Peripheral artery disease (PAD) is obstruction of the arterial lumen resulting in decreased blood flowBlood flowBlood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute).Vascular Resistance, Flow, and Mean Arterial Pressure to the distal limbs. The disease can be a result of atherosclerosisAtherosclerosisAtherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis or thrombosisThrombosisFormation and development of a thrombus or blood clot in the blood vessel.Epidemic Typhus. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship may be asymptomatic or have progressive claudication, skinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions discoloration, ischemic ulcers, or gangreneGangreneDeath and putrefaction of tissue usually due to a loss of blood supply.Small Bowel Obstruction. Onset may be insidious (atherosclerosisAtherosclerosisAtherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis) or abrupt (thrombosisThrombosisFormation and development of a thrombus or blood clot in the blood vessel.Epidemic Typhus). Diagnosis is made with the clinical history, exam, and measurement of the ankle-brachial indexAnkle-brachial indexComparison of the blood pressure between the brachial artery and the posterior tibial artery. It is a predictor of peripheral arterial disease.Cardiovascular Examination. Imaging studies can determine the location and extent of the arterial disease. Treatment varies depending on the severity but can include lifestyle modifications, antiplatelet therapy, risk factor modifications, phosphodiesterase inhibitorsPhosphodiesterase inhibitorsPhosphodiesterase (PDE) inhibitors are a group of drugs that act by inhibiting PDE enzymes. Phosphodiesterase inhibitors have various mechanisms of action depending on the subtype of PDE targeted, but their main action is increasing the amount of intracellular cAMP or cGMP, which in turn results in physiologic effects such as reducing inflammation, promoting smooth muscle relaxation, and vasodilation.Phosphodiesterase Inhibitors, and revascularizationRevascularizationThromboangiitis Obliterans (Buerger Disease).
PrevalencePrevalenceThe total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time.Measures of Disease Frequency:
Affects approximately 10 million people in the United States
Worldwide prevalencePrevalenceThe total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time.Measures of Disease Frequency is 1.52% or about 113 million people (2019)
Men > women
Higher prevalencePrevalenceThe total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time.Measures of Disease Frequency among African Americans and Hispanic American women
Higher rates seen in older patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship, families with atherosclerosisAtherosclerosisAtherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis and those with cardiovascular disease
Etiology[1,2,6,7]
Peripheral artery disease (PAD) usually has the same causative factors as coronary and carotid disease.
AtherosclerosisAtherosclerosisAtherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis:
Aging
HypertensionHypertensionHypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
SmokingSmokingWillful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand.Interstitial Lung Diseases and tobacco use
DiabetesDiabetesDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus mellitus
HypercholesterolemiaHypercholesterolemiaA condition with abnormally high levels of cholesterol in the blood. It is defined as a cholesterol value exceeding the 95th percentile for the population.Lipid Disorders
Hyperhomocysteinemia
ObesityObesityObesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
Arterial embolism:
CholesterolCholesterolThe principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils.Cholesterol MetabolismatheroembolismAtheroembolismAn embolus is an intravascular solid, liquid, or gaseous material that is carried by the blood to a site distant from its point of origin. Emboli of all types warrant immediate medical attention. The majority of emboli dislodge from a thrombus, forming a thromboembolus. Other less common nonthrombotic types of emboli are cholesterol, fat, air, amniotic fluid, and tumor emboli.Nonthrombotic Embolism
Atrial fibrillationAtrial fibrillationAtrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation
EndocarditisEndocarditisEndocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Endocarditis
Artificial heart valves
Functional:
Vasospasm
Previous injury to the limb
Risk groups:
Age ≥ 70 years
Age 50–69 years + smokingSmokingWillful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand.Interstitial Lung Diseases or diabetesDiabetesDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus
Age 40–49 + diabetesDiabetesDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus + 1 other risk factor for atherosclerosisAtherosclerosisAtherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis
AtherosclerosisAtherosclerosisAtherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis at other sites (e.g., coronary, carotid, renal)
AtherosclerosisAtherosclerosisAtherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis: endothelial cell dysfunction → macrophage and cholesterolCholesterolThe principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils.Cholesterol Metabolism accumulation → foam cell formation → platelet-derived growth factorPlatelet-derived growth factorMitogenic peptide growth hormone carried in the alpha-granules of platelets. It is released when platelets adhere to traumatized tissues. Connective tissue cells near the traumatized region respond by initiating the process of replication.Hypertrophic and Keloid Scars (PDGF) and fibroblast growth factorFibroblast growth factorA family of small polypeptide growth factors that share several common features including a strong affinity for heparin, and a central barrel-shaped core region of 140 amino acids that is highly homologous between family members. Although originally studied as proteins that stimulate the growth of fibroblasts this distinction is no longer a requirement for membership in the fibroblast growth factor family.X-linked Hypophosphatemic Rickets (FGF) release → smooth muscle cell migration → proliferation and extracellular matrixExtracellular matrixA meshwork-like substance found within the extracellular space and in association with the basement membrane of the cell surface. It promotes cellular proliferation and provides a supporting structure to which cells or cell lysates in culture dishes adhere.Hypertrophic and Keloid Scars deposition → fibrousFibrousFibrocystic ChangeplaquePlaquePrimary Skin Lesions
Subintimal accumulation of lipid and fibrousFibrousFibrocystic Change material of the arteriesArteriesArteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology → vessel lumen narrowing → restricted blood flowBlood flowBlood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute).Vascular Resistance, Flow, and Mean Arterial Pressure → chronic ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage of the affected limb
PlaquePlaquePrimary Skin Lesions rupture or thrombosisThrombosisFormation and development of a thrombus or blood clot in the blood vessel.Epidemic Typhus → abrupt occlusion of downstream vessels → acute ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage of the limb
Composition of the fibrous plaque in atherosclerosis
PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with PAD may be asymptomatic (20%–25%) or present with evidence of chronic or acute limb ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage.
