Peripheral Artery Disease

last authored:
last reviewed:

 

 

Introduction

PAD is a substantial burden on people and populations.

It is often asymptomatic, underdiagnosed.

 

 

The Case of...

return to top

 

 

 

Causes and Risk Factors

PAD can occur

Acute causes

Acute embolic occulsion, occuring in anyone. Emboli most often originate in the heart, following atrial fibrillation, myocardial infarction, or myxoma. Other causes include aneurysm.

Acute thrombotic occlusion is an acute on chronic disease following years of atherosclerotic buildup, often following dehydration, hypercoagulability, or other thrombotic situations.

trauma

 

Chronic Causes

Atherosclerosis, usually occurring in older patients, accounts for the majority of cases of chronic PAD. Risk factors include:

return to top

 

 

 

Pathophysiology

Atherosclerosis develops over years with vessel damage, inflammation, and plaque buildup. As the lumen diameter decreases, velocity increases. At rest, distal structures receive sufficient blood, but with exercise and increased oxygen demand, symptoms arise.

Atherosclerosis commonly occurs in more than one site, causing stroke and coronary artery disease.

PAD normally develops over time. As vascular supply decreases, collaterals develop, slightly increasing perfusion. Worsening disease. further decreases

Normally, one joint below the site of arterial disease is affected.

Pain evetually develops while at rest, 1-20 years after claudication occurs. Rest pain is especially bad at night due to the lack of gravity. Walking a few steps or sleeping in a chair improves symptoms as gravity assists in foot perfusion.

Dependent rubor represents the accumulation of venous blood in areas

return to top

 

 

 

Signs and Symptoms

PAD can be remembered by the five P's:

 

  • history
  • physical exam

History

 

  • intermittent claudication: pain, tightening, or cramping, brought on by exercise and releived by rest.

Physical Exam

Bruits can be heard over arteries in aorta or peripheral vessels

Pallor in elevated limbs

A reddened, mottled foot should be raised to distinguish between severe dependent rubor and lobster foot.

return to top

 

 

 

Investigations

  • lab investigations
  • diagnostic imaging

Lab Investigations

Diagnostic Imaging

Ankle-brachial index (systolic) can be taken using doppler flow

  • normal: >0.91
  • mild-moderate: 0.4-0.9
  • severe: <0.4

CTA

MRA

angiogram

return to top

 

 

 

Differential Diagnosis

return to top

 

 

 

Treatments

Treatment depends on chronic or acute etiology, disease severity, and patient co-morbidities.

 

Lifestyle

exercise, quitting smoking, diet modifaction.

 

Surgery

Chronic PAD has a relative indication while patients have claudication. Grafts have a limited lifetime, and patients will often die of other causes (ie stroke, myocardial infarction) before PAD becomes too severe.

and an absolute indication when the limb is threatened. Not everyone with chronic PAD

 

Acute disease

Acute emboli are treated by balloon catheterization and embolectomy.

Acute thrombosis is treated with arthroplasty or bypass.

return to top

 

 

 

Consequences and Course

With severe PAD, ongoing ischemia can lead to ulcers,

Once rest pain develops, it is only weeks to months before total occlusion occurs and gangrene sets in. A threatened limb accordingly

return to top

 

 

 

Additional Resources

return to top

 

 

 

Topic Development

created:

authors:

editors:

reviewers:

 

 

return to top