Peripheral Arterial Disease

Vascular

Clinicals - History

Fact Explanation
Introduction Peripheral arterial disease(PAD) is characterized by presence of significant chronic occlusion of arteries supplying limbs, most often due to atherosclerosis. PAD commonly involves the arteries distal to bifurcation of aorta, affecting the lower limbs. The severity of the signs and symptoms discussed in this article depends on the size, site of artery involved and the presence of alternative/collateral blood supply. In about 75% of patients, the symptoms may stabilize or improve over time without interventions. The remaining 25%, symptoms may worsen requiring therapeutic intervention. The risk of PAD increases with advancing age. Thromboangitis obliterans or Buerger's disease is seen in fairly young(in early 30s) male smokers and has a poorer prognosis. Studies have shown that smoking, diabetes mellitus, hypertension, hypercholesterolemia, hyperhomocysteinemia are strongly associated with development of PAD. The Fontaine classification can be used to classify the spectrum of symptoms seen in PAD, as follows. Stage I – Asymptomatic.
Stage IIa – Intermittent claudication after more than 200 meters of pain free walking.
Stage IIb – Intermittent claudication after less than 200 meters of walking
Stage III – Rest pain.
Stave IV – Ischemic ulcers or gangrene.
Introduction
Peripheral arterial disease(PAD) is characterized by presence of significant chronic occlusion of arteries supplying limbs, most often due to atherosclerosis. PAD commonly involves the arteries distal to bifurcation of aorta, affecting the lower limbs. The severity of the signs and symptoms discussed in this article depends on the size, site of artery involved and the presence of alternative/collateral blood supply. In about 75% of patients, the symptoms may stabilize or improve over time without interventions. The remaining 25%, symptoms may worsen requiring therapeutic intervention. The risk of PAD increases with advancing age. Thromboangitis obliterans or Buerger's disease is seen in fairly young(in early 30s) male smokers and has a poorer prognosis. Studies have shown that smoking, diabetes mellitus, hypertension, hypercholesterolemia, hyperhomocysteinemia are strongly associated with development of PAD. The Fontaine classification can be used to classify the spectrum of symptoms seen in PAD, as follows. Stage I – Asymptomatic.
Stage IIa – Intermittent claudication after more than 200 meters of pain free walking.
Stage IIb – Intermittent claudication after less than 200 meters of walking
Stage III – Rest pain.
Stave IV – Ischemic ulcers or gangrene.
Intermittent claudication Claudication stands for reproducible pain of muscle ischemia. This is a cramp like pain felt in muscles brought on by walking and relieved by standing still. It is not present on taking the first step. The distance of walking before pain is felt, changes only slightly from day to day. The pain of claudication usually involves calf muscles but it can also involve thigh or buttock. The involvement of muscle group depends on the site of arterial occlusion. The resting blood flow in a normal limb and a limb with claudication are the same. During exercise there is vasodilatation in the muscles and the blood flow increases greatly. This increase in flow does not occur in the diseased leg, rendering incapable to meet the increased demand. Thus there is muscle ischemia. This leads to release of pain inducing metabolites in the muscles, so that the patient feels pain in the muscle involved. Intermittent claudication
