Claudication

Fatigue, discomfort, cramping, or pain of vascular origin in the muscles of the lower extremities that is consistently induced by exercise and consistently relieved by rest (within 10 min).

Acute limb ischemia (ALI)

Acute (<2 wk), severe hypoperfusion of the limb characterized by these features: pain, pallor, pulselessness, poikilothermia (cold), paresthesias, and paralysis.

• One of these categories of ALI is assigned (ALI Section):

  I. Viable—Limb is not immediately threatened; no sensory loss; no muscle weakness; audible arterial and venous Doppler.

  II. Threatened—Mild-to-moderate sensory or motor loss; inaudible arterial Doppler; audible venous Doppler; may be further divided into IIa (marginally threatened) or IIb (immediately threatened).

  III. Irreversible—Major tissue loss or permanent nerve damage inevitable; profound sensory loss, anesthetic; profound muscle weakness or paralysis (rigor); inaudible arterial and venous Doppler.

Tissue loss

Type of tissue loss:

• Minor—non-healing ulcer, focal gangrene with diffuse pedal ischemia.
• Major—extending above transmetatarsal level; functional foot no longer salvageable.

Critical limb ischemia (CLI)

A condition characterized by chronic (≥2 wk) ischemic rest pain, non-healing wound/ulcers, or gangrene in 1 or both legs attributable to objectively proven arterial occlusive disease.

• The diagnosis of CLI is a constellation of both symptoms and signs. Arterial disease can be proved objectively with ankle-brachial index (ABI), toe-brachial index (TBI), transcutaneous oxygen pressure (TcPO2), or skin perfusion pressure. Supplementary parameters, such as absolute ankle and toe pressures and pulse volume recordings, may also be used to assess for significant arterial occlusive disease. However, a very low ABI or TBI does not necessarily mean the patient has CLI. The term CLI implies chronicity and is to be distinguished from ALI.

In-line blood flow

Direct arterial flow to the foot, excluding collaterals.

Functional status

Patient’s ability to perform normal daily activities required to meet basic needs, fulfill usual roles, and maintain health and well-being. Walking ability is a component of functional status.

Nonviable limb

Condition of extremity (or portion of extremity) in which loss of motor function, neurological function, and tissue integrity cannot be restored with treatment.

Salvageable limb

Condition of extremity with potential to secure viability and preserve motor function to the weight-bearing portion of the foot if treated.

Structured exercise program

Planned program that provides individualized recommendations for type, frequency, intensity, and duration of exercise.

• Program provides recommendations for exercise progression to assure that the body is consistently challenged to increase exercise intensity and levels as functional status improves over time.
• There are 2 types of structured exercise program for patients with PAD:
  1. Supervised exercise program
  2. Structured community- or home-based exercise program

Supervised exercise program

Structured exercise program that takes place in a hospital or outpatient facility in which intermittent walking exercise is used as the treatment modality.

• Program can be standalone or can be made available within a cardiac rehabilitation program.
• Program is directly supervised by qualified healthcare provider(s).
• Training is performed for a minimum of 30–45 min per session, in sessions performed at least 3 times/wk for a minimum of 12 wk. Patients may not initially achieve these targets, and a treatment goal is to progress to these levels over time.
• Training involves intermittent bouts of walking to moderate-to-maximum claudication, alternating with periods of rest.
• Warm-up and cool-down periods precede and follow each session of walking.

Structured community- or home- based exercise program

Structured exercise program that takes place in the personal setting of the patient rather than in a clinical setting.

• Program is self-directed with the guidance of healthcare providers who prescribe an exercise regimen similar to that of a supervised program.
• Patient counseling ensures that patients understand how to begin the program, how to maintain the program, and how to progress the difficulty of the walking (by increasing distance or speed).
• Program may incorporate behavioral change techniques, such as health coaching and/or use of activity monitors.

