Clinical Challenges in Peripheral Artery Disease

Dear Colleagues,

Peripheral arterial disease (PAD) is a common cardiovascular (CV) condition with important health consequences. It is estimated that PAD affects over 200 million people worldwide, adversely impacting morbidity, mortality, and quality of life. In clinical ASCVD trials, subset with PAD has consistently shown a worse natural history. However, aggressive preventive treatment can lead to an important improvement in outcome.

The clinical presentation of PAD may vary from asymptomatic to atypical leg symptoms (requiring diagnostic vigilance), as well as to classic claudication, non-healing wounds, and critical limb ischemia (CLI). Special attention is appropriate for those over age 65, for those with risk factors for atherosclerotic cardiovascular disease (ASCVD), i.e., smoking, diabetes, hypertension, hyperlipidemia, and those with ASCVD in another vascular bed. Diagnosis is typically made or confirmed by physical examination and non-invasive testing (i.e., ankle brachial index (ABI) determination, Duplex ultrasound), which may lead to CTA or MRA of the lower extremities. Invasive angiography is reserved for CLI and when revascularization is considered. Standard medical therapies include antiplatelets, statins, antihypertensives, antidiabetics, smoking cessation, and structured exercise. Optimal use of anticoagulants is still being defined. Revascularization is reserved for those with an inadequate response to medical therapy.

There are many unmet needs and future directions for PAD. Improving prognosis must begin with a better understanding of vascular biology and pathology, which can identify additional targets for the prevention and treatment of native disease and for restenosis after vascular intervention. Papers which focused on advances in PAD diagnostics are also welcomed. Improved medical options for relief of claudication are needed. Advances are envisioned in the selection and combination of antiplatelets and anticoagulants and their relative medical and cost effectiveness. Progress in lifestyle interventions to augment statins and other medical therapies will be useful. Additional trials of the various revascularization options and techniques (angioplasty and stenting or surgical bypass with vein or synthetic grafts) are needed, as well as for whom amputation should be reserved. Progress in PAD has been steady and rewarding over the past two decades, but prevention, diagnosis, and treatment  are still suboptimal, so ongoing advances are essential to optimizing PAD outcomes. This Special Issue of the Journal of Clinical Medicine addresses several of these critical areas in understanding, preventing, and treating PAD.

Prof. Dr. Jeffrey L. Anderson
Guest Editor

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