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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Intermittent claudication

  • Resting leg pain, ulceration, or gangrene

  • Reduced amplitude or absence of peripheral pulses

  • Iliofemoral bruits

  • Ankle–brachial artery pressure ratio < 0.9

  • Cool feet when supine that blanch on elevation and become rubrous and warm when dependent

GENERAL CONSIDERATIONS

  • The major cause of peripheral arterial disease in developed countries is atherosclerosis

  • Asymptomatic peripheral atherosclerosis is 3 or 4 times more common than symptomatic disease

  • Men and women have the same prevalence of this disease

  • Acute arterial occlusions are usually caused by embolism from the heart or more proximal vessels

  • The blue toe syndrome is caused by microemboli of cholesterol or thrombotic material from more proximal vessels

  • It is often difficult to distinguish embolism from thrombosis in situ unless surgery is done and the occluding material is examined histologically

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Intermittent claudication is the hallmark of peripheral arterial disease

    • – Pelvic artery disease results in thigh or buttock claudication

    • – Femoral or popliteal disease results in calf claudication

  • Chronic critical leg ischemia can cause persistent rest pain, ulcerations, or gangrene of the foot

PHYSICAL EXAM FINDINGS

  • Femoral or iliac bruits

  • Weak distal pulses

  • Distal extremity ulcerations, especially at pressure points

  • Leg elevation results in a pale color

  • Sitting after leg raising results in a slow return of color (1 or more minutes), which develops into a red-blue hue

  • Decreased nail growth and hair loss in the extremity

  • Extremity cool to the touch

  • Blue toes

DIFFERENTIAL DIAGNOSIS

  • Sciatica from lower back disease

  • Arterial embolism

  • Erythromelalgia

  • Vascular compartment compression syndromes

  • Buerger’s disease

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC, erythrocyte sedimentation rate, prothrombin time, fibrinogen

  • Plasma viscosity

IMAGING STUDIES

  • Duplex ultrasound images the vessel and the flow inside it

  • Vital capillaroscopy can assess the capillaries in the skin

DIAGNOSTIC PROCEDURES

  • Angiography can delineate stenoses

  • Intravascular ultrasound can clarify lesion characteristics

  • Magnetic resonance angiography can be useful

  • Invasive angiography only if surgery or a percutaneous procedure is planned

TREATMENT

CARDIOLOGY REFERRAL

  • Suspected coronary artery disease

HOSPITALIZATION CRITERIA

  • Threatened limb loss

  • Gangrene

  • Planned surgery

MEDICATIONS

  • Stop smoking

  • Exercise training

  • Antiplatelet drugs—aspirin 81 mg/day, clopidogrel 75 mg/day PO

  • Vasodilators: pentoxifylline 400 mg PO tid

  • Prostacyclin analogs

  • Anticoagulants in selected cases

THERAPEUTIC PROCEDURES

  • Hyperbaric oxygen may help wound healing in chronic limb ischemia

  • Angioplasty in selected cases

  • Thrombectomy in selected cases

SURGERY

  • Revascularization

  • Amputation

MONITORING

  • Monitor blood ...

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