UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Overview of lower extremity peripheral artery disease

Authors
Jeffrey S Berger, MD, MS, FAHA, FACC
Mark G Davies, MD, PhD, MBA, FACS, FACC
Section Editors
Emile R Mohler III, MD
Denis L Clement, MD, PhD
John F Eidt, MD
Joseph L Mills, Sr, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS

INTRODUCTION

Atherosclerosis results in the accumulation of lipid and fibrous material between the layers of the arterial wall and causes disease of the coronary, cerebral, and peripheral arteries. Atherosclerotic disease often involves the arteries providing flow to the lower extremities, referred to as lower extremity peripheral artery disease (PAD). Atherosclerosis can lead to acute or chronic symptoms due to embolism from more proximal disease, or due to thrombosis of an artery that has been progressively narrowed.

Management of patients with lower extremity PAD should include medical therapies aimed at reducing the risk for future cardiovascular events related to atherosclerosis, such as myocardial infarction, stroke, and peripheral arterial events. These therapies are also particularly important for reducing the risk of events at the time of intervention (surgical or endovascular), when indicated, and for improving long-term survival.

An overview of atherosclerotic occlusive disease affecting the lower extremities is provided here. Disease affecting the upper extremity is reviewed separately. (See "Overview of upper extremity peripheral artery disease".)

ANATOMY AND PATHOPHYSIOLOGY

The subintimal accumulation of lipid and fibrous material can narrow the vessel lumen, or the plaque can rupture causing embolism. Multiple factors contribute to the pathogenesis of atherosclerosis, including endothelial dysfunction, dyslipidemia, inflammatory and immunologic factors, plaque rupture, and tobacco use. (See "Pathogenesis of atherosclerosis".)

The symptoms related to atherosclerotic narrowing of the aorta or lower extremity arteries depend upon the location and severity of disease. Atherosclerotic disease tends to be well localized and usually occurs in the proximal or midportions of a given arterial bed. Atherosclerotic disease follows anatomic patterns, which also have a bearing on the natural history and progression of disease. Patients with diabetes or with end stage renal disease generally present with more distal disease.

                        

