Peripheral Artery Disease

Peripheral artery disease (PAD) is obstruction of the arterial lumen resulting in decreased blood flow Flow Blood 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 to the distal limbs. The disease can be a result of atherosclerosis Atherosclerosis Atherosclerosis 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 thrombosis. Patients may be asymptomatic or have progressive claudication, skin Skin The 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. Structure and Function of the Skin discoloration, ischemic ulcers, or gangrene. Onset may be insidious ( atherosclerosis Atherosclerosis Atherosclerosis 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 (thrombosis). Diagnosis is made with the clinical history, exam, and measurement of the ankle-brachial index. 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 inhibitors Phosphodiesterase inhibitors Phosphodiesterase (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 revascularization.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Epidemiology and Etiology

Epidemiology

  • Affects approximately 10% of the population > 55 years of age in the United States
  • Worldwide prevalence is 3%–12%
  • Men > women
  • Higher prevalence among African Americans and non-Hispanic Whites
  • Lower rates in Hispanics and Asians

Etiology

Peripheral artery disease (PAD) usually has the same causative factors as coronary and carotid disease.

  • Atherosclerosis:
    • Aging
    • Hypertension Hypertension Hypertension, 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
    • Smoking and tobacco use
    • Diabetes mellitus Diabetes mellitus Diabetes 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
    • Hypercholesterolemia
    • Hyperhomocysteinemia
    • Obesity
  • Arterial embolism:
    • Cholesterol atheroembolism
    • Atrial fibrillation Atrial fibrillation Atrial 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
    • Endocarditis Endocarditis Endocarditis 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 + smoking or diabetes
    • Age 40–49 + diabetes + 1 other risk factor for atherosclerosis Atherosclerosis Atherosclerosis 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
    • Atherosclerosis at other sites (e.g., coronary, carotid, renal)

Pathophysiology

  • Atherosclerosis: endothelial cell dysfunction → macrophage and cholesterol accumulation → foam cell formation → platelet-derived growth factor (PDGF) and fibroblast growth factor (FGF) release  → smooth muscle cell migration → proliferation and extracellular matrix deposition → fibrous plaque
  • Subintimal accumulation of lipid and fibrous material of the arteries Arteries Arteries 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 → vessel lumen narrowing → restricted blood flow Flow Blood 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 → chronic ischemia of the affected limb
  • Plaque rupture or thrombosis → abrupt occlusion of downstream vessels → acute ischemia of the limb
Atherosclerosis

Composition of the fibrous plaque in atherosclerosis Atherosclerosis Atherosclerosis 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

Image by Lecturio.

Clinical Presentation

Patients with PAD may be asymptomatic (20%–25%) or present with evidence of chronic or acute limb ischemia Acute limb ischemia Acute limb ischemia (ALI) is a major vascular emergency because of the rapid decrease in limb perfusion that causes a potential threat to limb viability. The majority of cases are caused by arterial thrombosis due to plaque progression or embolism, but ALI can also be caused by blockage of the venous drainage. Acute Limb Ischemia.

Chronic arterial insufficiency

  • Symptoms:
    • The lower extremities are most commonly affected.
    • Intermittent claudication: 
      • Reproducible, painful cramping in the buttock, hips, thighs, calf, or foot Foot The 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 with exertion 
      • Relieved with rest
    • Atypical limb pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain or feeling of “heaviness”
    • Limb numbness or weakness
    • Impotence, erectile dysfunction Erectile Dysfunction Erectile 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
  • Physical exam findings:
    • Poorly healing wounds
    • Discoloration
      • Pale with limb elevation
      • Redness when limb is lowered
      • Cyanosis
    • Weak or absent pulse below a narrowed area of the artery
    • Bruits over arteries Arteries Arteries 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 heard on auscultation
    • Decreased blood pressure in the affected limb
    • Severe disease: 
      • Loss of hair follicles, sweat glands, and sebaceous glands 
      • Skin 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 claudication after walking > 200 meters (219 yards)
2b Intermittent claudication after walking < 200 meters (219 yards)
3 Nocturnal or resting pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
4 Necrosis or gangrene of the limb

Chronic limb-threatening (critical) ischemia

Any 1 of the following indicates that blood flow Flow Blood 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 no longer meets the metabolic demands of the limb tissues at rest:

  • Resting pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Worse distally
    • Aggravated by limb elevation
  • Ulcer
  • Gangrene

Acute limb ischemia

Acute limb ischemia is most commonly due to an embolism or plaque rupture. Patients will demonstrate acute onset of:

  • 6 Ps: 
    1. Pain
    2. Pallor 
    3. Pulseless 
    4. Poikilothermia (cold)
    5. Paresthesia 
    6. Paralysis
  • Blue toe syndrome
    • Due to cholesterol atheroembolism to digital arteries Arteries Arteries 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
    • Pedal pulses will be normal.
  • Ulceration or gangrene
  • Ankle blood pressure ≤ 50 mm Hg

Diagnosis

Diagnostic algorithm for PAD

This algorithm demonstrates the diagnostic pathway for a patient presenting with signs or symptoms of PAD:

Diagnostic algorithm for pad

Diagnostic algorithm for PAD

Image by Lecturio.