Chronic arterial insufficiency[2,6,7,9]
Symptoms:
The lower extremities are most commonly affected.
Intermittent claudicationIntermittent claudicationA symptom complex characterized by pain and weakness in skeletal muscle group associated with exercise, such as leg pain and weakness brought on by walking. Such muscle limpness disappears after a brief rest and is often relates to arterial stenosis; muscle ischemia; and accumulation of lactate.Thromboangiitis Obliterans (Buerger Disease):
Reproducible, painful cramping in the buttock, hips, thighs, calf, or footFootThe foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons.Foot: Anatomy with exertion
Relieved with rest
Atypical limb painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways or feeling of “heaviness”
Limb numbness or weakness
Impotence, erectile dysfunctionErectile DysfunctionErectile dysfunction (ED) is defined as the inability to achieve or maintain a penile erection, resulting in difficulty to perform penetrative sexual intercourse. Local penile factors and systemic diseases, including diabetes, cardiac disease, and neurological disorders, can cause ED. Erectile Dysfunction
CyanosisCyanosisA bluish or purplish discoloration of the skin and mucous membranes due to an increase in the amount of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule.Pulmonary Examination
Weak or absent pulse below a narrowed area of the artery
Bruits over arteriesArteriesArteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology heard on auscultation
Decreased blood pressure in the affected limb
Severe disease:
Loss of hair follicles, sweat glandsSweat glandsSweat-producing structures that are embedded in the dermis. Each gland consists of a single tube, a coiled body, and a superficial duct.Soft Tissue Abscess, and sebaceous glands
SkinSkinThe skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue.Skin: Structure and Functions becomes smooth and shiny.
Fontaine classification:
Used to determine the severity of PAD
Stages are based on symptoms and exam (see table).
Table: Fontaine classification of peripheral artery disease
Stage
Symptoms
1
Asymptomatic
2a
Intermittent claudicationIntermittent claudicationA symptom complex characterized by pain and weakness in skeletal muscle group associated with exercise, such as leg pain and weakness brought on by walking. Such muscle limpness disappears after a brief rest and is often relates to arterial stenosis; muscle ischemia; and accumulation of lactate.Thromboangiitis Obliterans (Buerger Disease) after walking > 200 meters (219 yards)
2b
Intermittent claudicationIntermittent claudicationA symptom complex characterized by pain and weakness in skeletal muscle group associated with exercise, such as leg pain and weakness brought on by walking. Such muscle limpness disappears after a brief rest and is often relates to arterial stenosis; muscle ischemia; and accumulation of lactate.Thromboangiitis Obliterans (Buerger Disease) after walking < 200 meters (219 yards)
3
Nocturnal or resting painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
4
NecrosisNecrosisThe death of cells in an organ or tissue due to disease, injury or failure of the blood supply.Ischemic Cell Damage or gangreneGangreneDeath and putrefaction of tissue usually due to a loss of blood supply.Small Bowel Obstruction of the limb
Rutherford classification:[10]
Used to determine the severity of PAD with greater precision
Categories are based on clinical symptoms and objective vascular testing criteria, such as ankle pressure measurements (see table).
