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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1313–e1410. DOI: 10.1161/CIR.0000000000001251 June 11, 2024 e1329

and MRA have improved spatial resolution over duplex ultrasound; however, CTA is limited by the need for iodinated contrast7 and radiation exposure. Contrast-enhanced MRA uses gadolinium, certain formulations of which are contraindicated in patients with severe renal dysfunction secondary to the risk for nephrogenic systemic sclerosis.11,12 Noncontrast MRA sequences that provide high spatial resolution and the ability to visualize infrapopliteal and pedal vessels have emerged as a promising imaging modality for imaging lesions associated with PAD.13 In certain clinical scenarios, performance of noninvasive imaging studies for anatomic assessment (ie, CTA, or MRA) may be perceived to confer greater risk to the patient than invasive angiography (eg, patients with advanced CKD for whom contrast dose for invasive angiography would be lower than that required for CTA). For such patients in whom revascularization is being planned, diagnostic catheter angiography followed by endovascular revascularization during the same session or in a staged manner before the revascularization procedure can provide timely anatomic assessment and minimize risk associated with other studies. 2.	 Timely diagnosis and treatment, including revascularization, are essential to prevent tissue loss and preserve the limb in patients with CLTI (see Section 10, “Management of CLTI”). The imaging approach for planning revascularization in patients with CLTI is individualized based on patient-specific and imaging modality-based factors and local availability of resources. Noninvasive cross-sectional imaging (ie, duplex ultrasound, CTA, or MRA) is often obtained in planning revascularization, and validation studies comparing these modalities with catheter angiography have included patients with CLTI.1–3,5,6 However, for some patients with CLTI, proceeding directly to invasive catheter angiography followed by endovascular revascularization during the same session avoids delay and can minimize potential risks (eg, additional iodinated contrast exposure and radiation) associated with prerevascularization noninvasive imaging. 3.	 There are clinical situations in which a patient

has potential signs or symptoms of PAD but ABI and physiological testing results are inconclusive. Additional noninvasive imaging may be considered to establish the diagnosis of PAD and to determine a treatment strategy. This is particularly important for patients with nonhealing wounds (ie, suspected CLTI) for whom noncompressible vessels may lead to nondiagnostic physiological testing. Further, in patients with exertional leg symptoms who are unable to participate in physiological tests such as treadmill testing, establishing the presence of PAD or the severity of PAD may be difficult. For these patients, noninvasive imaging may be helpful to assess for the presence and severity of PAD on an individualized basis, especially if establishing the diagnosis of PAD will lead to change in treatment (eg, different medical therapy, consideration of revascularization). 4.	 CTA, MRA, and catheter angiography are associ-

ated with potential risks. CTA and catheter angiography expose the patient to ionizing radiation and iodinated contrast, which are associated with the risk of contrast nephropathy and risks related to radiation exposure.7,8 MRA exposes the patient to gadolinium-containing contrast agents, certain formulations of which increase the risk of nephrogenic systemic fibrosis in patients with renal disease.10,12 Risks of CTA and MRA also include discomfort and complications related to intravenous line placement and contrast infusion and potential for allergic reactions. Beyond risk associated with radiation and contrast exposure, catheter angiography is associated with risk of procedural discomfort and access site complications, including bleeding events.9 In patients for whom the diagnosis of PAD has been established, the primary value of CTA, MRA, and catheter angiography is to plan revascularization procedures when they are clinically indicated (eg, for CLTI or functionally limiting claudication despite GDMT). For patients with asymptomatic PAD or chronic symptomatic PAD managed with GDMT for whom no revascularization is being considered, there is no need to define lower extremity artery anatomy, and the risks of these imaging studies outweigh any potential benefit.

4. SPECIAL CONSIDERATIONS IN PAD: RISK AMPLIFIERS, HEALTH DISPARITIES, AND PAD IN OLDER PATIENTS

Special considerations in the evaluation care of patients with PAD include identification of factors that amplify the risk of MACE and MALE. Additionally, recognizing health disparities has the potential to impact outcomes for individual patients as well as at the population level.

4.1 Amplifiers of Cardiovascular and

Limb-Related Risk in Patients With PAD Recommendation for Amplifiers of Cardiovascular and Limb-Related Risk in Patients With PAD COR LOE Recommendation

1 C-EO 1 In the evaluation of patients with PAD, clinicians

should assess for and incorporate the presence of PAD-related risk amplifiers (Table 9) when developing patient-focused treatment recommendations.

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