Current and emerging approaches to managing peripheral artery disease: a specialist review

Peripheral artery disease (PAD) affects over 113 million people worldwide and is a marker of systemic atherosclerosis associated with significant cardiovascular and limb morbidity. While classic claudication is the most recognised presentation, PAD often manifests asymptomatically or with atypical symptoms, particularly in high-risk populations such as those with diabetes mellitus and chronic kidney disease. In advanced stages, chronic limb-threatening ischaemia (CLTI) confers high risks of amputation and mortality, underscoring the need for early diagnosis and aggressive management. Atherosclerosis accounts for >90% of PAD cases, while non-atherosclerotic causes are rare but critical to recognise, particularly in younger patients. History and physical exam remain the cornerstone of PAD diagnosis; however, non-invasive haemodynamic assessments remain necessary diagnostic adjuncts. In symptomatic patients, duplex arterial ultrasound, CT or magnetic resonance angiography imaging can also be useful. Optimal management hinges on risk factor modification, including smoking cessation, blood pressure control, lipid-lowering therapy, diet, supervised exercise therapy and glycaemic control. Antiplatelet therapy remains first-line, while dual pathway inhibition reduces cardiovascular and limb events in high-risk patients. Supervised exercise therapy is a cornerstone of claudication management, often delaying or avoiding revascularisation. Revascularisation should be reserved for lifestyle-limiting claudication refractory to medical therapy or for CLTI, with an appropriate approach (surgical, endovascular or hybrid) guided by anatomy, comorbidities and shared decision making. The 2024 American Heart Association/American College of Cardiology guidelines reinforce a patient-centred, evidence-based approach integrating medical therapy, functional assessment and timely intervention. Accordingly, this review provides a practical, contemporary framework for the diagnosis and management of atherosclerotic PAD, with consideration of future directions in PAD care.