Table: Rutherford classification of peripheral artery disease
Grade
Category
Clinical Description
Objective Criteria
0
0
Asymptomatic
Normal treadmill/stress test
I
1
Mild claudication
Completes treadmill test; AP after exercise > 50 mmHg but at least 20 mmHg lower than resting
I
2
Moderate claudication
Between categories 1 and 3
I
3
Severe claudication
Cannot complete standard treadmill test; AP after exercise < 50 mmHg
II
4
Ischemic rest painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
Resting AP < 40 mmHg, ankle/metatarsal PVR flat or barely pulsatile; TP < 30 mmHg
III
5
Minor tissue loss (non-healing ulcers, focal areas of poor blood flowBlood flowBlood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute).Vascular Resistance, Flow, and Mean Arterial Pressure)
Resting AP < 60 mmHg, ankle/metatarsal PVR flat or barely pulsatile; TP < 40 mmHg
IV
6
Major tissue loss (damage extends above TMTmTubular System level, non-salvageable footFootThe foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons.Foot: Anatomy)
Image: “Bilateral toes showing cyanosis” by Department of Anaesthesia and Intensive Care, Bhubaneswar, India. License: CC BY 2.0
Chronic limb-threatening (critical) ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage[1,9]
Any 1 of the following indicates that blood flowBlood flowBlood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute).Vascular Resistance, Flow, and Mean Arterial Pressure no longer meets the metabolic demands of the limb tissues at rest:
Resting painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways:
Non-healing arterial ulcer on the dorsum of the foot in a patient with PAD
Image: “Severe peripheral arterial disease” by Jonathan Moore. License: CC BY 3.0
Peripheral arterial disease resulting in necrosis of multiple toes
Image: “Peripheral arterial disease” by Karl-Christian Münter. License: CC BY 4.0
Acute limb ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage[2,6]
Acute limb ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage is most commonly due to an embolism or plaquePlaquePrimary Skin Lesions rupture. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship will demonstrate acute onset of:
6 Ps:
Pain
Pallor
Pulseless
Poikilothermia (cold)
Paresthesia
Paralysis
Blue toe syndrome:
Due to cholesterolCholesterolThe principal sterol of all higher animals, distributed in body tissues, especially the brain and spinal cord, and in animal fats and oils.Cholesterol MetabolismatheroembolismAtheroembolismAn embolus is an intravascular solid, liquid, or gaseous material that is carried by the blood to a site distant from its point of origin. Emboli of all types warrant immediate medical attention. The majority of emboli dislodge from a thrombus, forming a thromboembolus. Other less common nonthrombotic types of emboli are cholesterol, fat, air, amniotic fluid, and tumor emboli.Nonthrombotic Embolism to digital arteriesArteriesArteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology
Categories of Severity in acute limb ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage[2,10]
Viable or not immediately threatened (I)
Mild (not continuous)) painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
Intact capillary refill
No neurologic deficit
Audible arterial dopplerDopplerUltrasonography applying the doppler effect, with frequency-shifted ultrasound reflections produced by moving targets (usually red blood cells) in the bloodstream along the ultrasound axis in direct proportion to the velocity of movement of the targets, to determine both direction and velocity of blood flow.Ultrasound (Sonography)
Threatenedviability(II): reversible limb ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage (salvageable if arterial obstruction is relieved immediately)
Moderate (not continuous) painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
Inaudible arterial dopplerDopplerUltrasonography applying the doppler effect, with frequency-shifted ultrasound reflections produced by moving targets (usually red blood cells) in the bloodstream along the ultrasound axis in direct proportion to the velocity of movement of the targets, to determine both direction and velocity of blood flow.Ultrasound (Sonography)
Severe (continuous) painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
Inaudible arterial dopplerDopplerUltrasonography applying the doppler effect, with frequency-shifted ultrasound reflections produced by moving targets (usually red blood cells) in the bloodstream along the ultrasound axis in direct proportion to the velocity of movement of the targets, to determine both direction and velocity of blood flow.Ultrasound (Sonography)
Nonviable (III): major irreversible ischemic damage; significant neuromuscular damage expected (major amputationAmputationAn amputation is the separation of a portion of the limb or the entire limb from the body, along with the bone. Amputations are generally indicated for conditions that compromise the viability of the limb or promote the spread of a local process that could manifest systemically. Amputation needed)
Absent capillary refill
Neurologic deficit: profound sensorySensoryNeurons which conduct nerve impulses to the central nervous system.Nervous System: Histology loss, + paralysis
Inaudible arterial dopplerDopplerUltrasonography applying the doppler effect, with frequency-shifted ultrasound reflections produced by moving targets (usually red blood cells) in the bloodstream along the ultrasound axis in direct proportion to the velocity of movement of the targets, to determine both direction and velocity of blood flow.Ultrasound (Sonography)
This algorithm demonstrates the diagnostic pathway for a patient presenting with signs or symptoms of PAD:
Diagnostic algorithm for PAD
Image by Lecturio.
The diagnosis is usually established through clinical history, exam, and non-invasive testing techniques (ankle-brachial indexAnkle-brachial indexComparison of the blood pressure between the brachial artery and the posterior tibial artery. It is a predictor of peripheral arterial disease.Cardiovascular Examination (ABI), exercise testing).