Claudication stands for reproducible pain of muscle ischemia. This is a cramp like pain felt in muscles brought on by walking and relieved by standing still. It is not present on taking the first step. The distance of walking before pain is felt, changes only slightly from day to day. The pain of claudication usually involves calf muscles but it can also involve thigh or buttock. The involvement of muscle group depends on the site of arterial occlusion. The resting blood flow in a normal limb and a limb with claudication are the same. During exercise there is vasodilatation in the muscles and the blood flow increases greatly. This increase in flow does not occur in the diseased leg, rendering incapable to meet the increased demand. Thus there is muscle ischemia. This leads to release of pain inducing metabolites in the muscles, so that the patient feels pain in the muscle involved.
Reduced walking distance This is a symptom related to intermittent claudication. The patient will complain of reduced walking distance due to pain in the muscles, not present on the first step but develops as he/she walks some distance. The distance they can walk before onset of pain, changes only slightly from day to day. Reduced walking distance
This is a symptom related to intermittent claudication. The patient will complain of reduced walking distance due to pain in the muscles, not present on the first step but develops as he/she walks some distance. The distance they can walk before onset of pain, changes only slightly from day to day.
Rest pain This is pain felt in limb at rest. The pain increases by lying down or elevation foot. It is also worse during night and is felt in foot or toes unlike the claudication pain which involves muscle groups. This pain is relieved by keeping the legs hanging down. Presence of rest pain indicates the presence of severe arterial narrowing which makes it incapable to provide adequate limb perfusion even during rest. This state is referred to as critical limb ischemia. There is threatened loss of that limb. Rest pain
This is pain felt in limb at rest. The pain increases by lying down or elevation foot. It is also worse during night and is felt in foot or toes unlike the claudication pain which involves muscle groups. This pain is relieved by keeping the legs hanging down. Presence of rest pain indicates the presence of severe arterial narrowing which makes it incapable to provide adequate limb perfusion even during rest. This state is referred to as critical limb ischemia. There is threatened loss of that limb.
Numbness/paresthesia (pins and needles/tingling feeling )/ reduced sensation These symptoms are seen in the presence of moderate and severe ischemia but a neurological cause should be excluded. Numbness/paresthesia (pins and needles/tingling feeling )/ reduced sensation
These symptoms are seen in the presence of moderate and severe ischemia but a neurological cause should be excluded.
Painful erosion between toes/shallow non-healing wounds in foot/ areas of black dead tissue Ulceration and gangrene formation are seen when there is severe ischemia. Painful erosion between toes/shallow non-healing wounds in foot/ areas of black dead tissue
Ulceration and gangrene formation are seen when there is severe ischemia.
Impotence Is present when the arterial occlusion involves the aortoiliac region. It is associated with buttock claudication and is called Leriche's syndrome. Impotence
Is present when the arterial occlusion involves the aortoiliac region. It is associated with buttock claudication and is called Leriche's syndrome.
Diagnosed with or has clinical features suggestive of diabetes mellitus, hypertension, hyperlipidaemia These are some modifiable risk factors associated with peripheral arterial disease. Diagnosed with or has clinical features suggestive of diabetes mellitus, hypertension, hyperlipidaemia
These are some modifiable risk factors associated with peripheral arterial disease.
Smoking Is also another important modifiable risk factor associated with peripheral arterial disease. Smoking
Is also another important modifiable risk factor associated with peripheral arterial disease.
Family history Presence of a positive family history is a non-modifiable risk factor associated with peripheral arterial disease. Family history
Presence of a positive family history is a non-modifiable risk factor associated with peripheral arterial disease.