Emergency versus urgent

• An emergency procedure is one in which life or limb is threatened if the patient is not in the operating room or interventional suite and/or where there is time for no or very limited clinical evaluation, typically within <6 h.
• An urgent procedure is one in which there may be time for a limited clinical evaluation, usually when life or limb is threatened if the patient is not in the operating room or interventional suite, typically between 6 and 24 h.

Interdisciplinary care team

A team of professionals representing different disciplines to assist in the evaluation and management of the patient with PAD.

• For the care of patients with CLI, the interdisciplinary care team should include individuals who are skilled in endovascular revascularization, surgical revascularization, wound healing therapies and foot surgery, and medical evaluation and care.
• Interdisciplinary care team members may include:
  • Vascular medical and surgical specialists (i.e., vascular medicine, vascular surgery, interventional radiology, interventional cardiology)
  • Nurses
  • Orthopedic surgeons and podiatrists
  • Endocrinologists
  • Internal medicine specialists
  • Infectious disease specialists
  • Radiology and vascular imaging specialists
  • Physical medicine and rehabilitation clinicians
  • Orthotics and prosthetics specialists
  • Social workers
  • Exercise physiologists
  • Physical and occupational therapists
  • Nutritionists/dieticians

Cardiovascular ischemic events

Acute coronary syndrome (acute MI, unstable angina), stroke, or cardiovascular death.

Limb-related events

Worsening claudication, new CLI, new lower extremity revascularization, or new ischemic amputation.

Patients at increased risk of PAD (Table 2) should undergo a comprehensive medical history and a review of symptoms to assess for exertional leg symptoms, including claudication or other walking impairment, ischemic rest pain, and nonhealing wounds.

I

B-NR

Patients at increased risk of PAD (Table 2) should undergo vascular examination, including palpation of lower extremity pulses (i.e., femoral, popliteal, dorsalis pedis, and posterior tibial), auscultation for femoral bruits, and inspection of the legs and feet.

I

B-NR

Patients with PAD should undergo noninvasive blood pressure

measurement in both arms at least once during the initial assessment.

In patients with history or physical examination findings suggestive of PAD (Table 3), the resting ABI, with or without segmental pressures and waveforms, is recommended to establish the diagnosis.

I

C-LD

Resting ABI results should be reported as abnormal (ABI ≤0.90), borderline (ABI 0.91–0.99), normal (1.00–1.40), or noncompressible (ABI >1.40).

IIa

B-NR

In patients at increased risk of PAD (Table 2) but without history or physical examination findings suggestive of PAD (Table 3), measurement of the resting ABI is reasonable.

III: No Benefit

B-NR

In patients not at increased risk of PAD (Table 2) and without history or physical examination findings suggestive of PAD (Table 3), the ABI is NOT recommended.

TBI should be measured to diagnose patients with suspected PAD when the ABI is >1.40.

I

B-NR

Patients with exertional non–joint-related leg symptoms and normal or borderline resting ABI (>0.90 and ≤1.40) should undergo exercise treadmill ABI testing to evaluate for PAD.

IIa

B-NR

In patients with PAD and an abnormal resting ABI (≤0.90), exercise treadmill ABI testing can be useful to objectively assess functional status.

IIa

B-NR

In patients with normal (1.00–1.40) or borderline (0.91–0.99) ABI in the setting of non-healing wounds or gangrene, it is reasonable to diagnose CLI by using TBI with waveforms, TcPO2, or SPP.

IIa

B-NR

In patients with PAD with an abnormal ABI (≤0.90) or with noncompressible arteries (ABI >1.40 and TBI ≤0.70) in the setting of nonhealing wounds or gangrene, TBI with waveforms, TcPO2, or SPP can be useful to evaluate local perfusion.