Note that those with features of limb-threatening ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage need urgent vascular surgeryVascular surgeryVascular surgery is the specialized field of medicine that focuses on the surgical management of the pathologies of the peripheral circulation. The main goal of most vascular procedures is to restore circulatory function to the affected vessels by relieving occlusions or by redirecting blood flow (e.g., bypass).Vascular Surgery evaluation. These patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship may still undergo imaging studies to locate the area of vascular obstruction or stenosisStenosisHypoplastic Left Heart Syndrome (HLHS) as part of surgical planning.
Non-invasive techniques
These studies are used to establish the diagnosis:[1,2,6]
Ankle-brachial indexAnkle-brachial indexComparison of the blood pressure between the brachial artery and the posterior tibial artery. It is a predictor of peripheral arterial disease.Cardiovascular Examination
Usually the first choice in testing to establish a diagnosis
Equals the legLegThe lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia.Leg: Anatomy systolic blood pressure divided by the armArmThe arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior).Arm: Anatomy systolic blood pressure:
An ABI < 0.9 indicates PAD (see table below for the severity classification based on ABI).
An ABI > 1.3 may indicate noncompressible vessels due to calcification (common in diabetics).
If the ABI is > 1.3 and suspicion for PAD is high, consider measuring a BP in the 1st toe or proceed to DopplerDopplerUltrasonography applying the doppler effect, with frequency-shifted ultrasound reflections produced by moving targets (usually red blood cells) in the bloodstream along the ultrasound axis in direct proportion to the velocity of movement of the targets, to determine both direction and velocity of blood flow.Ultrasound (Sonography) ultrasound.
Treadmill exercise test
Indicated for patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with a classic history suggesting PAD and normal resting ABI (0.91–1.30)
ABIs are measured before and after exercise:
Normal physiology: ABI should ↑ or stay the same.
In PAD: post-exercise ABI ↓ by ≥ 20%
Table: Interpretation of the ankle-brachial indexAnkle-brachial indexComparison of the blood pressure between the brachial artery and the posterior tibial artery. It is a predictor of peripheral arterial disease.Cardiovascular Examination (ABI)
Parameter
Value
Normal
≥ 0.9
Mild
0.71–0.9
Moderate
0.41–0.7
Severe
≤ 0.4
Image demonstrating how to measure the ankle-brachial index: This assists in the diagnosis and severity determination of PAD.
Image by Lecturio.
Imaging
These studies are used to evaluate the location and severity of disease:[2,6]
DopplerDopplerUltrasonography applying the doppler effect, with frequency-shifted ultrasound reflections produced by moving targets (usually red blood cells) in the bloodstream along the ultrasound axis in direct proportion to the velocity of movement of the targets, to determine both direction and velocity of blood flow.Ultrasound (Sonography) ultrasound
Noninvasive, but operator-dependent
Can determine blood flowBlood flowBlood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute).Vascular Resistance, Flow, and Mean Arterial Pressure through arteriesArteriesArteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology
Computed tomography with angiographyAngiographyRadiography of blood vessels after injection of a contrast medium.Cardiac Surgery (CTACTAA non-invasive method that uses a ct scanner for capturing images of blood vessels and tissues. A contrast material is injected, which helps produce detailed images that aid in diagnosing vascular diseases.Pulmonary Function Tests)
Quick, but requires contrast administration
Becoming more commonly utilized to locate stenotic lesions
Can avoid ionizing radiationRadiationEmission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles).Osteosarcoma
High diagnostic accuracy
Digital subtraction arteriography
Reference standard
Intravenous contrast is injected imaged with a series of radiographs.
Has the highest diagnostic accuracy
Arteriography showing occlusion of the posterior tibial artery (arrow)
Image: “Posterior tibial artery occlusion” by C. Voiculeț et al. License: CC BY 2.0
An MRA demonstrating occluded left distal common and proximal superficial (thin arrow) and profunda (thick arrow) femoral arteries, with a collateral artery connecting the 2
Image: “F1” by Bariatric and Metabolic Institute & Dept. of Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland 44950, Ohio, USA. License: CC BY 2.0
These CTA images demonstrate stenosis (arrows) in the left superficial femoral artery.
Image: “Example of a run-off CTA” by Klinik für Radiologie, Charité Universitätsmedizin Berlin, Berlin, Germany. License: CC BY 4.0
Laboratory testing
These studies are not used for the diagnosis of PAD, but can help evaluate risk factors or organ injury:
Hemoglobin A1cHemoglobin A1cProducts of non-enzymatic reactions between glucose and hemoglobin a, occurring as a minor fraction of the hemoglobin components of human erythrocytes. Hemoglobin a1c is hemoglobin a with glucose covalently bound to the terminal valine of the beta chain. Glycated hemoglobin a is used as an index of the average blood sugar level over a lifetime of erythrocytes.Diabetes Mellitus → diabetesDiabetesDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus
ScreeningScreeningPreoperative Care is performed in patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship who may be asymptomatic but have risk factors or evidence of PAD.
