How PAD Is Actually Diagnosed and Treated

How PAD Is Actually Diagnosed and Treated

In short: PAD is diagnosed primarily through a simple, non-invasive test — the ankle-brachial index — with imaging reserved for more detailed evaluation. Treatment is layered: risk factor management and supervised exercise form the foundation for most people, with antithrombotic medication and procedures like angioplasty, stenting, or surgery reserved for specific situations. Counterintuitively, trial evidence shows supervised exercise often outperforms stenting for improving walking capacity in claudication.

How the Diagnosis Actually Happens

The ankle-brachial index (ABI) — comparing systolic blood pressure at the ankle to blood pressure at the arm — is the standard first-line test. It's quick, non-invasive, and reasonably accurate for detecting significant arterial narrowing; a ratio of 0.9 or below is generally considered diagnostic. When more detail is needed — to plan a procedure, or when the diagnosis is unclear — duplex ultrasound, CT angiography, or catheter angiography provide direct visualization of where and how severe the narrowing is.

The Foundation: Risk Factor Management

Regardless of severity, managing the underlying atherosclerosis process is central to treatment. This means blood pressure control, cholesterol management (typically with a statin), blood sugar control in diabetes, and smoking cessation — the same risk factors driving progression, addressed directly.

Supervised Exercise Therapy: More Effective Than Most People Expect

Randomized controlled trials consistently show supervised exercise therapy improves walking distance, functional status, and quality of life in people with claudication. In the CLEVER trial, which directly compared optimal medical care alone, medical care plus supervised exercise, and medical care plus stenting, supervised exercise produced the greatest improvement in peak walking time at 6 months — outperforming stenting on this specific measure. This isn't a minor finding; it's a genuinely counterintuitive result that reshapes how claudication should be approached, with exercise as a first-line treatment rather than something to try only if a procedure isn't available.

Medication

Cilostazol is the primary medication specifically approved for improving walking distance in claudication, used alongside — not instead of — risk factor management and exercise.

Antithrombotic Therapy: The COMPASS Trial

A more recent, important advance came from the COMPASS trial (2018), which tested a combination of low-dose rivaroxaban (2.5 mg twice daily) plus aspirin against aspirin alone, in more than 27,000 patients with coronary artery disease and/or PAD. In PAD patients specifically, this combination reduced major adverse limb events (MALE — amputations, hospitalizations, and limb-related deaths) by 43%, and reduced major adverse cardiovascular events (MACE) by 24%.

This is clinically significant because a MALE event isn't a minor outcome — it's associated with a three-fold increase in death and a 200-fold increase in amputation risk. A related trial, VOYAGER PAD, confirmed similar benefit specifically in patients who had already undergone revascularization. This low-dose rivaroxaban plus aspirin combination is now a strong consideration for PAD patients without a high bleeding risk, adding another layer of treatment beyond cilostazol and exercise.

When Procedures Become Appropriate

Angioplasty and stenting are generally considered when symptoms significantly limit quality of life despite exercise and medical therapy, or in more advanced disease including critical limb ischemia, where restoring blood flow becomes urgent rather than elective. Trial data comparing stenting to medical therapy and to supervised exercise shows procedures can improve symptoms, but the comparative evidence — including CLEVER — suggests they aren't automatically superior to a well-executed exercise program for straightforward claudication.

When Surgery Is the Better Option

Angioplasty and stenting aren't always the right procedural choice — for certain artery segments, longer blockages, or when endovascular options have failed or aren't durable enough, surgical bypass (rerouting blood flow around the blocked segment using a graft) remains a well-established option, particularly for more complex disease. Endarterectomy — surgically removing plaque directly from an artery — is another option in specific locations, such as the femoral artery, where it's often preferred over stenting. These are more invasive than endovascular procedures, but they can offer more durable results in the right circumstances, which is part of why the choice between endovascular and surgical approaches depends heavily on exactly where and how the artery is affected, decided case by case with a vascular specialist.

What the Evidence Shows

Multiple randomized trials and meta-analyses support supervised exercise therapy as an effective, evidence-based first-line treatment for claudication, with benefit demonstrated both as a standalone treatment and in combination with revascularization. The COMPASS trial, and the meta-analysis combining COMPASS and VOYAGER PAD, reinforce the role of combined antithrombotic therapy in reducing cardiovascular and limb events in this population. The 2024 ESC guidelines for peripheral arterial and aortic disease management reflect this evidence base in current treatment recommendations.

Vascular Surgeon's Take

The CLEVER trial result surprises most patients, but what it doesn't capture is adherence in the real world — supervised exercise only outperforms stenting if someone actually completes the program, and dropout rates in unsupervised, self-directed versions are notably higher. When I discuss this option, I'm as focused on whether a patient can realistically access supervised sessions as I am on the trial data itself, because the two treatments aren't equally demanding to follow through on.

References

Exercise Therapy in Symptomatic Peripheral Artery Disease: Summary of Current Knowledge and Future Directions. American College of Cardiology, 2025.
Murphy TP, et al. — Supervised Exercise Versus Primary Stenting for Claudication Resulting From Aortoiliac Peripheral Artery Disease (CLEVER trial). Circulation, 2012. doi: 10.1161/CIRCULATIONAHA.111.075770
Mazzolai L, et al. — 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. European Heart Journal, 2024. DOI: 10.1093/eurheartj/ehae179
Parmenter BJ, et al. — Exercise training for management of peripheral arterial disease: a systematic review and meta-analysis. Sports Medicine, 2015. DOI: 10.1007/s40279-014-0261-z
Anand SS, et al. — Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease (COMPASS trial). Lancet, 2018. DOI: 10.1016/S0140-6736(17)32409-1
Bonaca MP, et al. — Rivaroxaban in Peripheral Artery Disease after Revascularization (VOYAGER PAD trial). New England Journal of Medicine, 2020. DOI: 10.1056/NEJMoa2000052

Recommended Reading
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