Clinicals - Examination

Fact Explanation
General examination Look for pallor, plethora in conjunctiva. Pallor indicates presence of anemia and plethora indicates presence of polycythemia. Correction of anemia or plethora improves symptoms. Look for xanthelasma around eyes and xanthomata which indicate presence of dyslipidemia. Look for nicotin stains in the hands of smokers. Look for atrophic changes such as loss of extremity hair, atrophy of muscles, thickened, discoloured nails that indicate of underlying peripheral arterial disease. The limb with arterial occlusion will blanch on elevation and develop purple discolouration on dependent position. An ischemic limb is usually cold but it can equilibrate with the ambient temperature and appear warm. Ulcers and gangrene if present, are signs of severe limb ischemia. Look for ulcers between the toes, on dorsum of feet, on shins and around malleoli. Gagrene presents as blackened, dead tissue. If the patient is diabetic look for changes such as claw foot deformity, callus, glove and stoking sensory loss, Charcoat's foot etc. General examination
Look for pallor, plethora in conjunctiva. Pallor indicates presence of anemia and plethora indicates presence of polycythemia. Correction of anemia or plethora improves symptoms. Look for xanthelasma around eyes and xanthomata which indicate presence of dyslipidemia. Look for nicotin stains in the hands of smokers. Look for atrophic changes such as loss of extremity hair, atrophy of muscles, thickened, discoloured nails that indicate of underlying peripheral arterial disease. The limb with arterial occlusion will blanch on elevation and develop purple discolouration on dependent position. An ischemic limb is usually cold but it can equilibrate with the ambient temperature and appear warm. Ulcers and gangrene if present, are signs of severe limb ischemia. Look for ulcers between the toes, on dorsum of feet, on shins and around malleoli. Gagrene presents as blackened, dead tissue. If the patient is diabetic look for changes such as claw foot deformity, callus, glove and stoking sensory loss, Charcoat's foot etc.
Cardiovascular system examination All peripheral pulses should be examined. When there is an arterial occlusion, the pulses distal to it are absent or diminished. If there are well developed collateral circulation the pulses will be normal to palpation. Arterial insufficiency can still be determined by exercising to point of claudication and examining the pulse.The previously palpable pulse will be impalpable. Exercise cause vasodilatation and increases the vascular space when arterial inflow cannot keep pace with this the pressure falls and pulse disappears. Pulse of carotid, radial, femoral, popliteal, posterior tibial, dorsalis pedis arteries and abdominal aorta should be examined and compared with its opposite. Expansile pulsation is felt when there is an aneurysm. Peripheral arterial aneurysms can present with limb ischemia. Blood pressure should be measured to detect hypertension. Auscultate the subclavian, carotid and femoral arteries and abdominal aorta. Presence of a bruit indicates presence of stenosis. In severe stenosis arterial bruit may be even palpable. Ankle-brachial pressure index (ABPI) should be measured to determine presence of PAD. ABPI is the ratio between systolic blood pressure at the ankle to that of the arm. An ABPI value above 0.9 is considered normal. Values below 0.9 indicate presence of some arterial occlusive disease. Values less than 0.3 suggest imminent tissue ischemia and necrosis. Cardiovascular system examination
All peripheral pulses should be examined. When there is an arterial occlusion, the pulses distal to it are absent or diminished. If there are well developed collateral circulation the pulses will be normal to palpation. Arterial insufficiency can still be determined by exercising to point of claudication and examining the pulse.The previously palpable pulse will be impalpable. Exercise cause vasodilatation and increases the vascular space when arterial inflow cannot keep pace with this the pressure falls and pulse disappears. Pulse of carotid, radial, femoral, popliteal, posterior tibial, dorsalis pedis arteries and abdominal aorta should be examined and compared with its opposite. Expansile pulsation is felt when there is an aneurysm. Peripheral arterial aneurysms can present with limb ischemia. Blood pressure should be measured to detect hypertension. Auscultate the subclavian, carotid and femoral arteries and abdominal aorta. Presence of a bruit indicates presence of stenosis. In severe stenosis arterial bruit may be even palpable. Ankle-brachial pressure index (ABPI) should be measured to determine presence of PAD. ABPI is the ratio between systolic blood pressure at the ankle to that of the arm. An ABPI value above 0.9 is considered normal. Values below 0.9 indicate presence of some arterial occlusive disease. Values less than 0.3 suggest imminent tissue ischemia and necrosis.
Respiratory system examination In smokers look for features that may suggest presence of chronic lung disease. For an example those who have chronic obstructive pulmonary disease(COPD) will have dyspnea, barrel chest, wheeze/ronchi etc. Respiratory system examination
In smokers look for features that may suggest presence of chronic lung disease. For an example those who have chronic obstructive pulmonary disease(COPD) will have dyspnea, barrel chest, wheeze/ronchi etc.
Examination of abdomen Abdomen should be examined for the presence of abdominal aortic aneurysm(AAA) which is palpated as an expansile abdominal mass. Auscultate renal arteries for the presence of bruit. AAA can be associates with PAD. Examination of abdomen
Abdomen should be examined for the presence of abdominal aortic aneurysm(AAA) which is palpated as an expansile abdominal mass. Auscultate renal arteries for the presence of bruit. AAA can be associates with PAD.

