Patient will present as → a 63-year-old male complaining of bilateral leg pain, which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. Past medical and surgical history is significant for hypertension, hyperlipidemia, and coronary artery bypass graft (5 years ago). He has a 60-pack-year smoking history. Vital signs are as follows: Temp 37C, HR 70, BP 143/89, and RR 18. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally; they are warm and well perfused. Ankle-brachial indices are 0.7 and 0.8.
PAD is most commonly the result of atherosclerosis and is a significant independent risk factor for cardiovascular and cerebrovascular morbidity and mortality
- Lower extremity atherosclerotic PAD is initially asymptomatic but typically progresses to claudication, ischemia, and pain with exercise
- Acute arterial occlusion may be caused by thrombosis or embolism
- Thrombotic disease also may be a result of trauma, hypovolemia, inflammatory arteritis (including Takayasu arteritis and Buerger disease), polycythemia, dehydration, repeated arterial punctures, and hypercoagulable states
Intermittent claudication, foot or lower leg pain with exercise that is relieved by rest, is usually the first symptom of PAD. As the condition progresses, pain at rest develops.
- Femoral and distal pulses will be weak or absent; an aortic, iliac, or femoral bruit may be present.
- Skin changes to the lower extremity include loss of hair, shiny atrophic skin, and pallor with dependent rubor
- Severe, chronic disease results in numbness, tingling, and ischemic ulcerations, which may lead to gangrene.
- Acute arterial occlusion threatens limb viability and results in the “6 Ps”: pain, pallor, pulselessness, paresthesias, poikilothermia, and paralysis
|Intermittent claudication||Occurs distal to the level of stenosis or occlusion
|An ankle-brachial index (ABI), which uses Doppler measurements to compare the BP in the upper and lower extremities, is a highly sensitive and specific test
Angiography remains the gold standard study
|Stop smoking first line
|Asymptomatic PAD||Screen patients with
Abnormal or absent pedal pulse
Age > 7o
Ages 50-69 with a history of smoking or DM
Screen with ABI
|Preventative treatment: ASA, lipid-lowering, blood pressure control|
|PAD or PVD||Occlusive atherosclerotic disease of lower extremities (noncardiac vessels)
Sites: superficial femoral artery (most common), popliteal, aortoiliac
Risk factors: smoking, hyperlipidemia, DM, HTN
Pain in one or more lower extremity muscle groups
Diminished or absent pulses
|Lipids: hypercholesterolemia >240, hypertriglyceridemia >250
||Prevention of atherosclerosis Control HLD, HTN, weight, DM
Manage primary hyperlipidemia: statins, diet, exercise
Graduated exercise: walk to point of claudication, rest, then continue walking Foot care
Most important Medical intervention:
Prognosis: Stable: 70%-80% Worsening: 10%-
Doppler ultrasound flow studies can be used to determine systolic pressures in the peripheral arteries.
- An ankle-brachial index (ABI), which uses Doppler measures to compare the BP in the upper and lower extremities, is a highly sensitive and specific test
- An ABI of ≤ 0.9 indicates significant disease
- Angiography remains the gold standard study
- CT or magnetic resonance angiography is also useful for locating stenotic sites and for accurate diagnosis of thrombosis or embolism.
- Although not regularly used for screening, elevated homocysteine has a strong association with incidence and progression of PAD.
- Exercise - walking to the point of claudication
- Platelet inhibitors: Cilostazol, Aspirin, Clopidogrel
- ACE inhibitors, statins, progressive exercise, and supervised exercise programs have been shown to be helpful at reducing symptoms of claudication
- If these interventions fail, revascularization with PTA, bypass grafts, stenting
- Surgical graft bypass
- Angioplasty—balloon dilation
- Endarterectomy—remove diseased intima and media
- Surgical patch angioplasty (place patch over stenosis)
- Erectile dysfunction may require revascularization or treatment with a phosphodiesterase, such as sildenafil.
Thrombolysis would be appropriate for a patient with an ischemic stroke.
A fasciotomy might be indicated after this patient's embolectomy, but would not be the initial management for this patient.
An amputation would be premature but may be indicated if the patient developed an infected limb.
No intervention necessary
This patient has an intervenable condition; thus, an embolectomy would be indicated.
Elastic compression stockings
Elastic compression stockings should be avoided as it can decrease arterial circulation to the skin.
Calcium channel blockers
Calcium channel blockers have not proven to be beneficial.
Warfarin may prevent more cardiovascular events but causes more major bleeding and has not been shown to improve outcomes in those with chronic PAD.
βblockers are contraindicated in isolated PAD as it will worsen claudication
Ankle/ brachial indices
MRI of the lumbar spine
Ultrasonography of the lower extremities
EMG of the lower extremities
Arteriogram of the lower extremities
The use of arteriogram is not necessary unless the patient is considering surgery.