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
...atment...
...Management of Asymptomatic Disease...
...recommends multidisciplinary comprehens...
...commends providing education about the signs and...
...S recommends against invasive treatments for P...
...Medical Treatment for Intermittent...
...ommends multidisciplinary comprehens...
...mends statin therapy in patients with symptoma...
...he SVS recommends optimizing diabetes cont...
...mends the use of indicated β-blockers (eg, for hy...
...atients with IC due to atherosclerosis, th...
The SVS recommends clopidogrel in doses...
In patients with IC due to atheroscl...
...ests against using folic acid and vitamin B12 supp...
...n patients with IC who do not have congest...
...IC who cannot tolerate or have contraindicatio...
...commendation for using ramipril in IC was...
...Exercise Therapy...
The SVS recommends as first-line therapy...
...commends home-based exercise, with a goal o...
...have undergone revascularization therapy for...
...ommends that patients with IC be followed up annu...
...6. General Considerations on Invasive...
...mmends endovascular therapy (EVT) or surgica...
...mends an individualized approach to se...
...e 7. Interventions for Aortoiliac Occ...
...ecommends endovascular procedures...
...ommends endovascular interventions...
...ds the selective use of BMS or covered...
...e SVS recommends the use of covered st...
...r patients with diffuse AIOD (eg, extensiv...
...ventions for Aortoiliac Occlusive Disea...
...AIOD in the presence of aneurysmal diseas...
...nts undergoing revascularization for...
In patients with iliac artery disease and involve...
...nds direct surgical reconstruction (bypass, en...
...unger patients (ag...
...VS recommends either axial imaging (eg, co...
...g surgical bypass for aortoiliac d...
...ss graft originating from the CFA, the don...
...rvention For Femoropopliteal Occlusive Disea...
...commends endovascular procedures ove...
...focal lesions (...
...intermediate-length lesions (5–15 c...
...s the use of preoperative ultrasound vein mappin...
...ommends against EVT of isolated infrapopliteal dis...
...ds surgical bypass as an initial revascularization...
The SVS recommends using the saphenous vein as t...
...of a suitable vein, the SVS suggests...
...le 10. Postinterventional Medical...
...patients after endovascular or open surgical int...
...rgoing lower extremity bypass (venous or prost...
In patients undergoing infrainguinal...
...illance After Interventions for Intermittent...
...ggests that patients treated with open or endovasc...
...S suggests that patients treated with...
...SVS suggests that patients who have previously un...