Peripheral artery disease resident survival guide

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Peripheral artery disease
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: José Eduardo Riceto Loyola Junior, M.D.[2]

Synonyms and Keywords: Peripheral artery disease approach, Approach to claudication, Approach to the peripheral arterial disease

For the complete wikidoc page on claudication click here.

Overview

Claudication is the description of cramping muscle pain that occurs after a certain degree of exercise and is relieved by rest. Claudication is classically caused by peripheral arterial disease, in which an obstruction in the artery of the lower limbs can lead to an insufficient blood flow which is not enough to supply the demands from the muscles of that region, but there are other conditions that can mimic its symptoms such as nerve root compression, spinal stenosis, hip arthritis, symptomatic Baker's cyst, venous claudication and chronic compartment syndrome.

Causes

Life Threatening Causes

There are no life-threatening causes, which include conditions that may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Diagnosis

Shown below is a flowchart for diagnostic testing for suspected peripheral arterial disease according to the 2016 AHA/ACC guidelines:[2]

 
 
 
 
 
 
 
 
 
Suspected PAD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Symptoms:
Leg pain at rest
❑ Reduced or absent pulses
Leg pain during exertion
Gangrene
❑ Pale extremity
❑ Non healing wound
Calf or foot cramping
Paresthesias
 
 
Suspected critical limb ischemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order Ankle brachial index
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
≤ 0.90
 
 
 
 
Normal
1.00-1.40
Borderline
0.91-0.99
 
 
 
 
 
 
 
 
> 1.40
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order Exercise ankle-brachial index if exertion non-joint related leg symptoms
If absent - search for alternative diagnosis
 
 
 
 
 
 
 
 
Order Toe-Brachial Index
 
Exercise ankle-brachial index
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have > 20% decrease in Postexercise ABI?
 
 
 
 
 
 
 
 
Is TBI < 0.7?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
No
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PAD confirmed
 
 
 
 
 
No PAD - search for alternative diagnosis
 
 
 
 
 
 
PAD confirmed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lifestyle-limited claudication despite guideline-directed management and therapy, revascularization considered
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
No?
Continue guideline-directed management and therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anatomic assessment: (Class I)
❑ Duplex ultrasound
❑ Computed tomography angiography
❑ Magnetic resonance angiography
 
 
 
Anatomic assessment: (Class IIa)
❑ Invasive angiography
 
 
 
 
 
 
 
 
 
 
 
 

Shown below is a table summarizing the differential diagnosis of claudication according the age and clinical presentation:

Differential Diagnosis of Intermittent Claudication and Lower Limb Pain[3][4][5][6][7]
In younger patients
Diagnosis Clinical Features Diagnostic Method of Choice Treatment
Buerger's Disease Rare vasculitis mostly seen in young Asians males who are smokers. Causes inflammation and thrombosis of the arteries of the legs, feet, forearms, and hands. Conventional angiography - multilevel occlusions and segmental narrowing of the lower extremity arteries with extensive collateral flow showing a corkscrew or “tree root” appearance Smoking cessation
Extrinsic Compression by Bone Lesions Not a common cause, 40% of osteochondromas arise from the posterior aspect of distal femur compressing the femoral artery. MRI, limb x-ray or CT scan Excision of the lesion and repair of the affected artery
Popliteal Artery Entrapment Syndrome Common in young patients with claudication, especially athletes - compression of the popliteal artery by the medial head of the gastrocnemius muscle. Stress angiography Surgery
Fibromuscular Dysplasia Affects young women of childbearing age, affects mostly renal, cerebral and visceral arteries but may affect limbs as well. Angiography - string-of-beads appearance Angioplasty
Takayasu's Arteritis Rare vasculitis mostly seen on Asian and South American women. Stenosis of the abdominal aorta and iliac arteries are present in 17% of the patients and may cause claudication. Conventional angiography Corticosteroids, methotrexate, azathioprine, and cyclophosphamide
Cystic Adventitial Disease 1 in 1200 cases of claudication, most common in men, 20-50 years without risk factors for atherosclerosis. It is caused by repetitive trauma, which causes the formation of a mucin-containing cystic structure in the wall of the popliteal artery. Conventional angiography, MRI Complete excision of the cyst with prosthetic and vein replacement, as well as bypass
In older patients
Spinal Stenosis Motor weakness is the most important symptom, which may be accompanied by pain. It starts soon after standing up, and may be relieved by sitting or bending (lumbar spine flexion) MRI Analgesic drugs, physical therapy, acupuncture or surgery (gold standard)
Peripheral Arterial Disease May present with absent or reduced peripheral pulses, and audible bruits but some patients may not present with these symptoms. A low ankle-brachial pressure index (<0.9) is suggestive of the disease but if normal it does not exclude it. An exercise ankle-brachial pressure index can be done on patients that don't present with these signs.

Other clinical features include decreased skin temperature, shiny, hairless skin over the lower extremities, pallor on the elevation of the extremity, dystrophic toenails, and rubor when the limb is dependent.

