Journal of the American College of Cardiology Vol. xx, No.

x, 2006
© 2006 by the American College of Cardiology Foundation and the American Heart Association, Inc. ISSN 0735-1097/06/$32.00
Published by Elsevier Inc. doi:10.1016/j.jacc.2005.10.009

ACC/AHA GUIDELINES

ACC/AHA Guidelines for the Management of

Patients With Peripheral Arterial Disease (Lower
Extremity, Renal, Mesenteric, and Abdominal Aortic)
A Collaborative Report From the American Association for Vascular
Surgery/Society for Vascular Surgery*, Society for Cardiovascular
Angiography and Interventions, Society of Interventional Radiology,
Society for Vascular Medicine and Biology, and the ACC/AHA Task
Force on Practice Guidelines (Writing Committee to Develop Guidelines
for the Management of Patients With Peripheral Arterial Disease [Lower
Extremity, Renal, Mesenteric,
and Abdominal Aortic])—Executive Summary
Endorsed by the American Association of Cardiovascular and Pulmonary
Rehabilitation; National Heart, Lung, and Blood Institute; Society for
Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease
Foundation
WRITING COMMITTEE MEMBERS
Alan T. Hirsch, MD, FACC, FAHA, Chair
Ziv J. Haskal, MD, FAHA, FSIR, Co-Chair
Norman R. Hertzer, MD, FACS, Co-Chair
Curtis W. Bakal, MD, MPH, FAHA, FSIR Kenneth A. Rosenfield, MD, FACC
Mark A. Creager, MD, FACC, FAHA David Sacks, MD, FACR, FSIR‡
Jonathan L. Halperin, MD, FACC, FAHA† James C. Stanley, MD, FACS§
Loren F. Hiratzka, MD, FACC, FAHA, FACS Lloyd M. Taylor, JR, MD, FACS§
William R. C. Murphy, MD, FACC, FACS Christopher J. White, MD, FACC, FAHA, FESC, FSCAI¶
Jeffrey W. Olin, DO, FACC John White, MD, FACS§
Jules B. Puschett, MD, FAHA Rodney A. White, MD, FACS§
*AAVS/SVS when Guideline initiated, now merged into SVS; †Society for Vascular Medicine and Biology official representative; ‡Society of Interventional Radiology official
representative; §Society for Vascular Surgery official representative; ¶Society for Cardiovascular Angiography and Interventions official representative

TASK FORCE MEMBERS

Elliott M. Antman, MD, FACC, FAHA, Chair
Sidney C. Smith, JR, MD, FACC, FAHA, Vice-Chair
Cynthia D. Adams, MSN, APRN-BC, FAHA Loren F. Hiratzka, MD, FACC, FAHA, FACS
Jeffrey L. Anderson, MD, FACC, FAHA Sharon A. Hunt, MD, FACC, FAHA
David P. Faxon, MD, FACC, FAHA** Alice K. Jacobs, MD, FACC, FAHA
Valentin Fuster, MD, PHD, FACC, FAHA, FESC** Rick Nishimura, MD, FACC, FAHA
Raymond J. Gibbons, MD, FACC, FAHA†† Joseph P. Ornato, MD, FACC, FAHA
Jonathan L. Halperin, MD, FACC, FAHA Richard L. Page, MD, FACC, FAHA
Barbara Riegel, DNSC, RN, FAHA
**Former Task Force member during this writing effort, ††Immediate Past Chair
2 Hirsch et al. JACC Vol. xx, No. x,
2006
ACC/AHA Guidelines for the Management of PAD Month 2006:1–75

This document was approved by the American College of Cardiology Foundation Committee to Develop Guidelines for the Management of Patients With Peripheral
Arterial
Board of Trustees in October 2005 and by the American Heart Association Science Disease [Lower Extremity, Renal, Mesenteric, and Abdominal Aortic]). J Am Coll
Cardiol
Advisory and Coordinating Committee in October 2005. 2006;XX:XXX–XXX. Available at:
http://www.acc.org/clinical/guidelines/pad/summary.pdf.
The ACC/AHA Task Force on Practice Guidelines makes every effort to avoid any Copies: This document is available on the World Wide Web sites of the American
College
actual or potential conflicts of interest that might arise as a result of an outside of Cardiology (www.acc.org) and the American Heart Association (www.
relationship or personal interest of a member of the writing panel. Specifically, all americanheart.org). ‡‡Single copies of this document are available by calling 1-800-253-
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members of the writing panel are asked to provide disclosure statements of all such or writing the American College of Cardiology Foundation, Resource Center, at 9111
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relationships that might be perceived as real or potential conflicts of interest. These Georgetown Road, Bethesda, MD 20814-1699. Ask for reprint number 71-0348. To
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of the document, is located in an appendix of the full-text guideline, which is available
Cardiovas-
on the ACC, AHA, SCAI, SVMB, SVS, and VDF (see “Copies” for Web addresses).
When citing this document, the American College of Cardiology Foundation requests that
(www.svs.vascularwe-
the following citation format be used: Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW,
Creager MA, Halperin JL, Hiratzka LF, Murphy WRC, Olin JW, Puschett JB, Rosenfield
KA, Sacks D, Stanley JC, Taylor LM Jr., White CJ, White J, White RA. ACC/AHA
guidelines for the management of patients with peripheral arterial disease (lower extremity,
the
renal, mesenteric, and abdominal aortic): executive summary: a report of the American College
requests to
of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing
‡‡Can also be found on the World Wide Web sites of the Society for
cular Angiography and Interventions (www.scai.org), Society for Vascular Medicine
and Biology (www.svmb.org), Society for Vascular Surgery
b.org), Society of Interventional Radiology (www.sirweb.org), and Vascular Disease
Foundation (www.vdf.org).
Permissions: Multiple copies, modification, alteration, enhancement, and/or dis-
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JACC Vol. xx, No. x, 2006
Month 2006:1–75

