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NATURAL HISTORY

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During the past half century, vascular specialists have made major progress in treating vascular diseases with chronic ischemia of the lower extremities. Peripheral arterial occlusive disease (PAOD) presents a clinical spectrum from asymptomatic, intermittent claudication, or critical ischemic change.

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The TransAtlantic Inter-Society Consensus (TASC) conference defined critical limb ischemia (CLI) as persistent recurring ischemic rest pain requiring opiate analgesia for at least 2 weeks, ulceration or gangrene of the foot or toes, and ankle systolic pressure <50 mm Hg or toe systolic pressure <30 mm Hg (or absences of pedal pulses in patients with diabetes).

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Most patients with rest pain or tissue necrosis have limb loss. Small ulcers may heal with aggressive local management and intermittent rest pain or night pain may improve with the development of collaterals or improvement of cardiac hemodynamics. The mortality rate associated with patients who have claudication is 50% at 5 years, and for patients with CLI, the rate is 70%. This high mortality rate is most commonly associated with cardiac disease, and is generally unrecognized by clinicians. Consequently, the opportunity for risk factors or cardiac intervention maybe overlooked.1

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NONOPERATIVE TREATMENT

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Atherosclerosis is a systemic disease that is most frequently associated with fatal and nonfatal myocardial infarction (MI), stroke and disease of the aorta, and lower extremities. Peripheral arterial disease (PAD), atherosclerosis in the arteries of the lower extremities; whether it is asymptomatic or symptomatic is a common disorder in the general population. The prevalence of PAD increases with age and presence of vascular risk factors. The estimated overall prevalence of PAD among people of 55 years of age or older varies between 9% and 23%.2 The incidence of PAD measured in an open population is 9.9 per 1000 people per year.3 Because of aging population in Western societies, the prevalence of PAD will rise and the medical treatment will become increasingly important.

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The majority of patients with PAD is asymptomatic or has leg symptoms other than classic intermittent claudication, which is defined as leg pain usually involving one or both calves that arises by walking and is relieved by rest only. It is estimated that only 22% of patients with PAD have these symptoms.4 Elderly male patients with diabetes are especially more likely to have asymptomatic PAD.5 The overall annual incidence of symptomatic PAD, with typical intermittent claudication is 1.5 to 2.6 per 1000 men and 1.2 to 3.6 per 1000 women.6

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Of the patients with asymptomatic PAD, only 5% to 10% will develop symptomatic PAD in a period of over 5 years.7 The majority of patients with intermittent claudication as the clinical symptoms of PAD can remain stable over many years. Approximately 15% of these patients develop critical leg ischemia (with ulceration and rest pain) and a high risk for amputation. The annual incidence of CLI is estimated to be 0.25 to 0.45 per 1000 persons.8,9 Of the patients with CLI, between approximately 20% ...

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