Atherosclerotic Occlusive Disease of the Lower Extremities

Publication Date: March 2, 2015

Diagnosis

Diagnosis

Figure 1. Odds Ratios (ORs) for Risk Factors for Peripheral Arterial Disease (PAD)


Figure 2. Natural History of Intermittent Claudation (IC)


Table 1. Diagnosis of Peripheral Arterial Disease (PAD)

The SVS recommends using the ABI as the first-line noninvasive test to establish a diagnosis of PAD in individuals with symptoms or signs suggestive of disease. When the ABI is borderline or normal (>0.9) and symptoms of claudication are suggestive, the SVS recommends an exercise ABI. ( S , A )
681
The SVS suggests against routine screening for lower extremity PAD in the absence of risk factors, history, signs, or symptoms of PAD. ( W , A )
681
For asymptomatic individuals who are at elevated risk, such as those aged >70, smokers, diabetic patients, those with an abnormal pulse examination, or other established cardiovascular disease, screening for lower extremity PAD is reasonable if used to improve risk stratification, preventive care, and medical management. ( W , A )
681
In symptomatic patients who are being considered for revascularization, the SVS suggests using physiologic noninvasive studies, such as segmental pressures and pulse volume recordings, to aid in the quantification of arterial insufficiency and help localize the level of obstruction. ( W , A )
681
In symptomatic patients in whom revascularization treatment is being considered, the SVS recommends anatomic imaging studies, such as arterial duplex ultrasound, computed tomography angiography, magnetic resonance angiography, and contrast arteriography. ( S , B )
681

Table 2. The Differential Diagnosis for Intermittent Claudication (IC)

Condition Location Prevalence Characteristic Effect of exercise Effect of rest Effect of position Other characteristic
Calf IC Calf muscles 3% of adult Cramping, aching discomfort Reproducible onset Quickly relieved None May have atypical limb symptoms on exercise
Thigh and Buttock IC Buttocks, hip, thigh Rare Cramping, aching, discomfort Reproducible onset Quickly relieved None Impotence. May have normal pedal pulses with isolated iliac artery disease
Foot IC Foot arch Rare Severe pain on exercise Reproducible onset Quickly relieved None Also may present as numbness
Chronic compartment syndrome Calf muscles Rare Tight, bursting pain After much exercise (jogging) Subsides very slowly Relief with
elevation
Typically heavily muscled athletes
Venous claudication Entire leg, worse in calf Rare Tight, bursting pain After walking Subsides slowly Relief speeded by elevation History of iliofemoral deep vein thrombosis, signs of venous congestion, edema
Nerve root compression Radiates down leg Common Sharp lancinating pain Induced by sitting, standing, or walking Often present at rest Improved by change in position History of back problems. Worse with sitting. Relief when supine or sitting. Not intermittent
Symptomatic
Baker cyst
Behind knee, down calf Rare Swelling, tenderness With exercise Present at rest None Not intermittent
Hip arthritis Lateral hip, thigh Common Aching discomfort After variable degree of exercise Not quickly relieved Improved when not weight bearing Symptoms variable. History of degenerative arthritis
Spinal stenosis Often bilateral buttocks, posterior leg Common Pain and weakness May mimic IC Variable relief but can take a long time to recover Relief by lumbar spine flexion Worse with standing and extending spine
Foot/ankle arthritis Ankle, foot, arch Common Aching pain After variable degree of exercise Not quickly relieved May be relieved by not bearing weight Variable, may relate to activity level and present at rest

Adapted from Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)


Treatment

...Treatment...

...Table 3. Ma...

...e SVS recommends multidisciplinary co...

The SVS recommends providing educa...

...mmends against invasive treatments for PAD in...


...Table 4. Medical T...

...e SVS recommends multidisciplinary comprehensive s...

...S recommends statin therapy in patients with sympt...

...commends optimizing diabetes control...

The SVS recommends the use of indicated...

...with IC due to atherosclerosis, the SVS recommends...

...ommends clopidogrel in doses of 75 mg...

...ents with IC due to atherosclerosis, th...

...ests against using folic acid and vitamin B12 sup...

...with IC who do not have congestive hea...

...ith IC who cannot tolerate or have contra...

...recommendation for using ramipril i...


...Table 5. Exer...

...nds as first-line therapy a supervised exer...

The SVS recommends home-based exercise, with a g...

...patients who have undergone revascula...

...mmends that patients with IC be followed up annu...


...Table 6. General Conside...

...recommends endovascular therapy (EVT) or surgica...

...ds an individualized approach to select an invas...


...Table 7. I...

...VS recommends endovascular procedures over op...

...SVS recommends endovascular interventions as f...

...ecommends the selective use of BMS or...

The SVS recommends the use of covered stents for...

...tients with diffuse AIOD (eg, exte...


...Table 8. Interventions f...

...AIOD in the presence of aneurysmal disea...

...tients undergoing revascularization for AIO...

...s with iliac artery disease and inv...

...VS recommends direct surgical reconstructio...

In younger patients (ag...

...ds either axial imaging (eg, computed tomogr...

When performing surgical bypass for...

...s graft originating from the CFA, the don...


...Table 9. I...

...S recommends endovascular procedures o...

...cal lesions (...

...intermediate-length lesions (5–15 cm) in the S...

...the use of preoperative ultrasound vein mapp...

...ends against EVT of isolated infrapopliteal d...

...S recommends surgical bypass as an...

...SVS recommends using the saphenous ve...

...e absence of a suitable vein, the SVS suggests usi...


...Table 10. Post...

...n all patients after endovascular o...

...ents undergoing lower extremity bypass (venous or...

...undergoing infrainguinal endovascular...


...Table 11. Surveillance A...

...that patients treated with open or endovascular...

...gests that patients treated with lower extremity...

...uggests that patients who have previously...