The diagnosis is usually established through clinical history, exam, and non-invasive testing techniques (ankle-brachial index (ABI), exercise testing).

Note that those with features of limb-threatening ischemia need urgent vascular surgery Vascular surgery Vascular 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 patients may still undergo imaging studies to locate the area of vascular obstruction or stenosis as part of surgical planning.

Non-invasive techniques

These studies are used to establish the diagnosis:

  • Ankle-brachial index
    • Usually the first choice in testing to establish a diagnosis
    • Equals the leg Leg The 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 systolic blood pressure divided by the arm Arm The 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 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 Doppler ultrasound.
  • Treadmill exercise test 
    • Indicated for patients 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 index (ABI)
Parameter Value
Normal ≥ 0.9
Mild 0.71–0.9
Moderate 0.41–0.7
Severe ≤ 0.4
Measure the ankle-brachial index

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:

  • Doppler ultrasound
    • Noninvasive, but operator-dependent
    • Can determine blood flow Flow Blood 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 through arteries Arteries Arteries 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
    • Measured velocities through diseased portions allow estimation of percent stenosis.
  • Computed tomography with angiography (CTA)
    • Quick, but requires contrast administration
    • Becoming more commonly utilized to locate stenotic lesions
  • Magnetic resonance imaging with angiography (MRA)
    • Can avoid ionizing radiation
    • High diagnostic accuracy
  • Digital subtraction arteriography
    • Reference standard
    • Intravenous contrast is injected imaged with a series of radiographs.
    • Has the highest diagnostic accuracy

Laboratory testing

These studies are not used for the diagnosis of PAD, but can help evaluate risk factors or organ injury:

  • Lipid profile → hyperlipidemia
  • Hemoglobin A1c → diabetes
  • Homocysteine → hyperhomocysteinemia
  • Creatinine → renal disease

Screening asymptomatic patients

Screening asymptomatic patients

Screening asymptomatic patients

Image by Lecturio.
  • Screening is performed in patients who may be asymptomatic but have risk factors or evidence of PAD.
  • Important in preventing progression and complications
  • Can be used to identify patients at risk for other types of cardiovascular disease
  • Again, ABI is the test of choice for establishing the diagnosis.

Management

Lifestyle modification

Lifestyle modification is the 1st line of therapy:

  • Smoking cessation
  • Diet 
  • Exercise therapy program 
    • Increases blood flow Flow Blood 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
    • Improves endurance and pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain tolerance
    • Helps develop collateral circulation
    • Reduces blood cell aggregation and blood viscosity
  • Glycemic control

Medications

  • Antiplatelet therapy (aspirin, clopidogrel)
  • Risk factor modification
    • Statin therapy
    • Antihypertensive treatment
    • Vitamins ( folate Folate Folate 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 inhibitors (cilostazol)
    • Most effective pharmaceutical treatment for improving claudication symptoms
    • Indicated after failure of conservative measures
    • Reduces platelet aggregation and allows arterial vasodilation
  • Thrombolysis
    • Used in arterial thrombosis or embolism where tissue salvage is thought to be likely
    • Not for patients with intermittent claudication or where tissue is immediately threatened or irreversibly damaged
    • May be catheter-directed

Revascularization therapy

  • Goal is to salvage the limb tissue and prevent amputation Amputation An 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:
    • Critical limb ischemia
    • Failure to improve with lifestyle modification and medications
    • Significant disability due to symptoms
  • Percutaneous transluminal angioplasty (PTA) 
    • Catheter is inserted into the artery.
    • Balloon is inflated to open an obstruction.
    • Vascular stenting may also be performed.
  • Atherectomy
    • Catheter procedure in which plaque is removed from the artery
    • Can be used for in-stent restenosis or in areas where stent placement is not feasible
  • Surgical procedures
    • Endarterectomy (direct removal of obstructive plaque)
    • Embolectomy (direct removal of a thrombus)
    • Vascular bypass grafting

