The most appropriate management for this patient with symptomatic peripheral arterial disease is to start a supervised exercise program. Supervised exercise therapy can effectively treat claudication, with increases in pain-free walking time and maximal walking time, and is recommended as part of the initial treatment regimen for intermittent claudication. The CLEVER study demonstrated superior improvement in walking distance with supervised exercise for patients with aortoiliac disease, as compared with stent revascularization or medical therapy alone.

Cilostazol is an oral phosphodiesterase-3 inhibitor that has demonstrated increases in pain-free walking and overall walking distance in patients with claudication in randomized clinical trials, although the gains with exercise are two- to three-fold greater than with cilostazol alone. However, cilostazol is contraindicated in patients with heart failure or a left ventricular ejection fraction below 40%. This contraindication exists because cilostazol has a similar pharmacologic action to the inotropic drugs milrinone and amrinone, which demonstrated increased mortality rates with long-term use in patients with heart failure.

Patients with stable claudication progress to critical limb ischemia and limb loss at a rate of less than 5% annually. For most symptomatic patients, therefore, noninvasive therapy with exercise and medication is appropriate. If conservative therapy fails or patients have symptoms limiting their lifestyle or employment, revascularization by an endovascular or surgical approach should be considered.