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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 often diseased, but lesions in these vessels are debilitating, resulting in short-distance claudication


  • 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 from profunda femoris are present

  • 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


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 < 0.4 suggest critical limb 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


  • Conservative management

    • Cornerstone of therapy

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

    • Cilostazol may improve intermittent claudication ...

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