Peripheral artery disease (PAD) or Peripheral vascular disease (PVD) is a narrowing of the arteries other than those that supply the heart or the brain.
- M/C affected artery: Femoral artery
Aetiology
Risk factors
- Smoking (M/imp risk factor)
- Diabetes mellitus
- Hypertension
- Heart disease
- Hyperlipidemia
- Non-modifiable:
- Family history of circulation problems
- Old age
- Male sex
Cause
- Organic PVD:
- Atherosclerosis (M/C)
- Thromboembolus
- Functional PVD:
- Vasospasms (short-term)
Pathophysiology
- Pain in foot:
- Block of lower tibial and plantar vessels
- Pain in calf:
- Block in femoropopliteal segment
- Pain in thigh:
- Block in superficial femoral artery
- Pain in hips/buttock:
- Block in common iliac or aortoiliac segment
- Usually associated with impotence: Leriche’s syndrome
Classification
Fontaine classification
- Stage I: Asymptomatic, incomplete blood vessel obstruction
- Stage II: Mild claudication pain in limb
- Stage IIA: Claudication when walking > 200 meters
- Stage IIB: Claudication when walking < 200 meters
- Stage III: Rest pain, mostly in the feet
- Stage IV: Necrosis and/or gangrene of the limb
Rutherford classification
- Grade 0, Category 0: Asymptomatic
- Grade I, Category 1: Mild claudication
- Grade I, Category 2: Moderate claudication
- Grade I, Category 3: Severe claudication
- Grade II, Category 4: Rest pain
- Grade III, Category 5: Minor tissue loss; Ischemic ulceration not exceeding ulcer of the digits of the foot
- Grade IV, Category 6: Major tissue loss; Severe ischemic ulcers or frank gangrene
Clinical features
Intermittent claudication:
Muscle pain on mild exertion (ache, cramp, numbness or sense of fatigue), classically in the calf muscle, which occurs during exercise, such as walking, and is relieved by a short period of rest.
- All the “P”s
- Pallor increase
- Pulses decreased
- Perishing cold
- Pain
- Paraesthesia
- Paralysis
II. Ischemic rest pain
Continuous burning pain in the lower leg or feet.
- Continuous pain on elevation
- Relieved on lowering (hanging feet or walking)
- Colour changes: Elevation pallor, dependent rubor
Critical limb ischemia (CLI):
Also referred to as limb threat, is an advanced stage of peripheral artery disease (PAD).
- TRIAD:
- Ischemic rest pain
- Arterial insufficiency ulcers
- Gangrene
Diagnosis
Ankle-brachial index (ABI): Best initial test
Ratio of the ankle systolic pressure to the arm systolic pressure
- ABPILeg: < 0.9
Buerger’s test
- Elevation pallor
- Vascular angle or Buerger’s angle is the angle to which the leg has to be raised before it becomes pale, whilst in supine decubitus
- Normal limb may not show pallor even at 90°
- Vascular angle < 20°: Severe ischemia
- Vascular angle or Buerger’s angle is the angle to which the leg has to be raised before it becomes pale, whilst in supine decubitus
- Sunset foot
- When patient shifts to sitting position, the leg will revert to the pink colour more slowly than normal and also pass through the normal pinkness to a red-orange colouring (rubor – redness)
- Rubor of dependency
- Foot will return to its normal colour if descended
Claudication test:
Differential diagnosis:
- Neurogenic claudication
- Diabetic neuropathy
- Statin myopathy
- Small vessel disease
Management
Modify risk factors:
- Smoking cessation
- Lipid management (Statins)
- BP control (ACEi, Beta blockers)
- Exercise program
Medical management:
- Lipid lowering therapy (statins)
- Antihypertensives: ACE inhibitors, ARBs & β-blockers
- Antiplatelet therapy (aspirin, clopidogrel)
- Cilostazol
- Pentoxyfylline
Revascularization procedures:
- Percutaneous transluminal angioplasty (PTA)
- Atherectomy
- Arterial bypass surgery
- Arterial thrombosis or embolism:
- Thrombolysis and thrombectomy
- Gangrene:
- Amputation
Summary