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Case 1: Management of Progressive Peripheral Arterial Disease Despite Initial Medical Management

A 65-year-old man was sent from the clinic for worsening of left calf severe pain and decrease in exercise tolerance due to left calf pain. The patient had a 3-month history of intermittent left calf pain and denied trauma, back pain, fever, and leg weakness. Otherwise, the medical history was significant for hyperlipidemia. He was a former smoker and stopped smoking 6 months ago; however, he smoked 1 pack of cigarettes per day for the past 40 years before quitting. The patient denied use of alcohol or recreational drugs. His medications were low-dose aspirin and high-intensity atorvastatin. On physical examination, vital signs were normal. Body mass index was 28 kg/m2. Femoral pulses were diminished bilaterally. Popliteal, right dorsalis pedis, and right posterior tibialis pulses were faint. The left dorsalis pedis and posterior tibialis pulses were not palpable. Cardiac examination was normal. Otherwise, the physical examination was unremarkable. The ankle-brachial index was 0.67 on the left and 0.91 on the right. He was enrolled in a supervised exercise program 3 months ago, but the patient reported no improvement despite adherence to the exercise program, and his symptoms progressed. How would you manage this case?

Case Review

This scenario represents a patient with progressive peripheral arterial disease (PAD) despite being on initial medical management. The signs of progressive PAD include progressive decrease in exercise tolerance due to worsening left leg pain and physical examination findings of nonpalpable dorsalis pedis and posterior tibialis pulse on the left side. The patient is already on initial medical management of PAD, including smoking cessation, aspirin, high-intensity statins, and a supervised exercise program.

Case Discussion

PAD is most commonly characterized by narrowing of the aortic bifurcation and arteries of the lower extremities, including the iliac, femoral, popliteal, and tibial arteries. Atherosclerosis is the most common cause. Risk factors for PAD include smoking (current or past), diabetes mellitus, and increasing age. Patients with PAD are at increased risk for ischemic events, including myocardial infarction, stroke, and cardiovascular death. Patients with atherosclerotic risk factors (smoking, diabetes, hypertension, dyslipidemia, and advanced age) who have atypical limb symptoms (eg, leg weakness, paresthesia), exertional leg discomfort, and/or nonhealing ulcers should undergo initial testing with ankle-brachial index (ABI) measurement.

Clinical Symptoms

There is a wide spectrum of clinical manifestations because lower extremity PAD is defined by an abnormal ABI value rather than by symptoms. Patients may present with exertional leg pain relieved by rest (intermittent claudication), atypical exertional leg pain, rest pain, nonhealing wounds, ischemic ulcers, or gangrene.

ABI interpretation is as follows:

  • ABI 0.00 to 0.40: Severe PAD

  • ABI 0.41 to 0.90: Mild to moderate PAD

  • ABI 0.91 to 0.99: Borderline PAD

  • ABI 1.00 to 1.40: Normal

  • ABI >1.40: Noncompressible (calcified) vessel (uninterpretable result)

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