In May 2024, the American College of Cardiology and the American Heart Association released a major update to the national guidelines for managing peripheral artery disease (PAD). This document—the 2024 ACC/AHA/Multisociety Guideline for the Management of Lower Extremity Peripheral Artery Disease (Gornik et al., J Am Coll Cardiol 2024;83(24):2497-2604)—is over 100 pages long, endorsed by eleven medical societies, and represents the most comprehensive update to PAD clinical practice in eight years.
If you’re a patient living with PAD—or if you suspect you might have it—this guideline has direct implications for how your condition should be diagnosed, monitored, and treated. But medical guidelines are written for clinicians, not patients. In this article, we’ll translate the most important changes into plain language and explain what they mean for your care.
At Surgical Associates (SACMD), our vascular specialists and interventional radiologists treat PAD patients across Maryland, DC, and Northern Virginia. We’ve incorporated these updated recommendations into our practice, and we believe informed patients make better decisions about their vascular health.
First, a Quick Refresher: What Is PAD?
Peripheral artery disease is a condition in which the arteries that carry blood to your legs become narrowed or blocked by plaque—the same process (atherosclerosis) that causes heart attacks and strokes. PAD affects approximately 6.5 million people in the United States and 237 million worldwide.
The symptoms range from no symptoms at all (asymptomatic PAD) to leg pain when walking (claudication), to the most severe form—chronic limb-threatening ischemia (CLTI), which can cause rest pain, non-healing wounds, gangrene, and ultimately amputation. An estimated 11% of PAD patients progress to CLTI, where one-year amputation rates run 15–20% and one-year mortality rates range from 15–40%.
The 2024 guideline addresses all four clinical presentations of PAD: asymptomatic disease, chronic symptomatic PAD, chronic limb-threatening ischemia, and acute limb ischemia. Here are the key takeaways for patients.
Key Change #1: Earlier and Broader Screening with the ABI
What it means for you: If you have risk factors for PAD, you should be screened—even if you have no symptoms.
The ankle-brachial index (ABI) is a simple, painless test that compares blood pressure in your ankle to blood pressure in your arm. A low ratio suggests that blood isn’t flowing freely to your legs. The 2024 guideline reinforces that ABI should be the primary screening and diagnostic tool for PAD and recommends it for patients with risk factors including smoking (current or past), diabetes, high blood pressure, high cholesterol, chronic kidney disease, and age over 65.
The important update here is the emphasis on screening even in the absence of classic symptoms. Many people with PAD don’t have the textbook symptom of leg pain when walking. Some have atypical symptoms—aching, fatigue, or heaviness in the legs—and some have no leg symptoms at all but are still at elevated cardiovascular risk. The guideline makes clear that PAD is a systemic vascular disease, not just a leg problem. Patients with PAD face significantly increased risk of heart attack, stroke, and cardiovascular death, and identifying the condition early allows for interventions that can reduce those risks.
What to ask your doctor: “Given my risk factors, should I have an ABI test?” This takes about 15 minutes, requires no preparation, and can be performed in most vascular surgery or interventional radiology offices, including all Surgical Associates locations.
Key Change #2: Structured Exercise Therapy as a First-Line Treatment
What it means for you: Before considering a procedure, supervised exercise may be the single most effective intervention for claudication.
The 2024 guideline gives structured exercise therapy a strong recommendation (Class 1 evidence) as a primary treatment for patients with chronic symptomatic PAD—specifically those with claudication (leg pain with walking). This isn’t a suggestion to “walk more.” The guideline specifically recommends supervised exercise programs: structured sessions, typically three times per week for 12 weeks, supervised by trained professionals.
The evidence behind this recommendation is robust. Supervised exercise therapy has been shown to improve walking distance, functional capacity, and quality of life in PAD patients, and in some studies, the magnitude of improvement rivals or exceeds what can be achieved with stents or bypass surgery for claudication.
The keyword here is “structured.” Walking on your own is beneficial, but formal exercise programs—often available through cardiac and vascular rehabilitation centers—produce consistently better outcomes. The guideline now emphasizes that revascularization (stents or surgery) for claudication should generally be considered only after an adequate trial of guideline-directed medical therapy, including structured exercise.
What to ask your doctor: “Is there a supervised exercise program available to me, and does my insurance cover it?” Medicare and many commercial plans now cover supervised exercise therapy for PAD.
Key Change #3: Rivaroxaban + Low-Dose Aspirin to Prevent Heart Attack, Stroke, and Limb Events
What it means for you: A specific medication combination can reduce your risk of major cardiovascular and limb events.
One of the most significant pharmacological updates in the 2024 guideline involves antithrombotic therapy. The guideline states that for patients with PAD who are not at increased bleeding risk, the combination of rivaroxaban (2.5 mg twice daily) plus low-dose aspirin (81 mg daily) is effective for preventing major adverse cardiovascular events (MACE) and major adverse limb events (MALE).
This recommendation is based on the landmark COMPASS trial, which demonstrated that this combination reduced the risk of cardiovascular death, stroke, and heart attack, as well as the risk of major amputation and acute limb ischemia, compared to aspirin alone.
This is a meaningful shift. For years, aspirin alone was the standard antiplatelet therapy for most PAD patients. The 2024 guideline acknowledges that many PAD patients—particularly those with symptomatic disease—may benefit from this dual pathway approach, provided their bleeding risk is acceptable.
Not every PAD patient is a candidate for this regimen. Patients with a history of significant bleeding, those on other blood thinners, and those with certain medical conditions may not be appropriate. This is a conversation to have with your vascular specialist.
What to ask your doctor: “Am I a candidate for rivaroxaban plus aspirin based on my PAD status and bleeding risk?”