Complications

Threatened limb from acute limb ischemia Acute limb ischemia Acute limb ischemia (ALI) is a major vascular emergency because of the rapid decrease in limb perfusion that causes a potential threat to limb viability. The majority of cases are caused by arterial thrombosis due to plaque progression or embolism, but ALI can also be caused by blockage of the venous drainage. Acute Limb Ischemia

  • Surgical emergency
  • Start a heparin drip.
  • Surgical embolectomy should be performed in most circumstances.
  • Intraoperative angiography follow-up to ensure normal flow Flow Blood 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 syndrome Compartment Syndrome Compartment 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 ischemia (> 6 hours)
  • Occurs due to reperfusion injury → leads to swelling and increased pressure (may result in further ischemia, necrosis, and limb loss)
  • Patients will develop severe pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, paresthesias Paresthesias Subjective cutaneous sensations (e.g., cold, warmth, tingling, pressure, etc.) that are experienced spontaneously in the absence of stimulation. Respiratory Alkalosis, and muscle weakness. 
  • Limb may feel tense.
  • Diagnosis is made by measuring compartment pressures.
  • Requires 4-compartment fasciotomy

Subclavian steal syndrome Subclavian steal syndrome Subclavian steal syndrome occurs when narrowing/occlusion of the subclavian artery proximal to the origin of the vertebral artery causes a reversal of blood flow in the ipsilateral vertebral artery to continue perfusing the ipsilateral arm. The most common cause is atherosclerosis. Subclavian Steal Syndrome

  • Retrograde vertebral artery flow Flow Blood 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 stenosis or occlusion
  • Usually asymptomatic, but upper extremity ischemia and neurologic symptoms (from vetebrobasilar ischemia) indicate severe disease.
  • Management is similar to general PAD treatment.

Gangrene or limb loss

Amputation is performed when:

  • Revascularization has failed or is not possible
  • There is progressive gangrene
  • Uncontrolled infection
  • Unrelenting pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain

Differential Diagnosis

  • Arterial aneurysm Aneurysm An 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. Extremity and Visceral Aneurysms: abnormal dilation of the arteries Arteries Arteries 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 due to weakening of the arterial wall. Thrombosis of a popliteal artery aneurysm Aneurysm An 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. Extremity and Visceral Aneurysms can result in symptoms of lower extremity ischemia. Patients will have a cold, pale leg Leg The 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 with absent distal pulses and paresthesias Paresthesias Subjective cutaneous sensations (e.g., cold, warmth, tingling, pressure, etc.) that are experienced spontaneously in the absence of stimulation. Respiratory Alkalosis. Physical exam may reveal a large, pulsatile popliteal artery. Imaging will confirm the diagnosis and differentiate this diagnosis from PAD. Treatment involves surgical repair of the artery.
  • Arterial dissection: disruption in the medial layer of the arterial wall, resulting in bleeding into the vessel wall (creating a “false lumen”), which may be due to connective tissue Connective tissue Connective 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 disorders or from vascular interventions. Occlusion of the “true” lumen may result, causing symptoms of ischemia (such as limb-threatening ischemia). Ultrasound or CTA 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 ischemia Acute limb ischemia Acute limb ischemia (ALI) is a major vascular emergency because of the rapid decrease in limb perfusion that causes a potential threat to limb viability. The majority of cases are caused by arterial thrombosis due to plaque progression or embolism, but ALI can also be caused by blockage of the venous drainage. Acute Limb Ischemia and blue toe syndrome. The clinical history, hypercoagulable Hypercoagulable Hypercoagulable 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 anticoagulation and revascularization.
  • Popliteal artery entrapment syndrome: an uncommon condition in which an abnormally positioned, or enlarged, calf muscle compresses the popliteal artery. The compression leads to obstruction of blood flow Flow Blood 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 to the lower extremity, causing distal extremity ischemia, ulceration, or necrosis. The diagnosis is made with imaging, which will differentiate this condition from PAD. Management includes avoiding any inciting exercise and vascular surgery Vascular surgery Vascular 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 stenosis Spinal stenosis Spinal stenosis is the progressive narrowing of the central spinal canal, intervertebral foramen, and lateral recess, leading to compression of the nerve root. Spinal stenosis can occur in the cervical, thoracic, and lumbar spine and is commonly caused by degenerative bone disease (mostly affecting the elderly). Spinal Stenosis: compression of nerve roots due to narrowing of the spinal canal. Patients may have positional back pain Back pain Back pain is a common complaint among the general population and is mostly self-limiting. Back pain can be classified as acute, subacute, or chronic depending on the duration of symptoms. The wide variety of potential etiologies include degenerative, mechanical, malignant, infectious, rheumatologic, and extraspinal causes. Back Pain and exertional lower extremity pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain. The pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain will not be relieved with rest. Other symptoms include weakness, paresthesias Paresthesias Subjective cutaneous sensations (e.g., cold, warmth, tingling, pressure, etc.) that are experienced spontaneously in the absence of stimulation. Respiratory Alkalosis, and diminished reflexes. Unlike PAD, pulses will be intact. The diagnosis is made based on clinical exam and MRI imaging of the spine Imaging of the Spine The vertebral column and the spinal cord may be affected by various diseases, in which different imaging methods are important for correct diagnosis and management. Radiographs and CT scans are useful in evaluating bony structures, especially in excluding fractures and checking hardware. Imaging of the Spine and Spinal Cord. Treatment includes physical therapy, pain management Pain Management Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is a subjective experience. Acute pain lasts < 3 months and typically has a specific, identifiable cause. Pain Management, and surgery for severe cases.
  • Thromboangiitis obliterans Thromboangiitis Obliterans Thromboangiitis obliterans (TAO), also known as Buerger’s disease, is a rare condition causing inflammatory thrombosis of the small- to medium-sized arteries and veins of the upper and lower extremities. Thromboangiitis Obliterans (Buerger’s Disease) (Buerger’s disease): nonatherosclerotic segmental inflammatory disease that affects small to medium-sized vessels of the extremities. Patients are typically young smokers presenting with distal extremity ischemia, ulcers, or gangrene. Diagnosis is based on clinical findings, vascular testing, and angiography. Other potential diagnoses must be ruled out, including PAD. Smoking cessation is an essential part of management and decreases the risk of amputation Amputation An 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.
  • Vasculitis: a vascular inflammatory disease, often resulting in ischemia, necrosis, and organ damage. Any vessel can be involved. Etiologies include autoimmune disorders, drugs, and infections. Patients present with fever Fever Fever 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 arthritis, as well as potential end-organ damage. Diagnosis involves inflammatory markers, autoimmune serology, infectious workup, and biopsy, which will differentiate this disease from PAD. Management depends on the underlying cause.