TABLE OF CONTENTS
I. INTRODUCTION ..............................................................4
A. Definitions .......................................................................5
B. Vascular History and Physical Examination...................5

II. LOWER EXTREMITY PAD ............................................5

A. Epidemiology...................................................................5
1. Risk Factors................................................................5
2. Prevalence...................................................................5
B. Prognosis and Natural History .......................................5
1. Coprevalence of Coronary Arterial Disease
and Carotid Disease ...................................................5
C. Other Causes of Lower Extremity PAD........................6
D. Clinical Presentation .......................................................6
1. Asymptomatic.............................................................6
2. Claudication ...............................................................7
3. Critical Limb Ischemia ..............................................8
4. Acute Limb Ischemia...............................................11
5. Prior Limb Arterial Revascularization .....................12
E. Diagnostic Methods ......................................................13
1. Ankle-Brachial and Toe-Brachial Indices,
Segmental Pressure Examination.............................13
2. Pulse Volume Recording..........................................16
3. Continuous-Wave Doppler Ultrasound...................16
4. Treadmill Exercise Testing With and Without
ABI Assessments and 6-Minute Walk Test ...........15
5. Duplex Ultrasound ...................................................16
6. Computed Tomographic Angiography....................17
7. Magnetic Resonance Angiography ..........................17
8. Contrast Angiography..............................................17
F. Treatment ......................................................................18
1. Cardiovascular Risk Reduction ................................18
a. Lipid-Lowering Drugs ........................................18
b. Antihypertensive Drugs .......................................18
c. Diabetes Therapies ..............................................18
d. Smoking Cessation ..............................................19
e. Homocysteine-Lowering Drugs ..........................19
f. Antiplatelet and Antithrombotic Drugs..............19
2. Claudication .............................................................19
a. Exercise and Lower Extremity PAD
Rehabilitation .......................................................19
b. Medical and Pharmacological Treatment for
Claudication .........................................................20
Cilostazol .............................................................20
Pentoxifylline .......................................................20
Other Proposed Medical Therapies ....................21
c. Endovascular Treatment for Claudication ..........21
d. Surgery for Claudication......................................23
Indications............................................................23
Preoperative Evaluation .......................................23
Correlation of Symptoms and Lesions................23
Surgical Procedures..............................................23
Inflow Procedures: Aortoiliac Occlusive
Disease....24
Outflow Procedures: Infrainguinal
Disease.............24
Follow-Up After Vascular Surgical Procedures
......25
3. Critical Limb Ischemia and Treatment for Limb
Salvage ......................................................................26 Hirsch et al.
a. Medical and Pharmacological Treatment 3
for CLI.................................................................26 ACC/AHA Guidelines for the Management of PAD

Prostaglandins ......................................................2
6
Angiogenic Growth Factors ................................26
b. Endovascular Treatments for CLI ......................26
c. Thrombolysis for Acute and Chronic
Limb Ischemia .....................................................26
d. Surgery for CLI ...................................................28
Inflow Procedures: Aortoiliac Occlusive
Disease .................................................................2
8
Outflow Procedures: Infrainguinal Disease .........29
Postsurgical Care .................................................30
G. Algorithms .....................................................................30
1. Diagnostic and Treatment Pathways.......................30

III. RENAL ARTERIAL DISEASE ......................................30

A. Prevalence and Natural History ....................................30
B. Clinical Clues to the Diagnosis of RAS.......................30
C. Diagnostic Methods ......................................................34
Summary of Noninvasive Renal Artery
Diagnostic Imaging Strategies ......................................36
1. Catheter Angiography..............................................36
2. Renin ........................................................................37
a. Selective Renal Vein Renin Studies ....................37
b. Plasma Renin Activity: Captopril Test ...............37
D. Treatment of Renovascular Disease:
Renal Artery Stenosis....................................................37
1. Medical Treatment...................................................37
2. Indications for Revascularization .............................39
a. Asymptomatic Stenosis........................................39
b. Hypertension ........................................................39
c. Preservation of Renal Function ...........................40
d. Impact of RAS on Congestive Heart
Failure and Unstable Angina...............................40
3. Catheter-Based Interventions ................................409
4. Surgery for RAS.......................................................40
a. Results of Operative Therapy..............................40

IV. MESENTERIC ARTERIAL DISEASE .........................41

A. Acute Intestinal Ischemia..............................................41
1. Acute Intestinal Ischemia Caused by Arterial
Obstruction...............................................................41
a. Etiology................................................................41
b. Diagnosis..............................................................41
Clinical Presentation............................................41
Laboratory Findings.............................................41
Ultrasound............................................................41
Computed Tomographic (CT) Scanning............41
Arteriography .......................................................4
1
c. Natural History ....................................................42
d. Surgical Treatment ..............................................42
e. Endovascular Treatment ......................................42
2. Acute Nonocclusive Intestinal Ischemia..................42
a. Etiology................................................................42
b. Diagnosis..............................................................42
c. Treatment ............................................................43
B. Chronic Intestinal Ischemia ..........................................43
1. Etiology ....................................................................43
2. Diagnosis