Investigations - Diagnosis

Fact Explanation
Digital subtraction angiography (DSA) This is considered the standard test for detecting peripheral arterial disease. It is particularly important when an intervention is planned. It helps to assess the site, length of occlusion and also development of collateral circulation. A contrast medium is injected to the arterial circulation. The images obtained are digitized by a computer and background is subtracted so that the arterial tree is visualized clearly. Digital subtraction angiography (DSA)
This is considered the standard test for detecting peripheral arterial disease. It is particularly important when an intervention is planned. It helps to assess the site, length of occlusion and also development of collateral circulation. A contrast medium is injected to the arterial circulation. The images obtained are digitized by a computer and background is subtracted so that the arterial tree is visualized clearly.
Duplex ultrasonography Is an inexpensive, noninvasive method to assess flow within the arteries. Some consider this method to be as helpful as angiography to assess peripheral arterial occlusion. Duplex ultrasonography
Is an inexpensive, noninvasive method to assess flow within the arteries. Some consider this method to be as helpful as angiography to assess peripheral arterial occlusion.
Computed Tomographic Angiogram (CTA) This is also a method that can be used for assessment of peripheral arterial disease. Computed Tomographic Angiogram (CTA)
This is also a method that can be used for assessment of peripheral arterial disease.
Magnetic Resonance Angiogram (MRA) This test also helps in the assessment and planning of intervention for peripheral arterial disease. This method of scanning can provide two-dimensional or three-dimensional images. Even though the image quality is not as good as with DSA, it is satisfactory for most instances and has the benefit of no exposure to ionizing radiation. Magnetic Resonance Angiogram (MRA)
This test also helps in the assessment and planning of intervention for peripheral arterial disease. This method of scanning can provide two-dimensional or three-dimensional images. Even though the image quality is not as good as with DSA, it is satisfactory for most instances and has the benefit of no exposure to ionizing radiation.

Investigations - Management

Fact Explanation
Ankle-brachial pressure index (ABPI) This is done at regular intervals to assess the progression of the disease and response to management. Ankle-brachial pressure index (ABPI)
This is done at regular intervals to assess the progression of the disease and response to management.
Fasting blood sugar Should be monitored regularly in patients with diabetes mellitus to assess the control of disease and for appropriate adjustments in treatment. Fasting blood sugar
Should be monitored regularly in patients with diabetes mellitus to assess the control of disease and for appropriate adjustments in treatment.
Lipid profile Should be monitored in patients with dyslipidemia. Lipid profile
Should be monitored in patients with dyslipidemia.
Serum lipid profile Done to exclude hyperlipidemia which is important to consider in the patient management. Serum lipid profile
Done to exclude hyperlipidemia which is important to consider in the patient management.
Fasting blood sugar Done to diagnose diabetes which also is important in the patient management. Fasting blood sugar
Done to diagnose diabetes which also is important in the patient management.
Serum creatinine Done to assess renal function, especially if contrast agents are to be used for imaging because these can adversely affect renal function. Serum creatinine
Done to assess renal function, especially if contrast agents are to be used for imaging because these can adversely affect renal function.
Complete blood count Done to detect anemia, polycythemia, thrombocythemia which can worsen peripheral arterial disease. Complete blood count
Done to detect anemia, polycythemia, thrombocythemia which can worsen peripheral arterial disease.
Chest X ray Dona to assess the patient for lung disease when planning for surgical intervention. Other lung function tests may be necessary depending on the patient's condition. Chest X ray
Dona to assess the patient for lung disease when planning for surgical intervention. Other lung function tests may be necessary depending on the patient's condition.
Electrocardiogram Done to assess presence of ischemic heart disease which influences the patient management. Electrocardiogram
Done to assess presence of ischemic heart disease which influences the patient management.

Management - Supportive

Fact Explanation
Smoking cessation Studies have shown that smoking is the most important modifiable risk factor associated with peripheral arterial disease. Smoking cessation helps to limit the progression of the disease. Smoking cessation
Studies have shown that smoking is the most important modifiable risk factor associated with peripheral arterial disease. Smoking cessation helps to limit the progression of the disease.
Exercise Formal exercise programs help to increase the walking distance. The patient is encouraged to walk until maximal tolerable pain is reached in each session. Improvement of symptoms is best seen when each exercise session lasts longer than 30 minutes, done at least three times per week, for at least six months. Longer duration programs help to sustain the improvements.
Studies have shown that the improvement with exercise is significant compared with angioplasty and anti-platelet therapy.
Exercise
Formal exercise programs help to increase the walking distance. The patient is encouraged to walk until maximal tolerable pain is reached in each session. Improvement of symptoms is best seen when each exercise session lasts longer than 30 minutes, done at least three times per week, for at least six months. Longer duration programs help to sustain the improvements.
Studies have shown that the improvement with exercise is significant compared with angioplasty and anti-platelet therapy.
Control co-morbid diseases Good diabetes, hypertension and hyperlipidemia control has shown to improve the out come of peripheral arterial disease. Control co-morbid diseases
Good diabetes, hypertension and hyperlipidemia control has shown to improve the out come of peripheral arterial disease.
Dietary modifications Are required for patients who are over weight or have high blood lipids, hypertension or hyperglycemia. Dietary modifications
Are required for patients who are over weight or have high blood lipids, hypertension or hyperglycemia.
Life style modifications Changes in the place of work or sometimes change of the job will be needed according to the limitation of activity. Life style modifications
Changes in the place of work or sometimes change of the job will be needed according to the limitation of activity.
Patient and family education Patient and the family should be educated regarding the nature of the disease, prognosis, available treatment options, importance of exercise and other life style modification, importance of proper control of co-morbid conditions and regular follow up. Patient and family education
Patient and the family should be educated regarding the nature of the disease, prognosis, available treatment options, importance of exercise and other life style modification, importance of proper control of co-morbid conditions and regular follow up.

