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)

Having trouble viewing table?
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

...Table 3. Manageme...

...ecommends multidisciplinary comprehensiv...

The SVS recommends providing education...

...mmends against invasive treatments for P...


...Table 4...

...ds multidisciplinary comprehensive smoking cess...

...recommends statin therapy in patients with sympto...

The SVS recommends optimizing diabete...

The SVS recommends the use of indicated ...

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

...he SVS recommends clopidogrel in doses of 75 mg...

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

...ts against using folic acid and vitamin B1...

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

...ts with IC who cannot tolerate or hav...

A recommendation for using ramipril in IC was orig...


...Table 5. Exerc...

...recommends as first-line therapy a superv...

...ds home-based exercise, with a goal of ≥30 minu...

In patients who have undergone revascularizatio...

...mmends that patients with IC be foll...


...Table 6. Ge...

...ds endovascular therapy (EVT) or s...

The SVS recommends an individualiz...


...Table 7. In...

...ommends endovascular procedures ov...

...VS recommends endovascular interventions a...

...VS recommends the selective use of BMS or cover...

...VS recommends the use of covered stents...

...ients with diffuse AIOD (eg, extensi...


...Table 8. Interv...

...in the presence of aneurysmal disease should be...

...undergoing revascularization for AIOD, the...

...n patients with iliac artery disease and invol...

...SVS recommends direct surgical reconstruct...

...younger patients (age...

...recommends either axial imaging (eg, co...

When performing surgical bypass for aortoiliac di...

...bypass graft originating from the CFA, the donor...


...S recommends endovascular procedures ov...

...focal lesions (...

...e-length lesions (5–15 cm) in the SFA,...

...suggests the use of preoperative ult...

...commends against EVT of isolated infrapopliteal d...

...he SVS recommends surgical bypass as an init...

...recommends using the saphenous vein as the...

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


...Table 10. Post...

...ents after endovascular or open surgica...

...dergoing lower extremity bypass (venous or pros...

...ients undergoing infrainguinal endovas...


...T...

...e SVS suggests that patients treated...

...ests that patients treated with lower extremity...

...gests that patients who have previousl...