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Key Features

Essentials of Diagnosis

  • Claudication: cramping pain or tiredness in the calf, leg, or hip while walking

  • Diminished femoral pulses

  • Tissue loss (ulceration, gangrene) or rest pain

General Considerations

  • Pathologic changes of atherosclerosis may be diffuse, but flow-limiting stenoses occur segmentally

  • In the lower extremities, lesions classically occur in three anatomic segments

    • The aorto-iliac segment

    • The femoral-popliteal segment

    • The infrapopliteal, or tibial, segment of the arterial tree

  • Lesions in the distal aorta and proximal common iliac arteries often occur in relatively young men, age 50–60 years, who are smokers

  • Disease progression may lead to complete occlusion of one or both common iliac arteries, which can precipitate occlusion of the entire abdominal aorta to the level of the renal arteries

  • Atherosclerosis of the femoro-popliteal segment usually

    • Occurs about a decade following the development of aorto-iliac disease

    • Is evenly distributed between men and women

Demographics

  • Prevalence of peripheral artery disease (PAD) is 30% in patients who are

    • 50 years old who have either diabetes mellitus or a history of tobacco use

    • 70 years old even without those risk factors

Clinical Findings

Symptoms and Signs

  • About two-thirds of patients with PAD are either asymptomatic or do not have classic symptoms

  • Pain termed "claudication"

    • Occurs because blood flow cannot keep up with the increased demand of exercise

    • Severe and cramping in quality

    • Usually located in the calf muscles

    • May be bilateral

    • Severity varies day by day; called intermittent claudication

  • The pain from aorto-iliac lesions may extend into the thigh and buttocks

  • Weakness in the legs when walking or simply extreme limb fatigue

  • Symptoms relieved with rest

  • Erectile dysfunction common with bilateral common iliac disease

  • Femoral and distal pulses are absent or very weak

  • Bruits may be heard over the aorta, iliac, and femoral arteries

Differential Diagnosis

  • Vascular disease of the femoral or popliteal arteries

  • Lumbar spinal stenosis

  • Degenerative joint disease of the hips

Diagnosis

Imaging Studies

  • CT angiography and magnetic resonance angiography can identify the anatomic location of disease

  • Duplex ultrasound has a limited role in imaging the aortoiliac segment because of overlying bowel

  • Imaging is required only when symptoms necessitate intervention, since vascular testing should identify the involved levels of the arterial tree

Diagnostic Procedures

  • Doppler examination

    • Ratio of systolic blood pressure at ankle compared with brachial artery of upper arm is reduced to below 0.9 (normal ratio is 0.9–1.2)

    • This difference is exaggerated by exercise

  • Segmental wave-forms or pulse volume recordings

    • Obtained by strain gaze technology through blood pressure cuffs

    • Demonstrate blunting of the arterial inflow throughout the leg

Treatment

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