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

...atment...

...3. Management of Asymptomatic Disease...

...ecommends multidisciplinary comprehens...

...ecommends providing education about th...

...recommends against invasive treatments fo...


...l Treatment for Intermittent Claudication...

...nds multidisciplinary comprehensive smoking...

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

...he SVS recommends optimizing diabetes control (...

...SVS recommends the use of indicated β-blo...

...ients with IC due to atherosclerosis,...

...S recommends clopidogrel in doses of 7...

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

...VS suggests against using folic acid and...

...th IC who do not have congestive heart failure,...

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

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


...Exercise Therapy...

...e SVS recommends as first-line therapy a sup...

...ommends home-based exercise, with a goal of ≥3...

...have undergone revascularization therapy for I...

The SVS recommends that patients with IC be fo...


...al Considerations on Invasive Treatment...

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

...recommends an individualized appro...


...terventions for Aortoiliac Occlusive Diseas...

...nds endovascular procedures over open surgery for...

...SVS recommends endovascular interventions...

The SVS recommends the selective use of BMS...

...ecommends the use of covered stents for treatment...

...s with diffuse AIOD (eg, extensive aortic d...


...rventions for Aortoiliac Occlusive Disease in...

...of AIOD in the presence of aneurysma...

...ll patients undergoing revascularization for...

...h iliac artery disease and involvement of the C...

...ends direct surgical reconstruction (...

...younger patients (age...

...SVS recommends either axial imaging (eg...

When performing surgical bypass for aortoiliac...

...bypass graft originating from the C...


Table 9. Intervention For Femoropopliteal Occlusiv...

...ecommends endovascular procedures over open su...

...focal lesions...

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

...he SVS suggests the use of preoperative ul...

...VS recommends against EVT of isolated infrapop...

The SVS recommends surgical bypass as an...

...commends using the saphenous vein as the prefer...

...of a suitable vein, the SVS suggests using prosthe...


...ostinterventional Medical Therapy in Intermit...

...ients after endovascular or open surg...

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

...n patients undergoing infrainguinal endovascular...


...Surveillance After Interventions for...

The SVS suggests that patients treated...

...ts that patients treated with lower extremity ve...

...he SVS suggests that patients who have pr...