Symptomatic Baker’s cyst

Behind knee, down calf

Swelling, tenderness

With exercise

Also present at rest

None

Not intermittent

Venous claudication

Entire leg, worse in calf

Tight, bursting pain

After walking

Subsides slowly

Relief speeded by elevation

History of iliofemoral deep vein thrombosis; edema; signs of venous stasis

Chronic compartment syndrome

Calf muscles

Tight, bursting pain

After much exercise (jogging)

Subsides very slowly

Relief with rest

Typically heavy muscled athletes

Spinal stenosis

Often bilateral buttocks, posterior leg

Pain and weakness

May mimic claudication

Variable relief but can take a long time to recover

Relief by lumbar spine flexion

Worse with standing and extending spine

Nerve root compression

Radiates down leg

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

Hip arthritis

Lateral hip, thigh

Aching discomfort

After variable degree of exercise

Not quickly relieved

Improved when not weight bearing

Symptoms variable; history of degenerative arthritis

Foot/ankle arthritis

Ankle, foot, arch

Aching pain

After variable degree of exercise

Not quickly relieved

May be relieved by not bearing weight

Symptoms variable; may be related to activity level or present at rest

Modified from Norgren L, et al. Eur J Vasc Endovasc Surg. 2007;(33 suppl 1):S1-75.

Venous ulcer

Distal leg, especially above medial malleolus

• Develops in regions of skin changes due to chronic venous disease and local venous hypertension
• Typically wet (i.e., wound drainage) rather than dry lesion

Distal small arterial occlusion (microangiopathy)

Toes, foot, leg

• Diabetic microangiopathy
• End-stage renal disease
• Thromboangiitis obliterans (Buerger’s)
• Sickle-cell anemia
• Vasculitis (e.g., Churg-Strauss, Henoch-Schönlein purpura, leukocytoclastic vasculitis, microscopic polyangiitis, polyarteritis nodosa)
• Scleroderma
• Cryoagglutination
• Embolic (e.g., cholesterol emboli, thromboemboli, endocarditis)
• Thrombotic (e.g., antiphospholipid antibody syndrome, Sneddon’s syndrome, warfarin skin necrosis, disseminated intravascular coagulation, livedoid vasculitis, protein C or S deficiency, prolonged vasospasm)

Local injury

Toes, foot, leg

• Trauma
• Insect or animal bite
• Burn

Medication related

Toes, foot, leg

• Drug reactions (e.g., erythema multiforme)
• Medication direct toxicity (e.g., doxorubicin, hydroxyurea, some tyrosine kinase inhibitors)

Neuropathic

Pressure zones of foot

• Hyperkeratosis surrounds the ulcer
• Diabetes mellitus with peripheral neuropathy
• Peripheral neuropathy without diabetes mellitus
• Leprosy

Autoimmune injury

Toes, foot, leg

• With blisters (e.g., pemphigoid, pemphigus, epidermolysis bullosa)
• Without blisters (e.g., dermatomyositis, lupus, scleroderma)

Infection

Toes, foot, leg

• Bacterial (e.g., Pseudomonas, necrotizing Streptococcus)
• Fungal (e.g., blastomycosis, Madura foot, chromomycosis)
• Mycobacterial
• Parasitic (e.g., Chagas, leishmaniasis)
• Viral (e.g., herpes)

Malignancy

Toes, foot, leg

• Primary skin malignancy
• Metastatic malignancy
• Malignant transformation of ulcer

Inflammatory

Toes, foot, leg

• Necrobiosis lipoidica
• Pyoderma gangrenosum
• Granuloma annulare

Duplex ultrasound, computed tomography angiography (CTA), or magnetic resonance angiography (MRA) of the lower extremities is useful to diagnose anatomic location and severity of stenosis for patients with symptomatic PAD in whom revascularization is considered.

I

C-EO

Invasive angiography is useful for patients with CLI in whom revascularization is considered.

IIa

C-EO

Invasive angiography is reasonable for patients with lifestyle-limiting claudication with an inadequate response to GDMT for whom revascularization is considered.

III: Harm

B-R

Invasive and noninvasive angiography (i.e., CTA, MRA) should NOT be performed for the anatomic assessment of patients with asymptomatic PAD.

A screening duplex ultrasound for AAA is reasonable in patients with symptomatic PAD.