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Fri Sep 23 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Pande RL, Perlstein TS, Beckman JA, Creager MA. Secondary prevention and mortality in peripheral artery disease: National Health and Nutrition Examination Study, 1999 to 2004. Circulation 2011; 124:17.
  2. Hirsch AT, Allison MA, Gomes AS, et al. A call to action: women and peripheral artery disease: a scientific statement from the American Heart Association. Circulation 2012; 125:1449.
  3. Gallino A, Aboyans V, Diehm C, et al. Non-coronary atherosclerosis. Eur Heart J 2014; 35:1112.
  4. Berger JS, Hochman J, Lobach I, et al. Modifiable risk factor burden and the prevalence of peripheral artery disease in different vascular territories. J Vasc Surg 2013; 58:673.
  5. Joosten MM, Pai JK, Bertoia ML, et al. Associations between conventional cardiovascular risk factors and risk of peripheral artery disease in men. JAMA 2012; 308:1660.
  6. Society for Vascular Surgery Lower Extremity Guidelines Writing Group, Conte MS, Pomposelli FB, et al. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication. J Vasc Surg 2015; 61:2S.
  7. McDermott MM, Fried L, Simonsick E, et al. Asymptomatic peripheral arterial disease is independently associated with impaired lower extremity functioning: the women's health and aging study. Circulation 2000; 101:1007.
  8. Fernández-Friera L, Peñalvo JL, Fernández-Ortiz A, et al. Prevalence, Vascular Distribution, and Multiterritorial Extent of Subclinical Atherosclerosis in a Middle-Aged Cohort: The PESA (Progression of Early Subclinical Atherosclerosis) Study. Circulation 2015; 131:2104.
  9. Alahdab F, Wang AT, Elraiyah TA, et al. A systematic review for the screening for peripheral arterial disease in asymptomatic patients. J Vasc Surg 2015; 61:42S.
  10. Golomb BA, Dang TT, Criqui MH. Peripheral arterial disease: morbidity and mortality implications. Circulation 2006; 114:688.
  11. Mohty D, Magne J, Deltreuil M, et al. Outcome and impact of surgery in paradoxical low-flow, low-gradient severe aortic stenosis and preserved left ventricular ejection fraction: a cardiac catheterization study. Circulation 2013; 128:S235.
  12. Koelemay MJ, den Hartog D, Prins MH, et al. Diagnosis of arterial disease of the lower extremities with duplex ultrasonography. Br J Surg 1996; 83:404.
  13. Romano M, Mainenti PP, Imbriaco M, et al. Multidetector row CT angiography of the abdominal aorta and lower extremities in patients with peripheral arterial occlusive disease: diagnostic accuracy and interobserver agreement. Eur J Radiol 2004; 50:303.
  14. Menke J, Larsen J. Meta-analysis: Accuracy of contrast-enhanced magnetic resonance angiography for assessing steno-occlusions in peripheral arterial disease. Ann Intern Med 2010; 153:325.
  15. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl S:S5.
  16. Mills JL Sr, Conte MS, Armstrong DG, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg 2014; 59:220.
  17. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113:e463.
  18. Rooke TW, Hirsch AT, Misra S, et al. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery. J Vasc Surg 2011; 54:e32.
  19. 2011 WRITING GROUP MEMBERS, 2005 WRITING COMMITTEE MEMBERS, ACCF/AHA TASK FORCE MEMBERS. 2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2011; 124:2020.
  20. European Stroke Organisation, Tendera M, Aboyans V, et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:2851.
  21. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129:S76.
  22. Alonso-Coello P, Bellmunt S, McGorrian C, et al. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e669S.
  23. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet 1996; 348:1329.
  24. Bonaca MP, Bhatt DL, Storey RF, et al. Ticagrelor for Prevention of Ischemic Events After Myocardial Infarction in Patients With Peripheral Artery Disease. J Am Coll Cardiol 2016; 67:2719.
  25. Vorapaxar. Am J Cardiovasc Drugs 2010; 10:413.
  26. Morrow DA, Braunwald E, Bonaca MP, et al. Vorapaxar in the secondary prevention of atherothrombotic events. N Engl J Med 2012; 366:1404.
  27. Bonaca MP, Scirica BM, Creager MA, et al. Vorapaxar in patients with peripheral artery disease: results from TRA2{degrees}P-TIMI 50. Circulation 2013; 127:1522.
  28. Bonaca MP, Gutierrez JA, Creager MA, et al. Acute Limb Ischemia and Outcomes With Vorapaxar in Patients With Peripheral Artery Disease: Results From the Trial to Assess the Effects of Vorapaxar in Preventing Heart Attack and Stroke in Patients With Atherosclerosis-Thrombolysis in Myocardial Infarction 50 (TRA2°P-TIMI 50). Circulation 2016; 133:997.
  29. WAVE Investigators. The effects of oral anticoagulants in patients with peripheral arterial disease: rationale, design, and baseline characteristics of the Warfarin and Antiplatelet Vascular Evaluation (WAVE) trial, including a meta-analysis of trials. Am Heart J 2006; 151:1.
  30. Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 2000; 342:145.
  31. Ostergren J, Sleight P, Dagenais G, et al. Impact of ramipril in patients with evidence of clinical or subclinical peripheral arterial disease. Eur Heart J 2004; 25:17.
  32. Anderson JL, Halperin JL, Albert NM, et al. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013; 127:1425.
  33. Clever YP, Cremers B, Speck U, et al. Influence of a paclitaxel coated balloon in combination with a bare metal stent on restenosis and endothelial function: comparison with a drug eluting stent and a bare metal stent. Catheter Cardiovasc Interv 2014; 84:323.
  34. Leng GC, Lee AJ, Fowkes FG, et al. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. Int J Epidemiol 1996; 25:1172.
  35. Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med 1992; 326:381.
  36. Smith GD, Shipley MJ, Rose G. Intermittent claudication, heart disease risk factors, and mortality. The Whitehall Study. Circulation 1990; 82:1925.
  37. Murphy TP, Cutlip DE, Regensteiner JG, et al. Supervised exercise, stent revascularization, or medical therapy for claudication due to aortoiliac peripheral artery disease: the CLEVER study. J Am Coll Cardiol 2015; 65:999.
  38. Goodney PP, Schanzer A, Demartino RR, et al. Validation of the Society for Vascular Surgery's objective performance goals for critical limb ischemia in everyday vascular surgery practice. J Vasc Surg 2011; 54:100.
  39. Albäck A, Biancari F, Schmidt S, et al. Haemodynamic results of femoropopliteal percutaneous transluminal angioplasty. Eur J Vasc Endovasc Surg 1998; 16:7.
  40. Teraa M, Conte MS, Moll FL, Verhaar MC. Critical Limb Ischemia: Current Trends and Future Directions. J Am Heart Assoc 2016; 5.
  41. Welten GM, Schouten O, Hoeks SE, et al. Long-term prognosis of patients with peripheral arterial disease: a comparison in patients with coronary artery disease. J Am Coll Cardiol 2008; 51:1588.
  42. Leng GC, Fowkes FG, Lee AJ, et al. Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. BMJ 1996; 313:1440.
  43. Chung J, Timaran DA, Modrall JG, et al. Optimal medical therapy predicts amputation-free survival in chronic critical limb ischemia. J Vasc Surg 2013; 58:972.
  44. Suzuki H, Maeda A, Maezawa H, et al. The efficacy of a multidisciplinary team approach in critical limb ischemia. Heart Vessels 2016.
  45. Goodney PP, Beck AW, Nagle J, et al. National trends in lower extremity bypass surgery, endovascular interventions, and major amputations. J Vasc Surg 2009; 50:54.
  46. Benoit E, O'Donnell TF Jr, Kitsios GD, Iafrati MD. Improved amputation-free survival in unreconstructable critical limb ischemia and its implications for clinical trial design and quality measurement. J Vasc Surg 2012; 55:781.
  47. Ouriel K. Peripheral arterial disease. Lancet 2001; 358:1257.