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

  • Diminished femoral pulses.

  • Tissue loss (ulceration, gangrene) or rest pain.


Occlusive atherosclerotic lesions developing in the extremities, or peripheral artery disease (PAD), is evidence of a systemic atherosclerotic process. The prevalence of PAD is 30% in patients who are 70 years old without other risk factors, or 50 years old with risk factors such as diabetes mellitus or tobacco use. Pathologic changes of atherosclerosis may be diffuse, but flow-limiting stenoses occur segmentally. In the lower extremities, stenoses classically occur in three anatomic segments: the aortoiliac segment (eFigure 12–1), femoral-popliteal segment, and the infrapopliteal or tibial segment of the arterial tree. Lesions in the distal aorta and proximal common iliac arteries classically occur in white male smokers aged 50–60 years. 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.

eFigure 12–1.

Magnetic resonance angiography showing atherosclerotic occlusive disease of the aortoiliac segment. The vessels proximally and distally are relatively unaffected.


A. Symptoms and Signs

Approximately two-thirds of patients with PAD are either asymptomatic or do not have classic symptoms. Intermittent claudication, which is pain with ambulation that occurs from insufficient blood flow relative to demand, is typically described as severe and cramping and primarily in the calf muscles. The pain from aortoiliac lesions may extend into the thigh and buttocks and erectile dysfunction may occur from bilateral common iliac disease. Rarely, patients complain only of weakness in the legs when walking, or simply extreme limb fatigue. The symptoms are relieved with rest and are reproducible when the patient walks again. Femoral pulses and distal pulses are absent or very weak. Bruits may be heard over the aorta, iliac, and femoral arteries.

B. Doppler and Vascular Findings

The ratio of systolic blood pressure detected by Doppler examination at the ankle compared with the brachial artery (referred to as the ankle-brachial index [ABI]) is reduced to below 0.9 (normal ratio is 0.9–1.2); this difference is exaggerated by exercise. Both the dorsalis pedis and the posterior tibial arteries are measured and the higher of the two artery pressures is used for calculation. Segmental waveforms or pulse volume recordings obtained by strain gauge technology through blood pressure cuffs demonstrate blunting of the arterial inflow throughout the lower extremity.

C. Imaging

CT angiography (CTA) and magnetic resonance angiography (MRA) can identify the anatomic location of disease. Due to overlying bowel, duplex ultrasound has a limited role in imaging the aortoiliac segment. Imaging is required only when symptoms necessitate intervention, since ...

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