Key Change #4: The WIfI Classification System for Limb-Threat Staging
What it means for you: If you have a wound, foot pain at rest, or signs of severe PAD, your doctor should be using a standardized system to assess your risk and guide treatment decisions.
The 2024 guideline formally endorses the WIfI classification system for patients with chronic limb-threatening ischemia. WIfI stands for Wound, Ischemia, and foot Infection—three factors that together predict the risk of amputation and the likely benefit of revascularization.
Each factor is graded on a scale from 0 (none) to 3 (severe), and the combined score helps clinicians determine whether a patient is likely to benefit from a revascularization procedure (such as angioplasty, stenting, or bypass surgery) to restore blood flow to the leg and foot.
Why does this matter for patients? Because it replaces older, less precise systems with a more objective framework for making treatment decisions. If you’re told you might need an amputation, you have the right to ask whether a WIfI assessment has been performed and whether revascularization has been considered to save the limb.
The guideline is emphatic that for patients with CLTI, revascularization is recommended to minimize tissue loss, heal wounds, relieve pain, and preserve a functional limb (Class 1 recommendation). This includes achieving in-line blood flow or maximizing perfusion to the wound bed whenever feasible.
What to ask your doctor: “Has my limb threat been assessed using the WIfI system? Have all revascularization options been considered?”
Key Change #5: Multispecialty Team-Based Care
What it means for you: Your PAD care shouldn’t depend on a single provider’s perspective. The best outcomes come from coordinated teams.
The 2024 guideline places significant emphasis on the importance of multidisciplinary care for PAD patients, particularly those with CLTI. The guideline specifically states that podiatrists and other specialists with expertise in foot care, wound healing, and foot surgery should be part of the care team.
For patients in the DMV area, this is particularly relevant. PAD disproportionately affects communities with limited access to vascular specialists. The guideline calls out racial and ethnic disparities in PAD detection, management, and outcomes, noting that amputation rates are significantly higher among Black patients compared to White patients, even after accounting for disease severity—a disparity driven in part by unequal access to vascular care and revascularization procedures.
At Surgical Associates, our team includes vascular surgeons and interventional radiologists who work together to provide comprehensive PAD care. With offices in Camp Springs, Waldorf, Silver Spring (Maryland), Washington DC, and Reston (Virginia), we’re committed to making advanced vascular care accessible to patients across our region—including communities that have historically been underserved.
Key Change #6: Longitudinal Follow-Up Is Now a Core Recommendation
What it means for you: PAD management doesn’t end after a procedure. Ongoing monitoring is essential.
The guideline recommends that all patients with PAD—whether or not they’ve undergone revascularization—receive longitudinal follow-up with physical examination (Class 1 recommendation). For patients who have undergone a procedure and develop new symptoms, ABI and arterial duplex ultrasound are recommended.
This reflects the understanding that PAD is a chronic, progressive disease. Stents can narrow again. Bypass grafts can fail. And the underlying atherosclerosis continues to pose cardiovascular risk. Regular follow-up allows your care team to catch problems early and adjust your treatment plan.
What This Means for Patients at Surgical Associates
At Surgical Associates, our approach to PAD care aligns with the 2024 guidelines’ emphasis on early detection, comprehensive medical therapy, and minimally invasive intervention when appropriate. Our services include ABI screening and vascular diagnostic testing at all locations, medical therapy optimization including statin therapy and antithrombotic counseling, endovascular revascularization procedures (angioplasty, stenting, atherectomy), wound care coordination for patients with CLTI, and longitudinal follow-up with duplex surveillance.
If you have risk factors for PAD—or if you’ve been told you have PAD and want to make sure your care plan reflects the latest evidence—we encourage you to schedule an evaluation.
The Bottom Line
The 2024 ACC/AHA PAD Guideline is the most important update to peripheral artery disease management in nearly a decade. Its core messages are clear: screen earlier and more broadly, treat with evidence-based medications including the rivaroxaban-aspirin combination for eligible patients, prioritize structured exercise, use standardized assessment tools like WIfI for severe disease, ensure multidisciplinary team-based care, and follow patients longitudinally.
For patients in Maryland, DC, and Virginia, this guideline represents both a challenge and an opportunity. The challenge is that PAD remains underdiagnosed and undertreated, particularly in communities of color. The opportunity is that effective, evidence-based treatments exist—and every patient deserves access to them.
Schedule a PAD screening or consultation: Call (240) 427-1630 or visit www.sacmd.com
Disclaimer: This article is for informational purposes only and does not constitute medical advice. Treatment decisions should be made in consultation with a qualified vascular specialist based on your individual clinical situation.
References:
- Gornik HL, Aronow HD, Goodney PP, et al. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease. J Am Coll Cardiol. 2024;83(24):2497-2604.
- ACC Key Points: 2024 ACC/AHA/Multisociety Guideline for Lower Extremity PAD. American College of Cardiology. Published May 14, 2024.
- ACC Guideline-at-a-Glance: 2024 Lower Extremity Peripheral Artery Disease. J Am Coll Cardiol. 2024.
- 2024 ACC/AHA/Multisociety Guideline: Foot Care in Patients with PAD. American College of Cardiology Expert Analysis. June 2025.
Dr. Rahbar is an esteemed vascular surgeon at Surgical Associates, known for their exceptional contributions to the field of vascular surgery. As a board-certified vascular surgeon with over 20 years of invaluable experience, Dr. Rahbar is a respected authority in the medical community serving Camp Spring, Maryland and the whole community of Maryland. Their unwavering dedication to providing advanced care for patients with diseases of the arteries and veins has earned them a reputation for excellence. Dr. Rahbar’s work embodies a passion for precision and compassion, improving the lives of those they serve, one procedure at a time.