Key Points
- Lower extremity peripheral artery disease (PAD) is a common cardiovascular disease that is estimated to affect approximately 8.5 million Americans above the age of 40 years and is associated with significant morbidity, mortality, and quality of life (QoL) impairment.
- It has been estimated that 202 million people worldwide have PAD.
Diagnosis
Table 1.Definition of PAD Key Terms
Term | Definition |
---|---|
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.
|
Tissue loss | Type of tissue loss:
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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.
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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.
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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.
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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.
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Emergency versus urgent |
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Interdisciplinary care team | A team of professionals representing different disciplines to assist in the evaluation and management of the patient with PAD.
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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. |
Table 2. Patients at Increased Risk of PAD
- Age ≥65 y
- Age 50–64 y, with risk factors for atherosclerosis (e.g., diabetes mellitus, history of smoking, hyperlipidemia, hypertension) or family history of PAD
- Age <50 y, with diabetes mellitus and 1 additional risk factor for atherosclerosis
- Individuals with known atherosclerotic disease in another vascular bed (e.g., coronary, carotid, subclavian, renal, mesenteric artery stenosis, or abdominal aortic aneurysm [AAA])
Table 3. History and/or Physical Examination Findings Suggestive of PAD
- History
- Claudication
- Other non–joint-related exertional lower extremity symptoms (not typical of claudication)
- Impaired walking function
- Ischemic rest pain
- Physical Examination
- Abnormal lower extremity pulse examination
- Vascular bruit
- Nonhealing lower extremity wound
- Lower extremity gangrene
- Other suggestive lower extremity physical findings (e.g., elevation pallor/dependent rubor)
Table 4. History and Physical Examination
COR | LOE | Recommendations |
---|---|---|
I | B-NR | 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. |
Table 5. Resting ABI for Diagnosing PAD
COR | LOE | Recommendations |
---|---|---|
I | B-NR | 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. |
Table 6. Physiological Testing
COR | LOE | Recommendations |
---|---|---|
I | B-NR | 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. |
Table 7. Alternative Diagnoses for Leg Pain or Claudication
With Normal Physiological Testing (Not PAD-Related)
Condition | Location | Characteristic | Effect of Exercise | Effect of Rest | Effect of Position | Other Characteristics | |
---|---|---|---|---|---|---|---|
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. |
Table 8. Alternative Diagnoses for Non-healing Wounds With Normal Physiological Testing (Not PAD-Related)
Condition | Location | Characteristics and Causes |
---|---|---|
Venous ulcer | Distal leg, especially above medial malleolus |
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Distal small arterial occlusion (microangiopathy) | Toes, foot, leg |
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Local injury | Toes, foot, leg |
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Medication related | Toes, foot, leg |
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Neuropathic | Pressure zones of foot |
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Autoimmune injury | Toes, foot, leg |
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Infection | Toes, foot, leg |
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Malignancy | Toes, foot, leg |
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Inflammatory | Toes, foot, leg |
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Table 9. Imaging for Anatomic Assessment
COR | LOE | Recommendations |
---|---|---|
I | B-NR | 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. |
Table 10. Abdominal Aortic Aneurysm
COR | LOE | Recommendation |
---|---|---|
IIa | B-NR | A screening duplex ultrasound for AAA is reasonable in patients with symptomatic PAD. |