveness of both endovascular and
2b surgical revascularization is unknown
Endovascular approach may be
2b considered based on surgical risk and
anatomical factors.
Note: Patients should have functionally limited claudication and inadequate response to GDMT
(including structured exercise) to be considered for revascularization.

Abbreviations: GDMT indicates guideline-directed management and therapy.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 19
Disease. Circulation.
Conduit for Surgical Revascularization for
Femoropopliteal Disease
Functionally
limiting
claudication
Significant
femoropopliteal
disease

Surgical
revascularization
planned

Autogenous vein preferred to

prosthetic graft material (Class 1)

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 20
Disease. Circulation.
Components of Care for CLTI

Selective
Multispeci Wound care amputation
alty care and (most distal
team manageme level
nt of possible)
infection
Antiplatelet/
Revascularizati Pressure antithrombot
on offloading ic therapy
(endovascular, and
surgical, hybrid) cardiovascul
ar risk
reduction

Abbreviations: CLTI indicates chronic limb threatening ischemia.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 21
Disease. Circulation.
Revascularization Goals for CLTI

COR RECOMMENDATIONS
In patients with CLTI, surgical,
endovascular, or hybrid revascularization
techniques are recommended, when
1 feasible, to minimize tissue loss, heal
wounds, relieve pain, and preserve a
functional limb.

In patients with CLTI, an evaluation for

revascularization options by a
1 multispecialty care team is recommended
before amputation.

Abbreviations: CLTI indicates chronic limb threatening ischemia.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 22
Disease. Circulation.
Revascularization Strategy for CLTI

COR RECOMMENDATIONS
In patients undergoing surgical revascularization
for CLTI, bypass to the popliteal or infrapopliteal
1 arteries should be constructed with autogenous
vein if available.

In patients with CLTI due to infrainguinal disease,

anatomy, available conduit, patient
comorbidities, and patient preferences should be
1 considered in selecting the optimal first
revascularization strategy (surgical bypass or
endovascular revascularization).

In patients with CLTI who are candidates for

surgical bypass and endovascular
1 revascularization, ultrasound mapping of the
great saphenous vein is recommended.

Abbreviations: CLTI indicates chronic limb threatening ischemia.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 23
Disease. Circulation.
Revascularization Strategy for CLTI-continued

COR RECOMMENDATIONS
In patients with CLTI for whom a surgical
approach is selected and a suitable
autogenous vein is not available, alternative
2a conduits such as prosthetic or cadaveric
grafts can be effective for bypass to the
popliteal and tibial arteries.

In patients with CLTI and nonhealing wounds

or gangrene, revascularization in a manner
2a that achieves in-line blood flow or
maximizes perfusion to the wound bed can
be beneficial.

In patients with CLTI with ischemic rest pain

attributable to multilevel arterial disease, a
2a revascularization strategy addressing inflow
disease first is reasonable.

Abbreviations: CLTI indicates chronic limb threatening ischemia.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 24
Disease. Circulation.
Minimizing Tissue Loss for CLTI:
Pressure offloading is key
COR RECOMMENDATIONS
Patients with CLTI and diabetic foot ulcers
should receive pressure offloading, when
1 possible, to promote tissue growth and
wound healing.

Patients with PAD and prior diabetic foot

ulcers should be referred for customized
1 footwear that accommodates, protects, and
fits the shape of their feet.

Patients with CLTI and foot ulcers who do not

have diabetes may be considered for
2b pressure offloading to promote tissue growth
and wound healing.

Abbreviations: CLTI indicates chronic limb threatening ischemia; and PAD, peripheral
artery disease.
Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 25
Disease. Circulation.
Wound Care and Infection for Patients with CLTI

COR RECOMMENDATIONS
Prompt management of foot infection
with antibiotics, debridement, and
1 other surgical management is
recommended.

With nonhealing wounds, wound care

should be provided to optimize the
1 wound healing environment after
revascularization with the goal of
complete wound healing.

In nonhealing diabetic foot ulcers,

hyperbaric oxygen therapy may be
2b considered to assist in wound healing
after revascularization.

Abbreviations: CLTI indicates chronic limb threatening ischemia.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 26
Disease. Circulation.
“No Option” Patients
In patients with CLTI for whom revascularization is not an option:
COR RECOMMENDATIONS

2b Usefulness of prostanoids is uncertain.

Arterial intermittent pneumatic compression

2b devices may be considered to augment wound
healing or ameliorate ischemic rest pain.