Important in preventing progression and complications
Can be used to identify patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship at risk for other types of cardiovascular disease
Again, ABI is the test of choice for establishing the diagnosis.
Lifestyle modification is the 1st line of therapy:
SmokingSmokingWillful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand.Interstitial Lung Diseases cessation
Helps develop collateral circulationCirculationThe movement of the blood as it is pumped through the cardiovascular system.ABCDE Assessment
Reduces blood cell aggregationAggregationThe attachment of platelets to one another. This clumping together can be induced by a number of agents (e.g., thrombin; collagen) and is part of the mechanism leading to the formation of a thrombus.Coagulation Studies and blood viscosityBlood viscosityThe internal resistance of the blood to shear forces. The in vitro measure of whole blood viscosity is of limited clinical utility because it bears little relationship to the actual viscosity within the circulation, but an increase in the viscosity of circulating blood can contribute to morbidity in patients suffering from disorders such as sickle cell anemia and polycythemia.Vascular Resistance, Flow, and Mean Arterial Pressure
Medications[1,3,6]
Antiplatelet therapy
Single antiplatelet therapy reduces major adverse cardiovascular events in those with symptomatic PAD.
AspirinAspirinThe prototypical analgesic used in the treatment of mild to moderate pain. It has anti-inflammatory and antipyretic properties and acts as an inhibitor of cyclooxygenase which results in the inhibition of the biosynthesis of prostaglandins. Aspirin also inhibits platelet aggregation and is used in the prevention of arterial and venous thrombosis.Nonsteroidal Antiinflammatory Drugs (NSAIDs)
ClopidogrelClopidogrelA ticlopidine analog and platelet purinergic p2y receptor antagonist that inhibits adenosine diphosphate-mediated platelet aggregation. It is used to prevent thromboembolism in patients with arterial occlusive diseases; myocardial infarction; stroke; or atrial fibrillation.Antiplatelet Drugs
RivaroxabanRivaroxabanA morpholine and thiophene derivative that functions as a factor Xa inhibitor and is used in the treatment and prevention of deep-vein thrombosis and pulmonary embolism. It is also used for the prevention of stroke and systemic embolization in patients with non-valvular atrial fibrillation, and for the prevention of atherothrombotic events in patients after an acute coronary syndrome.Anticoagulants (low dose anticoagulant) taken with low-dose aspirinAspirinThe prototypical analgesic used in the treatment of mild to moderate pain. It has anti-inflammatory and antipyretic properties and acts as an inhibitor of cyclooxygenase which results in the inhibition of the biosynthesis of prostaglandins. Aspirin also inhibits platelet aggregation and is used in the prevention of arterial and venous thrombosis.Nonsteroidal Antiinflammatory Drugs (NSAIDs) (81 mg daily): recommended in severely symptomatic PAD or after revascularizationRevascularizationThromboangiitis Obliterans (Buerger Disease)
Risk factor modification:
Statin therapy (goal LDL < 70 mg/dL)
Antihypertensive treatment (goal BP < 130/80)
DiabetesDiabetesDiabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance.Diabetes Mellitus control (use of GLP-1GLP-1A peptide of 36 or 37 amino acids that is derived from proglucagon and mainly produced by the intestinal l cells. Glp-1(1-37 or 1-36) is further n-terminally truncated resulting in glp-1(7-37) or glp-1-(7-36) which can be amidated. These glp-1 peptides are known to enhance glucose-dependent insulin release, suppress glucagon release and gastric emptying, lower blood glucose, and reduce food intake.Insulinomas agonists and/or SGLT inhibitors)
Vitamins (folateFolateFolate and vitamin B12 are 2 of the most clinically important water-soluble vitamins. Deficiencies can present with megaloblastic anemia, GI symptoms, neuropsychiatric symptoms, and adverse pregnancy complications, including neural tube defects. Folate and Vitamin B12 and vitamin B12) for hyperhomocysteinemia
Phosphodiesterase inhibitorsPhosphodiesterase inhibitorsPhosphodiesterase (PDE) inhibitors are a group of drugs that act by inhibiting PDE enzymes. Phosphodiesterase inhibitors have various mechanisms of action depending on the subtype of PDE targeted, but their main action is increasing the amount of intracellular cAMP or cGMP, which in turn results in physiologic effects such as reducing inflammation, promoting smooth muscle relaxation, and vasodilation.Phosphodiesterase Inhibitors (cilostazolCilostazolA quinoline and tetrazole derivative that acts as a phosphodiesterase type 3 inhibitor, with anti-platelet and vasodilating activity. It is used in the treatment of peripheral vascular diseases; ischemic heart disease; and in the prevention of stroke.Phosphodiesterase Inhibitors):
Most effective pharmaceutical treatment for improving claudication symptoms
Indicated after failure of conservative measures
Reduces platelet aggregationPlatelet aggregationThe attachment of platelets to one another. This clumping together can be induced by a number of agents (e.g., thrombin; collagen) and is part of the mechanism leading to the formation of a thrombus.Hemostasis and allows arterial vasodilationVasodilationThe physiological widening of blood vessels by relaxing the underlying vascular smooth muscle.Pulmonary Hypertension Drugs
Not for patientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship with intermittent claudicationIntermittent claudicationA symptom complex characterized by pain and weakness in skeletal muscle group associated with exercise, such as leg pain and weakness brought on by walking. Such muscle limpness disappears after a brief rest and is often relates to arterial stenosis; muscle ischemia; and accumulation of lactate.Thromboangiitis Obliterans (Buerger Disease) or where tissue is immediately threatened or irreversibly damaged
Goal is to salvage the limb tissue and prevent amputationAmputationAn amputation is the separation of a portion of the limb or the entire limb from the body, along with the bone. Amputations are generally indicated for conditions that compromise the viability of the limb or promote the spread of a local process that could manifest systemically. Amputation.
