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
...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 Î...
...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...