Chapter 3

### PATIENT STORY

A 61-year-old man was referred to vascular surgery for a several-year history of bilateral lower extremity calf claudication at two blocks. His claudication symptoms were described as significantly lifestyle limiting. Peripheral vascular risk factors included hypertension (HTN), hyperlipidemia, and tobacco abuse (20 pack-years). The patient denied symptoms of rest pain and did not have any evidence of tissue loss. His pedal pulses were not palpable but were heard with a Doppler bilaterally. After discussing options, the patient agreed to a 3-month trial of a supervised exercise program with an oral phosphodiesterase inhibitor (cilostazol) and tobacco cessation.

At the return office visit, the patient reported minimal improvement and he was unable to quit smoking. At this time, the patient wished to proceed with noninvasive vascular laboratory studies and aortography with possible intervention.

Aortogram findings indicated an occlusion of the left superficial femoral artery (SFA) (Figure 3-1) with reconstitution of the popliteal artery above the knee (Figure 3-2), with two-vessel runoff to the foot (Figure 3-3). The patient's right side showed a diffusely diseased but patent SFA with two-vessel runoff to the foot.

An endovascular attempt to re-establish flow in the left SFA was unsuccessful using a chronic total occlusion (CTO) device. Consequently, the patient decided to proceed with a femoral to popliteal bypass.

###### FIGURE 3-1

Angiography image of left leg superficial femoral artery (SFA) occlusion. White arrow marks contralateral right SFA, which is patent. Red arrows and yellow dots depict estimated course of left SFA. Orange arrow marks profunda femoral artery (PFA). Blue arrow indicates the common femoral artery (CFA).

###### FIGURE 3-2

Angiography image of the left leg SFA occlusion with reconstitution of the above-knee popliteal artery (white arrow). Red dots depict estimated course of occluded SFA. Diffusely diseased but patent right SFA is seen.

###### FIGURE 3-3

Angiography image of runoff vessels below the knee. Red arrow indicates the posterior tibial artery. White arrow denotes the peroneal artery.

### EPIDEMIOLOGY

#### Peripheral Arterial Disease

• Progressive narrowing of the arteries due to atherosclerosis.1

• Mostly silent in early stages until luminal narrowing exceeds 50% vessel diameter.2

• Prevalence of peripheral arterial disease (PAD) in adults over

• 40 years in the United States is approximately 4%.

• Prevalence of PAD in adults over 70 years in the Unites States is approximately 15%.

• 20% to 25% of patients will require revascularization.2

• Approximately 5% of patients will progress to critical limb ischemia.2

• Patients with limb loss have 30% to 40% mortality in the first 24 months.2

### ETIOLOGY AND PATHOPHYSIOLOGY

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