References

  1. Teo, K.K. (2019). Peripheral arterial disease. [online] MSD Manual Professional Version. Retrieved November 23, 2020, from https://www.msdmanuals.com/professional/cardiovascular-disorders/peripheral-arterial-disorders/peripheral-arterial-disease
  2. Neschis, D.G., and Golden, M.A. (2020). Clinical features and diagnosis of lower extremity peripheral artery disease. In Collins, K.A. (Ed.), UpToDate. Retrieved November 23, 2020, from https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-lower-extremity-peripheral-artery-disease
  3. Davies, M.G. (2020). Management of claudication due to peripheral artery disease. In Collins, K.A. (Ed.), UpToDate. Retrieved November 23, 2020, from https://www.uptodate.com/contents/management-of-claudication-due-to-peripheral-artery-disease
  4. Berger, J.S., and Newman, J.D. (2020). Overview of peripheral artery disease in patients with diabetes mellitus. In Collins, K.A. (Ed.), UpToDate. Retrieved November 23, 2020, from https://www.uptodate.com/contents/overview-of-peripheral-artery-disease-in-patients-with-diabetes-mellitus
  5. Hayward, R.A. (2020). Screening for lower extremity peripheral artery disease. In Givens, J. (Ed.), UpToDate. Retrieved November 23, 2020, from https://www.uptodate.com/contents/screening-for-lower-extremity-peripheral-artery-disease
  6. Berger, J.S., and Davies, M.G. (2020). Overview of lower extremity peripheral artery disease. In Collins, K.A. (Ed.), UpToDate. Retrieved November 23, 2020, from https://www.uptodate.com/contents/overview-of-lower-extremity-peripheral-artery-disease
  7. Harris, L. (2020). Epidemiology, risk factors, and natural history of lower extremity peripheral artery disease. In Collins, K.A. (Ed.), UpToDate. Retrieved November 23, 2020, from https://www.uptodate.com/contents/epidemiology-risk-factors-and-natural-history-of-lower-extremity-peripheral-artery-disease
  8. Stephens, E. (2017). Peripheral vascular disease. In Schraga, E.D. (Ed.), Medscape. Retrieved November 23, 2020, from https://emedicine.medscape.com/article/761556-overview

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