As previously mentioned, patients with PAD have a higher risk of cardiovascular mortality compared to the general population. CLTI subgroup specifically carries the highest mortality, with rates as high as 20% at 6 months to 50% at 5 years. The amputation rates in these patients can reach 10% to 40% in 1 year. ^, Therefore, close follow-up of these patients is needed. Unfortunately, loss to follow-up (LTF) is highly prevalent among this group of patients and it has been associated with worse outcomes such as postoperative complications, lower rate of technical success, higher rate of CLTI or urgent interventions, and higher mortality. ^, While LTF is a concerning phenomenon, these patients are also at a very high risk of emergency department visits and readmissions. Approximately 1 in 5 patients hospitalized for CLTI and undergoing revascularization are readmitted within 30 days, and up to 56% in 6 months. ^, Measures to decrease patients who are lost to follow-up and prevent readmissions should be undertaken right from the time of discharge. Implementation of transitional care planning such as follow-up telephone calls during the first week postdischarge has been associated with reduced readmission rates within 30 days in patients undergoing lower extremity bypass surgery (8.8% vs 17.5%, p = 0.008). In our experience, an early postdischarge follow-up within the first 2 weeks post intervention is key to decrease LTF, prevent readmissions, and for early detection and treatment of any postprocedural complications such as access site infection, pseudoaneurysm, renal failure or anemia, among others. While revascularization is an important part of limb salvage, it is only the first part of a long-term commitment which may include frequent wound care, medications adjustment, antibiotics, limited amputations, etc. The 2024 ACC/AHA PAD guidelines recommend a longitudinal follow-up, including periodic clinical evaluation of lower extremity symptoms, and pulse and foot assessment for all patients with PAD who have undergone lower extremity revascularization (Class I, level of evidence [LOE]—C).

Antiplatelet therapy is the cornerstone of treatment for PAD. While indefinite aspirin is the mainstay therapy, the use of dual antiplatelet therapy (DAPT) and its duration remains a matter of debate in patients who underwent a revascularization procedure. The 2016 ACC/AHA guidelines provided a Class IIb, LOE—C, to DAPT for PAD post revascularization without suggesting any specific duration of treatment. ^, More recent observational studies and meta-analyses showed better outcomes with DAPT than with single antiplatelet therapy. ^,, For example, in the study from Cho et al, patients who received DAPT for longer than 6 months after endovascular intervention had less major adverse cardiovascular events (MACE) (17.3% vs 31.3%; p < 0.001), and less major adverse limb events (MALE) (21.5% vs 43.7%; p < 0.001), compared to patients who received single antiplatelet therapy, during a 5-year follow-up. This was reflected in an upgrade of the recommendation in the most recent 2024 ACC/AHA guidelines giving a Class IIa, LOE—C, to DAPT with a P2Y12 antagonist and low-dose aspirin in patients undergoing endovascular revascularization. The duration of DAPT remained flexible with the guidelines mentioning a range between 1 and 6 months at the discretion of the treating physician, after taking in consideration various ischemic and bleeding risk factors ( Figure 1 ).

Postrevascularization care summary. Green color corresponds to a class I recommendation; yellow color corresponds to a class IIa recommendation. ABI = Ankle-brachial index; ACE = angiotensin converting enzyme; AF = atrial fibrillation; ARB = angiotensin II receptor blocker; BP = blood pressure; CLTI = chronic limb-threatening ischemia; DUS = duplex ultrasound; GLP-1 = glucagon-like peptide-1; LDL = low density lipoprotein; MACE = major adverse cardiovascular events; PCSK-9 = proprotein convertase subtilisin/kexin type 9; QOL = quality of life; SAPT = single antiplatelet therapy; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; SET = supervised exercise therapy; SGLT-2 = sodium-glucose cotransporter-2; VTE = venous thromboembolism.

More recently, VOYAGER PAD study looked at a new antithrombotic regimen in patients who underwent revascularization and it found that low dose Rivaroxaban (2.5 mg twice daily) plus aspirin significantly reduced the incidence of the composite outcome of acute limb ischemia, major amputation from vascular causes, myocardial infarction, ischemic stroke, or death from cardiovascular causes compared to aspirin therapy alone in patients without a previous stroke or increased risk of bleeding. Guidelines have now also reflected a major change in this regard giving the above-mentioned regimen a Class I, LOE—A.

Dyslipidemia is a major atherosclerotic risk factor, and lipid-lowering therapy with statins has been shown to improve cardiovascular outcomes and should be prescribed to all patients with PAD. The newest ACC/AHA 2024 guidelines for PAD provide a Class I, LOE—A recommendation to use of high-intensity statins for all patients with PAD, with an aim of achieving ≥50% reduction in low-density lipoprotein cholesterol LDL-C. Moreover, the guidelines further endorse the addition of ezetimibe or PCSK-9 inhibitors to reach a target level of LDL-C <70 mg/dl. However, despite these robust recommendations, there is underutilization of lipid-lowering therapies in patients with PAD. An analysis of over 250,000 patients showed that only ∼20% of the patients were on high-intensity lipid-lowering therapy, and 40% of the patients had no lipid-lowering therapy. Interestingly, 64% of the patients on high-intensity lipid-lowering therapy had an LDL ≥70 mg/dl, therefore highlighting the missed opportunities in implementation of life-saving medical therapies in these patients. ^,

The European Society of Cardiology Guidelines for the management of PAD and aortic diseases, 2024, recommend a LDL-C reduction by ≥50% from baseline and an LDL-C goal of <1.4 mmol/L (<55 mg/dl) to obtain a reduction in cardiovascular death, myocardial infarction, and stroke, and to improve walking distance.