Handheld Doppler, conventional angiography Smoking cessation, antiplatelet drugs, statins, diabetes and blood pressure control, exercise, percutaneous transluminal angioplasty.
Nerve Root Compression caused by compression of the nerve root by other structure, such as an herniated disc. The pain usually radiates down the back of the leg and is described as sharp lancinating pain. It may be relieved by adjusting the position of the back (leaning forward). MRI Surgery
Hip Arthritis Pain starts when the patient undergoes weight bearing and is worsened by activity. The pain is continuous and intensified by weight bearing, with inflammatory signs such as tenderness, swelling, and hyperthermia. MRI Surgery
Baker's Cyst Pain is worsened with activity, not relieved by resting, and may have tenderness and swelling behind the knee. Ultrasound, MRI Surgery

Treatment

Shown below is an algorithm summarizing the diagnosis of claudication due to peripheral arterial disease according the the British Medical Journal guidelines.[8]
 
 
 
 
 
Evaluate affected limb - check for color and trophic changes, early ulcerations, skin temperature, capillary refill time, pulses at the groin and popliteal fossa, and the pedal pulses.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If peripheral arterial disease is suspected: Screening test: ankle-brachial index (systolic blood pressure of the dorsalis pedis, posterior tibialis, or fibularis artery is obtained with a handheld Doppler and divided by the higher of the two brachial pressures) - if <0.9 confirms peripheral arterial disease.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Secondary prevention for coronary arterial disease: start aspirin 75mg daily and statins
 
Control cardiovascular risk factors (hyperglycemia, obesity, dyslipidemia, smoking)
 
Advise the patient to exercise for 30 minutes twice daily to increase pain-free walking and total walking distance by stimulating collateral blood flow)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cilostazol may be used for improving symptoms [9]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Be aware of the 5 Ps—pain, pale, pulseless, paraesthesia, paralysis—indicating an acute limb ischemia
 
 
 

Do's

Don'ts

  • Symptomatic treatment of the claudication and leg pain must not overshadow the reduction of cardiovascular risk, as these patients have a significantly increased risk of death.
  • When treating peripheral arterial disease, always attempt reducing symptoms with less invasive treatment options such as exercising, do not immediately refer patients to more invasive treatment options;
  • Don't forget to address other causes of claudication if the patient is presenting it at a younger age, or if the treatment doesn't improve the symptoms.
  • Do not perform invasive or non-invasive anatomic assessments for asymptomatic patients.[2]
  • In patients who are not at increased risk of peripheral arterial disease, and without a history of physical examination findings suggestive of PAD, the ankle-brachial index is not recommended.[2]
  • Anticoagulation should not be used to reduce the risk of cardiovascular ischemic events in patients with PAD.[2]
  • Pentoxifylline is not effective for treatment of claudication.[2]

References

  1. Simon RW, Simon-Schulthess A, Simon-Schulthess A, Amann-Vesti BR (2007). "Intermittent claudication". BMJ. 334 (7596): 746. doi:10.1136/bmj.39036.624306.68. PMC 1847882. PMID 17413176.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE; et al. (2017). "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Circulation. 135 (12): e686–e725. doi:10.1161/CIR.0000000000000470. PMC 5479414. PMID 27840332.
  3. Sutcliffe JB, Bui-Mansfield LT (2007). "AJR Teaching File: intermittent claudication of the lower extremity in a young patient". AJR Am J Roentgenol. 189 (3 Suppl): S17–20. doi:10.2214/AJR.06.0398. PMID 17715070 DOI: 10.2214/AJR.06.0398 PMID: 17715070 DOI: 10.2214/AJR.06.0398 Check |pmid= value (help).
  4. 4.0 4.1 Cassar K (2006). "Intermittent claudication". BMJ. 333 (7576): 1002–5. doi:10.1136/bmj.39001.562813.DE. PMC 1635612. PMID 17095782.
  5. Olin JW, Sealove BA (2011). "Diagnosis, management, and future developments of fibromuscular dysplasia". J Vasc Surg. 53 (3): 826–36.e1. doi:10.1016/j.jvs.2010.10.066. PMID 21236620.
  6. Hicks CW, Black JH, Ratchford EV (2019). "Popliteal artery entrapment syndrome". Vasc Med. 24 (2): 190–194. doi:10.1177/1358863X18822750. PMID 30739583.
  7. Keser G, Direskeneli H, Aksu K (2014). "Management of Takayasu arteritis: a systematic review". Rheumatology (Oxford). 53 (5): 793–801. doi:10.1093/rheumatology/ket320. PMID 24097290.
  8. Simon RW, Simon-Schulthess A, Simon-Schulthess A, Amann-Vesti BR (2007). "Intermittent claudication". BMJ. 334 (7596): 746. doi:10.1136/bmj.39036.624306.68. PMC 1847882. PMID 17413176.
  9. Carman TL, Fernandez BB (2000). "A primary care approach to the patient with claudication". Am Fam Physician. 61 (4): 1027–32, 1034. PMID 10706155.
  10. Malgor RD, Alahdab F, Alalahdab F, Elraiyah TA, Rizvi AZ, Lane MA; et al. (2015). "A systematic review of treatment of intermittent claudication in the lower extremities". J Vasc Surg. 61 (3 Suppl): 54S–73S. doi:10.1016/j.jvs.2014.12.007. PMID 25721067.