Indications:
Chronic limb-threatening ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage (CLTI)
Failure to improve with lifestyle modification and medications
Significant disabilityDisabilityDetermination of the degree of a physical, mental, or emotional handicap. The diagnosis is applied to legal qualification for benefits and income under disability insurance and to eligibility for social security and workman’s compensation benefits.ABCDE Assessment due to symptoms
Percutaneous transluminal angioplastyAngioplastyReconstruction or repair of a blood vessel, which includes the widening of a pathological narrowing of an artery or vein by the removal of atheromatous plaque material and/or the endothelial lining as well, or by dilatation (balloon angioplasty) to compress an atheroma. Except for endarterectomy, usually these procedures are performed via catheterization as minimally invasive endovascular procedures.Cardiac Surgery (PTAPTAA peritonsillar abscess (PTA), also called quinsy, is a collection of pus between the capsule of the palatine tonsil and the pharyngeal muscles. A pta is usually a complication of acute tonsillitis, an infection caused by group a streptococci. Patients often present with a sore throat, trismus, and a muffled voice.Peritonsillar Abscess):
Can be used for in-stent restenosis or in areas where stent placement is not feasible
Surgical procedures:
EndarterectomyEndarterectomySurgical excision, performed under general anesthesia, of the atheromatous tunica intima of an artery. When reconstruction of an artery is performed as an endovascular procedure through a catheter, it is called atherectomy.Intestinal Ischemia (direct removal of obstructive plaquePlaquePrimary Skin Lesions)
Embolectomy (direct removal of a thrombus)
Vascular bypass grafting
Left: left popliteal artery occlusion Right: return of blood flow after PTA with stenting
Image: “Popliteal arterial long occlusion case” by Department of Radiology, the First Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of China. License: CC BY 2.0
Complications
Threatened limbThreatened limbMinimal sensory loss, mild-to-moderate muscle weakness, absent arterial doppler tones, requires urgent intervention.Acute Limb Ischemia from acute limb ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage
Surgical embolectomy should be performed in most circumstances.
Intraoperative angiographyAngiographyRadiography of blood vessels after injection of a contrast medium.Cardiac Surgery follow-up to ensure normal flowFlowBlood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls.Vascular Resistance, Flow, and Mean Arterial Pressure
Compartment syndromeCompartment SyndromeCompartment syndrome is a surgical emergency usually occurring secondary to trauma. The condition is marked by increased pressure within a compartment that compromises the circulation and function of the tissues within that space.Compartment Syndrome
Increased risk after prolonged ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage (> 6 hours)
Occurs due to reperfusion injuryReperfusion injuryAdverse functional, metabolic, or structural changes in ischemic tissues resulting from the restoration of blood flow to the tissue (reperfusion), including swelling; hemorrhage; necrosis; and damage from free radicals. The most common instance is myocardial reperfusion injury.Ischemic Cell Damage → leads to swellingSwellingInflammation and increased pressure (may result in further ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage, necrosisNecrosisThe death of cells in an organ or tissue due to disease, injury or failure of the blood supply.Ischemic Cell Damage, and limb loss)
PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship will develop severe painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways, paresthesiasParesthesiasSubjective cutaneous sensations (e.g., cold, warmth, tingling, pressure, etc.) that are experienced spontaneously in the absence of stimulation.Posterior Cord Syndrome, and muscle weakness.
Limb may feel tense.
Diagnosis is made by measuring compartment pressures.