In addition to antiplatelet therapy and lipid-lowering medications, patients with PAD need comprehensive risk management not only to improve their vascular outcomes but also to decrease their coronary and cerebrovascular events.

HOPE and ONTARGET trials respectively showed that Ramipril and Telmisartan significantly reduced MACE in patients with PAD and hypertension. ^, Therefore, the 2024 PAD guidelines gave a Class I, LOE—B recommendation for the use of angiotensin-converting enzyme inhibitors (ACE) or angiotensin-receptor blockers as first-line antihypertensives in this group of patients.

Observational studies suggest that smoking cessation is associated with lower rates of MALE, including bypass graft failure, amputations, as well as death in patients with PAD. Per the guidelines, it is a Class I, LOE—A recommendation to advise PAD patients at every visit to quit smoking and assist them in developing plans for quitting including pharmacotherapy such as varenicline and bupropion and/or provide them with referrals to smoking cessation programs.

Finally, in patients with PAD and diabetes, glycemic control is beneficial to improve limb outcomes, especially in patients with CLTI and patients who underwent revascularization. ^,, Also, the 2024 AHA/ACC PAD guidelines recommend the use of glucagon-like peptide-1 (GLP-1) agonists and sodium-glucose cotransporter-2 (SGLT-2) inhibitors to reduce the risk of MACE in patients with PAD (Class I, LOE—A). In addition to reducing risk of MACE, in the more recent STRIDE study, Semaglutide was shown to significantly improve walking capacity in symptomatic patients with PAD (intermittent claudication) and diabetes mellitus compared to their placebo-controlled group. This would make Semaglutide an appealing alternative option especially for patients who can’t receive Cilostazol (i.e., patients with heart failure). Emerging observational and trial data in PAD populations also suggest that GLP-1 agonist use is associated with fewer cardiac and limb events, including lower rates of revascularization and limb-threatening ischemia, beyond glucose-lowering effects. These benefits involve weight loss, anti-inflammatory effects, and favorable impacts on blood pressure and lipids. ^,

Similarly, SGLT-2 inhibitors have become essential therapy for diabetes and cardiovascular prevention. These agents improve blood sugar control, decrease heart failure hospitalizations, slow the progression of kidney disease, and reduce cardiovascular risk in patients with high vascular risk—all of which are especially relevant in PAD, where polyvascular disease and chronic kidney disease are common. ^,

Cilostazol is a phosphodiesterase III inhibitor with antiplatelet and vasodilatory properties that has been shown to improve symptoms and walking performance in patients with intermittent claudication due to PAD. It is currently the only FDA-approved medication for the treatment of claudication.

Multiple RCTs and meta-analyses have demonstrated that cilostazol significantly increases pain-free walking distance and maximum walking distance compared to placebo, typically by 30% to 50% (40 to 70 meters) after 12 to 24 weeks of treatment. These improvements are often accompanied by better walking-related quality of life (QOL) and symptom relief.

The 2024 AHA/ACC PAD guidelines recommend cilostazol for: symptomatic improvement in patients with claudication, and reduction of restenosis risk following endovascular therapy for femoropopliteal lesions (Class I, LOE—A).

However, cilostazol is contraindicated in patients with heart failure of any severity, as it may increase mortality in this population due to its positive inotropic effects. Therefore, patient selection is critical. Cilostazol remains a first-line pharmacologic therapy to improve walking distance and daily function in patients with intermittent claudication who do not have heart failure, complementing lifestyle modification and supervised exercise therapy (SET).

SET is the cornerstone of care for patients with chronic symptomatic PAD. SET is not uniquely reserved for patients before their revascularization, but it is as important in patients who have undergone revascularization. Studies showed that in this population, SET is effective to improve functional status, walking performance, and QOL (Class I, LOE—A). ^, On the other hand, patients with PAD, including those who underwent revascularization, should receive preventative foot care. This includes foot inspection by a clinician at every visit, an annual comprehensive foot evaluation, as well as therapeutic footwear for those at high risk for ulcers and amputation (Class I, LOE—C). Additionally, patients with CLTI and a nonhealing wound, adequate wound care should be provided after revascularization by a multispecialty team with the goal of complete wound healing (Class I, LOE—C). ^, This includes pressure offloading therapies, customized footwear, management of infection, and limited debridement and amputation if needed. Finally, the 2024 ACC/AHA guidelines recommend the annual influenza vaccine and the SARS-CoV-2 vaccination sequence to all patients with PAD on top of their guideline-directed medical therapy, to reduce their overall cardiovascular risk (Class I, LOE—C). ^,

PAD is a chronic medical condition, and a comprehensive care plan is warranted to improve patients’ outcomes. Longitudinal care while providing guideline-directed medical management is a cardinal aspect in the follow-up of patients with PAD who underwent revascularization procedure, but assessing the outcomes of the intervention is equally important. Identification of restenosis may help in early intervention and possibly lead to better outcomes. Thus, patients who have undergone revascularization need ongoing surveillance, although the modality and optimal frequency of surveillance have yet to be determined.

