Recommendations for Longitudinal Follow-Up
COR	LOE	Recommendations
I	C-EO	Patients with PAD should be followed up with periodic clinical evaluation, including assessment of cardiovascular risk factors, limb symptoms, and functional status.
N/A		A comprehensive care plan for patients with PAD includes periodic clinical evaluation by a healthcare provider with experience in the care of vascular patients. Clinical evaluation should include assessment of cardiovascular risk factors, assessment of adherence to medical therapy, and re-evaluation of smoking cessation efforts. Comprehensive lifestyle modification, including heart-healthy nutrition, is encouraged.22 Patients with PAD should also undergo periodic assessment of limb symptoms, functional status, and their ability to participate in vocational and recreational activities. Ongoing participation in a structured exercise program should be facilitated. Foot examination and patient counseling about healthy foot behaviors in PAD are addressed in Section 7.
I	C-EO	Patients with PAD who have undergone lower extremity revascularization (surgical and/or endovascular) should be followed up with periodic clinical evaluation and ABI measurement.
N/A		In addition to the clinical evaluation of cardiovascular risk factors, functional status, and adherence to medical therapy and smoking cessation, patients with PAD who have previously undergone lower extremity revascularization (surgical and/or endovascular) require additional ongoing assessment and care. Follow-up visits after revascularization should include reassessment of the patient's limb symptoms and interval change in functional status, as well as participation in a structured exercise program. Pulse examination and ABI are included in the assessment. A change in ABI of 0.15 is considered clinically significant.388
IIa	B-R	Duplex ultrasound can be beneficial for routine surveillance of infrainguinal, autogenous vein bypass grafts in patients with PAD.389–395
See Online Data Supplements 51 and 52.		A general surveillance schedule may be at 4 to 6 weeks, 6 months, and 12 months in the first year and yearly thereafter. It is important that testing frequency is individualized to the patient, type of arterial bypass, and any prior duplex scan findings. Duplex graft surveillance focuses on the identification of high-grade stenosis (eg, peak systolic velocity >300 cm/s and peak systolic velocity ratio across the stenosis >3.5) or impending graft failure (eg, PSV <40 cm/s).392,395 Detection of a graft stenosis prompts the consideration of further revascularization to treat the stenosis and maintain graft patency. Duplex may detect significant stenoses that may not be detected by a decline in ABI.394 Although case series have demonstrated high rates of primary assisted patency with a duplex ultrasound-surveillance strategy, RCTs of duplex surveillance versus clinical surveillance with the ABI have demonstrated mixed results in terms of a benefit on patency and limb outcomes.391,393,396
IIa	C-LD	Duplex ultrasound is reasonable for routine surveillance after endovascular procedures in patients with PAD.397–399
See Online Data Supplement 52.		Studies have developed duplex ultrasound diagnostic criteria for diagnosing restenosis at the site of endovascular revascularization. Diagnostic criteria need to be customized to the location (eg, iliac or superficial femoral artery) and type of intervention (eg, angioplasty, uncovered stent, or covered stent). The optimal timing for surveillance after endovascular procedures is unclear.397–399 There are limited outcome data on routine duplex surveillance versus clinical surveillance plus the ABI after endovascular revascularization.397–399 The value of duplex ultrasound may be greater in cases with higher rates of restenosis, such as after interventions to treat very long lesions or occlusions.400
IIb	B-R	The effectiveness of duplex ultrasound for routine surveillance of infrainguinal prosthetic bypass grafts in patients with PAD is uncertain.393,401–403
See Online Data Supplements 51 and 52.		Duplex ultrasound of prosthetic bypass grafts may be used to characterize mid-graft velocity, because low velocities can predict impending graft failure.401–403 Outcome studies of duplex surveillance of prosthetic grafts have not shown consistent benefit.393,401–403 One RCT of duplex versus clinical surveillance with the ABI for femoropopliteal grafts did not show a benefit of duplex on outcome in the subset of patients with prosthetic grafts, though there was a benefit of duplex surveillance for vein bypass grafts.393