Requires 4-compartment fasciotomyFasciotomySurgical incision on the fascia. It is used to decompress compartment pressure (e.g. in compartment syndromes; circumferential burns and extremity injuries) or to release contractures (e.g. in dupuytren’s contracture).Compartment Syndrome
Subclavian stealSubclavian stealA clinically significant reduction in blood supply to the brain stem and cerebellum (i.e., vertebrobasilar insufficiency) resulting from reversal of blood flow through the vertebral artery from occlusion or stenosis of the proximal subclavian or brachiocephalic artery. Common symptoms include vertigo, syncope, and intermittent claudication of the involved upper extremity. Subclavian steal may also occur in asymptomatic individuals.Subclavian Steal Syndrome syndrome
Retrograde vertebral arteryVertebral arteryThe first branch of the subclavian artery with distribution to muscles of the neck; vertebrae; spinal cord; cerebellum; and interior of the cerebrum.Lateral Medullary Syndrome (Wallenberg Syndrome)flowFlowBlood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls.Vascular Resistance, Flow, and Mean Arterial Pressure due to subclavian artery stenosisStenosisHypoplastic Left Heart Syndrome (HLHS) or occlusion
Usually asymptomatic, but upper extremity ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage and neurologic symptoms (from vetebrobasilar ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage) indicate severe disease.
AmputationAmputationAn amputation is the separation of a portion of the limb or the entire limb from the body, along with the bone. Amputations are generally indicated for conditions that compromise the viability of the limb or promote the spread of a local process that could manifest systemically. Amputation is performed when:
There is progressive gangreneGangreneDeath and putrefaction of tissue usually due to a loss of blood supply.Small Bowel Obstruction
Uncontrolled infection
Unrelenting painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways
Images demonstrating an ischemic limb (A) that developed compartment syndrome: A fasciotomy (B) was required.
Arterial aneurysmAneurysmAn aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Thoracic Aortic Aneurysms: abnormal dilation of the arteriesArteriesArteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology due to weakening of the arterial wall. ThrombosisThrombosisFormation and development of a thrombus or blood clot in the blood vessel.Epidemic Typhus of a popliteal arteryPopliteal ArteryThe continuation of the femoral artery coursing through the popliteal fossa; it divides into the anterior and posterior tibial arteries.Popliteal Fossa: AnatomyaneurysmAneurysmAn aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Thoracic Aortic Aneurysms can result in symptoms of lower extremity ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship will have a cold, pale legLegThe lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia.Leg: Anatomy with absent distal pulses and paresthesiasParesthesiasSubjective cutaneous sensations (e.g., cold, warmth, tingling, pressure, etc.) that are experienced spontaneously in the absence of stimulation.Posterior Cord Syndrome. Physical exam may reveal a large, pulsatile popliteal arteryPopliteal ArteryThe continuation of the femoral artery coursing through the popliteal fossa; it divides into the anterior and posterior tibial arteries.Popliteal Fossa: Anatomy. Imaging will confirm the diagnosis and differentiate this diagnosis from PAD. Treatment involves surgical repair of the artery.
Arterial dissectionArterial dissectionArterial dissection is a violation of the structural integrity of the arterial wall that results in blood accumulating between the layers.Dissection of the Carotid and Vertebral Arteries: disruption in the medial layer of the arterial wall, resulting in bleeding into the vessel wall (creating a “false lumenFalse lumenAortic Dissection”), which may be due to connective tissueConnective tissueConnective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix.Connective Tissue: Histology disorders or from vascular interventions. Occlusion of the “true” lumen may result, causing symptoms of ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage (such as limb-threatening ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage). Ultrasound or CTACTAA non-invasive method that uses a ct scanner for capturing images of blood vessels and tissues. A contrast material is injected, which helps produce detailed images that aid in diagnosing vascular diseases.Pulmonary Function Tests may be used to establish the diagnosis and will differentiate this condition from PAD. Treatment may require surgical repair of the artery.
Thromboembolic disease: vascular occlusion due to a dislodged thrombus from a more proximal source. The presentation depends on the source, size, and location of the embolism, but includes acute limb ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage and blue toe syndrome. The clinical history, hypercoagulableHypercoagulableHypercoagulable states (also referred to as thrombophilias) are a group of hematologic diseases defined by an increased risk of clot formation (i.e., thrombosis) due to either an increase in procoagulants, a decrease in anticoagulants, or a decrease in fibrinolysis. Hypercoagulable States workup, and imaging aid in the diagnosis, and a source will typically be suspected or found on workup, which differentiates thromboembolic disease from PAD. Management includes anticoagulationAnticoagulationPulmonary Hypertension Drugs and revascularizationRevascularizationThromboangiitis Obliterans (Buerger Disease).