Management - Specific

Fact Explanation
Antiplatelet medication These have shown to delay progression of disease, increase the pain-free walking distance and resting blood flow, or the ABPI. They have the added benefit of reducing the risk of myocardial infarction and stroke.Aspirin is considered the first choice, clopidogrel being the second. Newer agents such as cilostazol, pentoxifylline can also be given. Cilostazol has shown to cause significant increase in walking distance. It has antiplatelet, antithrombotic, vasodilatory properties. Pentoxifylline works by increasing blood flow through reducing blood viscosity and increasing erythrocyte flexibility. Antiplatelet medication
These have shown to delay progression of disease, increase the pain-free walking distance and resting blood flow, or the ABPI. They have the added benefit of reducing the risk of myocardial infarction and stroke.Aspirin is considered the first choice, clopidogrel being the second. Newer agents such as cilostazol, pentoxifylline can also be given. Cilostazol has shown to cause significant increase in walking distance. It has antiplatelet, antithrombotic, vasodilatory properties. Pentoxifylline works by increasing blood flow through reducing blood viscosity and increasing erythrocyte flexibility.
Antilipemic medication Lipid lowering agents such as simvastatin, pravastatin lovastatin, atorvastatin are shown to improve out come for patients with peripheral arterial disease. These have shown to reduce the incidence of intermittent claudication and reduce the cardiovascular morbidity and mortality. Antilipemic medication
Lipid lowering agents such as simvastatin, pravastatin lovastatin, atorvastatin are shown to improve out come for patients with peripheral arterial disease. These have shown to reduce the incidence of intermittent claudication and reduce the cardiovascular morbidity and mortality.
Open bypass surgery This is considered the gold standard for treating arterial occlusion. It provides good long-term patency and can be used to treat multiple stenoses. But rate of morbidity is higher. By pass can be achieved using an autogenous vein (long saphenous vein/short saphenous vein/ an arm vein) or a prosthetic conduit. Open bypass surgery
This is considered the gold standard for treating arterial occlusion. It provides good long-term patency and can be used to treat multiple stenoses. But rate of morbidity is higher. By pass can be achieved using an autogenous vein (long saphenous vein/short saphenous vein/ an arm vein) or a prosthetic conduit.
Endovascular therapy These include placement of stents, balloons, or atherectomy devices to relieve arterial occlusion. Percutaneous transluminal angioplasty (PTA) is a widely used method of endovascular therapy. Advantages of this mode of treatment include being able to use in patients with significant comorbid conditions and faster recovery with shorter hospital stay. Disadvantages are that patency rates are lower and use is limited when there are multiple-level stenoses. Endovascular therapy
These include placement of stents, balloons, or atherectomy devices to relieve arterial occlusion. Percutaneous transluminal angioplasty (PTA) is a widely used method of endovascular therapy. Advantages of this mode of treatment include being able to use in patients with significant comorbid conditions and faster recovery with shorter hospital stay. Disadvantages are that patency rates are lower and use is limited when there are multiple-level stenoses.
Management of pain This is particularly important in patients with rest pain. Appropriate analgesia should be used according to the severity of pain felt by individual patient. Treatment with prostanoids, spinal cord stimulation and lumbar sympathectomy have shown to be effective in managing ischemic limb pain. Management of pain
This is particularly important in patients with rest pain. Appropriate analgesia should be used according to the severity of pain felt by individual patient. Treatment with prostanoids, spinal cord stimulation and lumbar sympathectomy have shown to be effective in managing ischemic limb pain.

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