Role and management of coagulation disorders in peripheral arterial disease.

Peripheral arterial disease (PAD) has often underlying risk factors, of which diabetes and cigarette smoking are the most common. Enhanced platelet activation and interaction with vessel wall associate with atherothrombotic disease, but also increased fibrinogen levels, thrombin generation and fibrin turnover are typical for PAD. The pathogenic role of fibrinogen, thrombin formation and fibrin degradation is suggested not only in acute thrombotic complications, but also in the stable form of PAD, where these markers associate with the functional severity (ankle-brachial blood pressure index). The coagulation-specific etiologies of PAD should be suspected if the atherothrombotic disease has severe manifestations, especially while the traditional risk factors are absent, or if the patient has also a history of venous thromboembolism. Malignant disease may be present in form of peripheral arterial thrombosis as well. Thrombophilia may expose patients to idiopathic thrombosis--both spontaneously and after vascular interventions. The management of these patients includes often combination therapies with antiplatelet agents and anticoagulants. Obviously, the strict policy to avoid risk factors and to treat them well in avoidance of progression of arterial disease is highly important. In the absence of published follow-up data the evidence to support the management strategies is weak and individual tailoring of efficacious and safe antithrombotic drug therapy remains our challenge. These patients benefit from continuous medical attention by the experts in the field of angiology. Management of PAD is an excellent example of the multidisciplinary approach where the hematologist meets the vascular surgeon or interventional radiologist to secure the best available patient care.