Atherosclerotic Occlusive Disease of the Lower Extremities
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)
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...