Venous arterialization may be considered for limb

2b preservation if a lack of outflow to the foot is
observed

Abbreviations: CLTI indicates chronic limb threatening ischemia.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 27
Disease. Circulation.
Amputation in Patients with CLTI

COR RECOMMENDATIONS
For those who require amputation, evaluation should be performed
by a multispecialty care team to assess for the most distal level of
1 amputation that facilitates healing and provides maximal
functional ability

Primary amputation is indicated when life over limb is the

1 prevailing consideration and clinical factors suggest the threatened
limb to be the cause of the patient’s instability

A patient-centered approach using objective classification of the

threatened limb, patient risk, and anatomic pattern of disease is
1 combined with patient and family goals is recommended to identify
those patients in whom primary amputation or palliative
management is appropriate
When undergoing a minor amputation, a customized program of
follow-up care that can include local wound care, pressure
1 offloading, serial evaluation of foot biomechanics and use of
therapeutic footwear is recommended to prevent wound
recurrence

Retrospective assessment of institutional outcomes with objective

2a limb threat classification tools can be useful for quality
improvement
Abbreviations: CLTI indicates chronic limb threatening ischemia.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 28
Disease. Circulation.
ALI Diagnosis and Management

Suspected ALI All Patients With ALI

Acutely cold, painful,
Heparin unless contraindicated
pulseless leg (symptoms
(1)
<14 days)
Comprehensive history/ physical
Suspected ALI
examination
Assess for underlying cause (2a)

Emergency clinical evaluation

Testing for acute CV cause (EKG,
including: symptoms, motor and echocardiography, heart rhythm
sensory assessment, arterial and monitoring) (2a)
venous Doppler signals (1)

Abbreviations: ALI indicates acute limb ischemia; CV, cardiovascular; and EKG, electrocardiogram.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 29
Disease. Circulation.
ALI Diagnosis and Management
Management Based on Clinical Assessment and Doppler Signals
Suspected Emergency clinical evaluation including symptoms, motor
and sensory assessment, arterial and venous Doppler
ALI signals (1)

Audible arterial / Inaudible arterial / Inaudible arterial /

Audible venous Audible venous Inaudible venous
Category III: Irreversible
Category I: Viable Motor function assessment • Complete loss of motor
• Normal motor function
• No sensory loss function
• Complete sensory loss
Category IIa: Marginally Category IIb: Immediately
Revascularization threatened threatened
(urgent) AND • Sensory loss limited to toes if • Sensory loss more than toes Revascularization should
anticoagulation with • Mild or moderate muscle not be performed (i.e.
present
heparin, unless • No muscle weakness primary amputation of non-
weakness
contraindicated (1) viable tissue is indicated)
Salvageable if treated Salvageable if treated (3: Harm)
Monitor/treat for urgently emergently
compartment syndrome
Revascularization (urgent Category
(fasciotomy) (1)
IIa/emergency Category IIb) AND
anticoagulation with heparin, unless
contraindicated (1)
Concurrent/early
Monitor/treat for
amputation if prolonged Prophylactic
compartment syndrome
ischemia (2a) fasciotomy (2a)
(fasciotomy) (1)

Abbreviations: ALI indicates acute limb ischemia.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 30
Disease. Circulation.
Revascularization for ALI

COR RECOMMENDATIONS Revascularization

In patients with ALI and a salvageable limb, revascularization (endovascular or surgical,
1 including catheter-directed thrombolysis) is indicated to prevent amputation.

In patients with ALI and a salvageable limb who are treated with catheter-directed
2a thrombolysis, adjunctive revascularization (i.e., endovascular or surgical) procedures can be
useful.

In patients presenting with ALI from chemotherapeutic or prothrombotic viral states, it may
2b be reasonable to take a more deliberate planning strategy before engaging in a definitive
revascularization or medical treatment plan.

3: In patients with ALI with a nonsalvageable limb, revascularization of nonviable tissue should
Harm not be performed.

Abbreviations: ALI indicates acute limb ischemia.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 31
Disease. Circulation.
Acute Limb Ischemia

Minimizing Tissue Loss Establishing Etiology

COR RECOMMENDATIONS CO
RECOMMENDATIONS
R
Patients with ALI should be monitored and
treated for compartment syndrome with
History and physical examination
1 fasciotomy after revascularization to
should be performed to determine
prevent reperfusion injury and need for 1
the cause of thrombosis or
amputation.
embolization.
In patients with ALI with a threatened but
2a salvageable limb, prophylactic fasciotomy
is reasonable. Testing for a cardiovascular cause
2a of thromboembolism can be useful.
In patients with ALI and prolonged ischemia
in whom revascularization is performed,
2a concurrent and early amputation can be
beneficial to avoid morbidity of reperfusion.

