|
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
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