ESSENTIALS OF DIAGNOSIS
Claudication: cramping pain or tiredness in the calf, thigh, or hip while walking.
Diminished femoral pulses.
Tissue loss (ulceration, gangrene) or rest pain.
Lesions in the distal aorta and proximal common iliac arteries classically occur in White men aged 50–60 years who smoke cigarettes. 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.
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.
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 a history and physical examination with vascular testing should appropriately identify the involved levels of the arterial tree.
A. Medical and Exercise Therapy
The cornerstones of aortoiliac disease treatment are cardiovascular risk factor reduction and a supervised or structured exercise program. Essential elements include cigarette smoking cessation, antiplatelet therapy, lipid and blood pressure management, and weight loss. Nicotine replacement therapy, bupropion, and varenicline have established benefits in cigarette smoking cessation (see Chapter 1). While no longer recommended for primary prevention of CVD, antiplatelet agents (aspirin [81 mg orally daily] or clopidogrel [75 mg orally daily]) remain important for secondary prevention of cardiovascular events in those with PAD and to reduce peripheral vascular morbidity. Low-dose rivaroxaban (2.5 mg orally twice daily) with aspirin 100 mg orally daily reduces both major cardiovascular and limb-related adverse events in symptomatic patients. All patients with PAD should receive high-dose statin (eg, ...