Abbreviations: ALI indicates acute limb ischemia.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 32
Disease. Circulation.
Longitudinal Follow-Up of Patients with PAD
CO CO
RECOMMENDATIONS RECOMMENDATIONS
R R
With or without revascularization, routine clinical After infrainguinal, autogenous vein bypass
evaluation, including assessment of limb graft(s) without new lower extremity signs or
1 symptoms and functional status, lower extremity symptoms, it is reasonable to perform ABI and
2a
pulse and foot assessment, and progress of risk arterial duplex ultrasound surveillance within
factor management is recommended. the first 1 to 3 months post procedure, then
repeat at 6 and 12 months, and then annually.
Coordination among specialists to improve
1
management and outcomes. After endovascular procedures without new
lower extremity signs or symptoms, it is
With or without revascularization, periodic
reasonable to perform ABI and arterial duplex
1 assessment of functional status and health- 2a
ultrasound surveillance within the first 1 to 3
related QOL.
months post procedure, then repeat at 6 and 12
Long-term use of GDMT to prevent MACE and months, and then annually.
1
MALE is recommended.
After infrainguinal, prosthetic bypass graft(s)
After lower extremity revascularization include without new lower extremity signs or
2b
periodic clinical evaluation of lower extremity symptoms, the effectiveness of ABI and arterial
1
symptoms and pulse and foot assessment is duplex ultrasound surveillance is uncertain.
recommended.
Telehealth can be used for vascular evaluation
After lower extremity revascularization with new and management and longitudinal follow-up,
2a
1 lower extremity signs or ABI
Abbreviations: symptoms, ABI and index; GDMT, guideline-directed
indicates ankle-brachial depending on the and
management urgency
therapy;of presenting
MACE, major adverse cardiovascular events; MALE, major adverse limb events; PAD, peripheral artery disease; and
arterial duplex ultrasound is recommended.QOL, quality of life. symptoms.
Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 33
Disease. Circulation.
Evidence Gaps
Studies to compare telehealth
technology vs. facility-based
Clinical trials in asymptomatic patients supervised exercise therapy.
• Benefit of screening in those at-
risk
RCT or registry data for chronic
• Benefit of medical therapies to symptomatic PAD treated by exercise
prevent MACE and MALE therapy, endovascular management,
and surgical management with hard
Studies to identify new medical therapies outcomes, including MACE and MALE.
to improve functional status

Comparative effectiveness studies of

Studies on patients who have undergone endovascular devices for
revascularization procedures revascularization of PAD.
• Determination of optimal Studies comparing outcomes of different
antiplatelet and antithrombotic strategies for revascularization of CLTI
regimen. (in-line flow, angiosome, would blush).
Studies to determine the ideal timing and
modality for vascular surveillance testing
post-revascularization procedures.
Studies on the effect of shared decision-
Development of patient-reported making strategies in the management of
metrics of functional status/walking chronic symptomatic PAD and CLTI
performance for outcome measures of
studies of revascularization.

Abbreviations: CLTI indicates chronic limb-threatening ischemia; GDMT, guideline-directed management

and therapy;
MACE, major adverse cardiovascular events; MALE, major adverse limb events; and PAD, peripheral artery
disease.
Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 34
Disease. Circulation.
Advocacy Priorities

Access to Care/Guideline
implementation Disparities National
Initiatives
Collaborative Address racial 20% reduction in non-
teamwork between disparity gap in
traumatic
all specialties amputation,
revascularization, amputations by 2030
Broad
dissemination and and risk
implementation of modification
Creation of national
these guidelines registry of
with focus on nontraumatic lower
Strategies
quality to
outcomes extremity 2
improve the use of amputation to
structured exercise identify
therapy. opportunities for
improvement and
Telemedicine and to unmask factors
remote patient- associated with
monitoring disparities in
devices. treatment.

Abbreviations: PAD indicates peripheral artery disease.

Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 35
Disease. Circulation.
Acknowledgments
Many thanks to our Guideline Ambassadors who were guided by Dr. Elliott
Antman in developing this translational learning product in support of the
2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral
Artery Disease.

Dr. Nicholas Brownell Dr. Joyce Han

Dr. Trevor Cline Dr. Usman Hasnie
Dr. Xing Dai Dr. Jake Mayfield
Dr. Eson Ekpo Dr. Eman Rashed
Dr. Prerna Gupta

The American Heart Association requests this electronic slide deck be

cited as follows:
Brownell, N., Cline, T., Dai, X., Ekpo, E., Gupta, P., Han, J., Hasnie, U., Mayfield, J.,
Rashed, E., Reyna, G., Bezanson, J. L., & Antman, E. M. (2024). AHA Clinical
Update; Adapted from: [PowerPoint slides]. Retrieved from the 2024 AHA/ACC
Guideline on the Management of Lower Extremity Peripheral Artery Disease.
https://professional.heart.org/en/science-news.
Gornik, H. L., et al. (2024). 2024 AHA/ACC Guideline on the Management of Lower Extremity Peripheral Artery 36
Disease. Circulation.