Clinical features and diagnosis of lower extremity peripheral artery disease
- David G Neschis, MD
David G Neschis, MD
- Clinical Associate Professor of Surgery
- University of Maryland School of Medicine
- Michael A Golden, MD
Michael A Golden, MD
- Associate Professor of Surgery
- University of Pennsylvania
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- Denis L Clement, MD, PhD
Denis L Clement, MD, PhD
- Section Editor — Vascular Medicine
- Emeritus Professor of Cardiology-Angiology
- University of Ghent, Belgium
- Emile R Mohler III, MD
Emile R Mohler III, MD
- Section Editor — Vascular Medicine
- Professor of Medicine
- University of Pennsylvania School of Medicine
Peripheral artery disease (PAD), specifically atherosclerotic disease leading to peripheral artery obstruction, may be silent or present with a variety of symptoms and signs indicative of extremity ischemia. The clinical manifestations of arterial insufficiency (regardless of etiology) are due to a lack of blood flow to the musculature relative to its metabolism, which results in pain in the affected muscle groups. The presence of an extremity ulcer is one of the more obvious clinical signs that can be due to ischemia, but other manifestations, such as claudication and rest pain, should be actively sought out and differentiated from nonatherosclerotic and nonvascular conditions to ensure timely referral to a vascular specialist, when indicated. Ideally, a multidisciplinary approach involving the primary care provider, medical specialists, podiatrist, vascular specialist (interventionalist and/or surgeon), and plastic surgery provides optimal medical and surgical care. PAD is a treatable condition. When recognized early and appropriately managed, complications that can lead to limb loss can be minimized.
The clinical features and diagnosis of lower extremity PAD are reviewed here. The epidemiology, risk factors, and natural history of PAD, as well as the medical and surgical treatment of PAD are discussed elsewhere. (See "Epidemiology, risk factors, and natural history of peripheral artery disease" and "Surgical management of claudication" and "Percutaneous interventional procedures in the patient with lower extremity claudication".)
The majority of patients with PAD have atherosclerotic disease of the lower extremity. Atherosclerotic PAD of the upper extremity is much less common and is discussed elsewhere. (See "Overview of upper extremity peripheral artery disease".)
PERIPHERAL ARTERY DISEASE
Many pathologic processes can cause arterial obstruction leading to symptoms of arterial insufficiency because of reduced blood flow. In this topic, we focus on atherosclerosis as a cause of progressive narrowing of the lower extremity arteries, or as a source of atheroembolization.
Variable terminology has been used to refer to arterial disease that is due to atherosclerosis. Older terms include arteriosclerotic disease, and peripheral artery occlusive disease. In many resources, the term peripheral artery disease (PAD) is regarded as a general term encompassing a range of noncoronary arterial syndromes caused by the altered structure and function of the aorta and peripheral arteries due to numerous pathophysiological processes [1-3]. We regard the term PAD as denoting arterial disease affecting the peripheral (noncoronary) vasculature due to atherosclerosis, distinguishing PAD from other processes, which are given below and discussed in separate topic reviews. (See 'Other causes of arterial obstruction' below.)
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- PERIPHERAL ARTERY DISEASE
- Epidemiology and risk factors
- CLINICAL PRESENTATIONS
- Asymptomatic patients screened for PAD
- Intermittent claudication and atypical lower extremity pain
- Threatened limb
- CLINICAL FEATURES
- - Lower extremity pain
- Atypical extremity pain
- Ischemic rest pain
- Severe diffuse pain
- - Nonhealing wound/ulcer
- - Skin discoloration/gangrene
- Physical examination
- - Extremity appearance
- Skin temperature and color
- - Pulses
- Bedside ABI
- - Neurologic assessment
- Laboratory studies
- Plain radiographs
- DIAGNOSIS OF LOWER EXTREMITY PAD
- Abnormal arterial examination/tissue loss
- Abnormal ankle-brachial index
- Site and severity of PAD
- - Segmental pressure and pulse volume recordings
- Exercise testing
- - Vascular imaging
- DIFFERENTIAL DIAGNOSIS OF PAD
- Other causes of arterial obstruction
- Nonarterial etiologies for limb pain
- Nonarterial etiologies for ulceration
- CLASSIFICATION OF DISEASE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS