PERIPHERAL ARTERIAL DISEASE
ESSENTIALS OF DIAGNOSIS
Common symptoms of leg discomfort with ambulation, rest pain, nonhealing ulcers, or gangrene.
Abnormal pulse exam in most patients.
Abnormal ankle-branchial index is diagnostic.
Evidence of systemic atherosclerosis is common.
History of diabetes mellitus, tobacco use, hypertension, or hyperlipidemia may be present.
Peripheral vascular disease broadly defines any vascular disease of the extracranial carotid arteries, the aorta and its branches, and the extremities. However, peripheral arterial disease (PAD) is usually used to refer to atherosclerotic disease of the lower extremities. Atherosclerotic PAD is the most common form of PAD in older adults, but the differential diagnosis for arterial vascular disease is quite broad (Table 43–1).
Table 43–1.Peripheral arterial disease. |Favorite Table|Download (.pdf) Table 43–1. Peripheral arterial disease.
Atherosclerotic disease—including the carotid, renal, aortomesenteric, and extremities
Embolic disease—including cardioembolic disease, paradoxical embolism, and artery-to-artery embolism
Thrombotic disease—related to inherited and acquired thrombophilic processes
Vasculitis—may affect any vessel, including large, medium, and small arteries
Segmental medial arteriolysis—arteriopathy demonstrating necrosis of the media of unknown etiology
Culprit agents may include cocaine, amphetamine, ephedrine, intravenous immunoglobulin, pressors (eg, epinephrine, norepinephrine, and phenylephrine), ergotamine, and heparin when associated with heparin-induced thrombocytopenia
Compression syndromes—popliteal artery entrapment and thoracic outlet syndrome
Endoluminal iliac artery fibrosis
Cystic adventitial disease
Hypothenar hammer syndrome
The prevalence of PAD is >10% in individuals older than age 60 years and increases to >25% in people older than 75 years. Although PAD is associated with cardiovascular risk factors such as smoking, hypertension, diabetes mellitus, and hypercholesterolemia, a prevalence of approximately 9% has been documented in patients without traditional risk factors. Nontraditional risk factors, including ethnicity, also influence disease prevalence. Recently, the US Preventive Services Task Force concluded there is insufficient evidence to recommend PAD screening in asymptomatic adults.
In evaluating older adults for PAD, it is important to perform a comprehensive clinical history, review of symptoms, and physical examination. There are two management issues in patients with PAD that are important to successful patient care. First is the need to adequately address underlying cardiovascular risk factors. Atherosclerosis is a systemic process where concomitant cerebrovascular or coronary disease has been demonstrated in up to 30% of patients. The second issue, which is usually more concerning to the patient, is the symptoms related to the vascular occlusive disease. ...