Occlusive Disease: Femoral & Popliteal Arteries

Key Features

Essentials of Diagnosis

• Cramping pain or tiredness in the calf with exercise

• Reduced popliteal and pedal pulses

• Foot pain at rest, relieved by dependency

• Foot gangrene or ischemic ulcers

General Considerations

• The superficial femoral artery is the peripheral artery most commonly occluded by atherosclerosis

• The disease frequently occurs where the superficial femoral artery passes through the abductor magnus tendon in the distal thigh (Hunter canal)

• The common femoral artery and the popliteal artery are less commonly diseased, but lesions in these vessels are debilitating, resulting in short-distance claudication

Demographics

• Atherosclerosis of the femoral-popliteal segment usually

  • Occurs about a decade after the development of aortoiliac disease

  • Has an even distribution between males and females

  • Affects black and Hispanic patients commonly

Clinical Findings

Symptoms and Signs

• Intermittent claudication is confined to the calf

• Claudication at about 2–4 blocks when superficial femoral artery is occluded at the abductor canal and good collateral vessels are maintained from profunda femoris

• Concomitant disease of the profunda femoris or the popliteal artery may trigger symptoms at much shorter distances

• Dependent rubor of the foot with blanching on elevation may be present with short-distance claudication

• Chronic low blood flow states cause atrophic changes in the lower leg and foot with

  • Loss of hair

  • Thinning of the skin and subcutaneous tissues

  • Disuse atrophy of the muscles

• With segmental occlusive disease of the superficial femoral artery, the common femoral pulsation is normal, but the popliteal and pedal pulses are reduced

• Popliteal and pedal pulses are reduced

Differential Diagnosis

• Occlusive disease of the iliac arteries

• Lumbar spinal stenosis

Diagnosis

Imaging Studies

• Duplex ultrasonography, CT angiography, or magnetic resonance angiography

  • All adequately show the anatomic location of the obstructive lesions

  • These studies are only done if revascularization is planned

Diagnostic Procedures

• The ankle-brachial index (ABI)

  • Values < 0.9 are diagnostic of PAD

  • Levels below 0.4 suggest chronic limb-threatening ischemia

  • Readings depend on arterial compression

  • Can be misleading since the vessels may be calcified in diabetes mellitus, chronic kidney disease, and the elderly

• The toe brachial index (TBI)

  • Usually reliable; done in those cases where vessels may be calcified

  • Value < 0.7 considered diagnostic of PAD

• Pulse volume recordings with cuffs placed at the high thigh, mid thigh, calf, and ankle will delineate the levels of obstruction with reduced pressures and blunted wave-forms

Treatment

• Conservative management

  • Cornerstone of therapy

  • Includes risk factor reduction, medical optimization (with high-dose statin), and exercise treatment

  • Cilostazol, 100 mg orally twice daily, may improve intermittent claudication symptoms

Surgery