Clinical follow-up: The simplest yet important part of follow-up is history and physical examination. While recurrence of symptoms may be an important marker of restenosis in the long term, loss of pedal pulses, pain at rest, appearance of new ulcers, or pallor in the extremities may be signs of more acute or critical vessel compromise, which require immediate attention. Similarly, patients with underlying wounds may need closer clinical follow-up to monitor the healing process of the wound and evaluate the need for any additional procedures in order to facilitate a faster recovery. The 2024 ACC/AHA PAD guidelines provide a Class I, LOE—C recommendation for postintervention longitudinal follow-up, including periodic clinical evaluation of lower extremity symptoms and pulse and foot assessment.

Physiological and imaging guided follow-up: Ankle-brachial index (ABI) is the most commonly used hemodynamic assessment tool to diagnose patients with PAD. It is also used to assess prognosis, and for patients’ follow-up after intervention. The change in ABI has been used to define both, hemodynamic improvement postprocedure and loss of vessel patency/restenosis when followed longitudinally. Since 1994, Decrinis et al demonstrated that an increase in ABI of 0.15 from baseline was associated with successful recanalization of superficial femoral artery (sensitivity 67%, specificity 100%), while a drop by 0.15 was associated with reocclusion or significant restenosis (sensitivity 60%, specificity 97%). While ABI is considered a good screening tool, it still has many limitations, such as its inability to localize the level of stenosis and its diminished accuracy in patients with calcified vessels. Therefore, the use of duplex ultrasonography (DUS) gained more and more popularity in following-up patients post revascularization. In their prospective analysis, Shrikhande et al found that 92% of patients with a peak systolic velocity ratio >2.5 had an angiographic stenosis of more than 70%. Similarly, a peak systolic velocity of ≥223 cm/sec had a sensitivity of 94.1% and a specificity of 95.2% in detecting ≥70% stenosis in the femoropopliteal territory. DUS-derived criteria of peak systolic velocity ratio <2.4 across the treated lesion has been consistently used as a criterion to assess vessel patency in recent randomized controlled trials and major observational studies. ^, The current guidelines recommend obtaining ABI and arterial DUS in patients with PAD who have undergone lower extremity revascularization and present with new or recurrent symptoms (Class I, LOE—C). Also, it suggests ABI and DUS surveillance for asymptomatic patients after endovascular revascularization within the first 1 to 3 months postprocedure, followed by repeat studies at 6 and 12 months, and then annually Class IIa, LOE—C. ^,,

It is safe to say that the above guidelines constitute a broad umbrella that covers the management of most patients with PAD, and a case-by-case approach should be adopted in the follow-up and surveillance of these patients, depending on the severity of their disease, the original indication for revascularization, as well as the type of revascularization. The main goal of surveillance remains the prevention of revascularization failure and ultimately the prevention of amputation. So, the specific timing and intervals of routine follow-up visits should be tailored to the patient-specific clinical context. For example, a patient with CLTI and open wound will require more frequent surveillance and lower threshold for reintervention in order to achieve wound healing and prevention of amputation, compared to a patient with claudication who may be monitored clinically and in whom an intervention for asymptomatic restenosis is of questionable benefit.

Patient-reported outcomes (PRO): Instruments used to measure PRO have been well studied in clinical trials and research, but integrating them into clinical practice is the need of the hour to quantify the quality of PAD care delivered. Measures such as walking impairment questionnaire can be used to assess the QOL, pre- and postintervention, and further follow these patients in the long term. The AHA scientific statement highlighted strategies using PRO to improve quality of care and outcomes of patients with PAD. These measures can help create a reproducible and accountable framework for quality PAD care, reduce variability and health care disparities, keep patient’s wishes and priorities in the first place, and help address the symptoms that matter most to the patient. Using these tools before and after the intervention constitutes a great follow-up strategy to monitor the patients and help them reach their healthcare goals.

In addition to commonly encountered comorbid conditions, more than one third of the patients with PAD have some sort of mental health concerns such as high levels of perceived stress, depression and anxiety, or substance use disorders and behavioral health issues. Harris et al showed that patients with CLTI who underwent revascularization procedure had an increased length of stay, increased hospital cost, and a higher risk of major amputation if they had a concomitant diagnosis of depression or anxiety disorder. Patients with PAD deserve comprehensive psychological and psychotropic interventions to improve their overall outcomes. The AHA scientific statement on PAD and mental health burden presents a road map for integrated behavioral care and multidisciplinary care to patients with PAD. ^,