Popliteal arteryPopliteal ArteryThe continuation of the femoral artery coursing through the popliteal fossa; it divides into the anterior and posterior tibial arteries.Popliteal Fossa: Anatomy entrapment syndrome: an uncommon condition in which an abnormally positioned, or enlarged, calf muscle compresses the popliteal arteryPopliteal ArteryThe continuation of the femoral artery coursing through the popliteal fossa; it divides into the anterior and posterior tibial arteries.Popliteal Fossa: Anatomy. The compressionCompressionBlunt Chest Trauma leads to obstruction of blood flowBlood flowBlood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute).Vascular Resistance, Flow, and Mean Arterial Pressure to the lower extremity, causing distal extremity ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage, ulcerationUlcerationCorneal Abrasions, Erosion, and Ulcers, or necrosisNecrosisThe death of cells in an organ or tissue due to disease, injury or failure of the blood supply.Ischemic Cell Damage. The diagnosis is made with imaging, which will differentiate this condition from PAD. Management includes avoiding any inciting exercise and vascular surgeryVascular surgeryVascular surgery is the specialized field of medicine that focuses on the surgical management of the pathologies of the peripheral circulation. The main goal of most vascular procedures is to restore circulatory function to the affected vessels by relieving occlusions or by redirecting blood flow (e.g., bypass).Vascular Surgery evaluation.
Spinal stenosisStenosisHypoplastic Left Heart Syndrome (HLHS):compressionCompressionBlunt Chest Trauma of nerve roots due to narrowing of the spinal canalSpinal CanalThe cavity within the spinal column through which the spinal cord passes.Spinal Cord Injuries. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship may have positional back painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways and exertional lower extremity painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways. The painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways will not be relieved with rest. Other symptoms include weakness, paresthesiasParesthesiasSubjective cutaneous sensations (e.g., cold, warmth, tingling, pressure, etc.) that are experienced spontaneously in the absence of stimulation.Posterior Cord Syndrome, and diminished reflexes. Unlike PAD, pulses will be intact. The diagnosis is made based on clinical exam and MRI imaging of the spineSpineThe human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum.Vertebral Column: Anatomy. Treatment includes physical therapyPhysical TherapyBecker Muscular Dystrophy, painPainAn unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons.Pain: Types and Pathways management, and surgery for severe cases.
Thromboangiitis obliteransThromboangiitis ObliteransA non-atherosclerotic, inflammatory thrombotic disease that commonly involves small and medium-sized arteries or veins in the extremities. It is characterized by occlusive thrombosis and fibrosis in the vascular wall leading to digital and limb ischemia and ulcerations. Thromboangiitis obliterans is highly associated with tobacco smoking.Thromboangiitis Obliterans (Buerger Disease) (Buerger’s disease): nonatherosclerotic segmental inflammatory disease that affects small to medium-sized vessels of the extremities. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship are typically young smokers presenting with distal extremity ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage, ulcers, or gangreneGangreneDeath and putrefaction of tissue usually due to a loss of blood supply.Small Bowel Obstruction. Diagnosis is based on clinical findings, vascular testing, and angiographyAngiographyRadiography of blood vessels after injection of a contrast medium.Cardiac Surgery. Other potential diagnoses must be ruled out, including PAD. SmokingSmokingWillful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand.Interstitial Lung Diseases cessation is an essential part of management and decreases the risk of amputationAmputationAn amputation is the separation of a portion of the limb or the entire limb from the body, along with the bone. Amputations are generally indicated for conditions that compromise the viability of the limb or promote the spread of a local process that could manifest systemically. Amputation.
VasculitisVasculitisInflammation of any one of the blood vessels, including the arteries; veins; and rest of the vasculature system in the body.Systemic Lupus Erythematosus: a vascular inflammatory disease, often resulting in ischemiaIschemiaA hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation.Ischemic Cell Damage, necrosisNecrosisThe death of cells in an organ or tissue due to disease, injury or failure of the blood supply.Ischemic Cell Damage, and organ damage. Any vessel can be involved. Etiologies include autoimmune disorders, drugs, and infectionsInfectionsInvasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases.Chronic Granulomatous Disease. PatientsPatientsIndividuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures.Clinician–Patient Relationship present with feverFeverFever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, arthralgias, and arthritisArthritisAcute or chronic inflammation of joints.Osteoarthritis, as well as potential end-organ damage. Diagnosis involves inflammatory markers, autoimmune serologySerologyThe study of serum, especially of antigen-antibody reactions in vitro.Yellow Fever Virus, infectious workup, and biopsyBiopsyRemoval and pathologic examination of specimens from the living body.Ewing Sarcoma, which will differentiate this disease from PAD. Management depends on the underlying cause.
Kim, W. (2022). Critical determinants of chronic limb threatening ischemia after endovascular treatment. Korean Circulation Journal, 52(6), 441–443. Retrieved Sept 28, 2025 from https://doi.org/10.4070/kcj.2022.0064
Rutherford, R. B., Baker, J. D., Ernst, C., Johnston, K. W., Porter, J. M., Ahn, S., & Jones, D. N. (1997). Recommended standards for reports dealing with lower extremity ischemia: revised version. Journal of vascular surgery, 26(3), 517–538. https://doi.org/10.1016/s0741-5214(97)70045-4
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