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, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- 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.)
- Rooke TW, Hirsch AT, Misra S, 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. J Am Coll Cardiol 2013; 61:1555.
- Layden J, Michaels J, Bermingham S, et al. Diagnosis and management of lower limb peripheral arterial disease: summary of NICE guidance. BMJ 2012; 345:e4947.
- 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.
- Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA 2001; 286:1317.
- McDermott MM, Greenland P, Liu K, et al. Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment. JAMA 2001; 286:1599.
- 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.
- 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.
- Schorr EN, Treat-Jacobson D. Methods of symptom evaluation and their impact on peripheral artery disease (PAD) symptom prevalence: a review. Vasc Med 2013; 18:95.
- Hoeks SE, Smolderen KG, Scholte Op Reimer WJ, et al. Clinical validity of a disease-specific health status questionnaire: the peripheral artery questionnaire. J Vasc Surg 2009; 49:371.
- Ouedraogo N, Mahe G, Marchand J, et al. Validation of a new simple questionnaire to "estimate ambulation capacity by history" (EACH) in patients with claudication. J Vasc Surg 2011; 54:133.
- Nicolaï SP, Kruidenier LM, Rouwet EV, et al. The walking impairment questionnaire: an effective tool to assess the effect of treatment in patients with intermittent claudication. J Vasc Surg 2009; 50:89.
- van Zitteren M, Vriens PW, Heyligers JM, et al. Self-reported symptoms on questionnaires and anatomic lesions on duplex ultrasound examinations in patients with peripheral arterial disease. J Vasc Surg 2012; 55:1025.
- Mathieu RA 4th, Powell-Wiley TM, Ayers CR, et al. Physical activity participation, health perceptions, and cardiovascular disease mortality in a multiethnic population: the Dallas Heart Study. Am Heart J 2012; 163:1037.
- Treat-Jacobson D, Lindquist RA, Witt DR, et al. The PADQOL: development and validation of a PAD-specific quality of life questionnaire. Vasc Med 2012; 17:405.
- Frans FA, Zagers MB, Jens S, et al. The relationship of walking distances estimated by the patient, on the corridor and on a treadmill, and the Walking Impairment Questionnaire in intermittent claudication. J Vasc Surg 2013; 57:720.
- Jain A, Liu K, Ferrucci L, et al. Declining walking impairment questionnaire scores are associated with subsequent increased mortality in peripheral artery disease. J Am Coll Cardiol 2013; 61:1820.
- Le Faucheur A, Noury-Desvaux B, Mahé G, et al. Variability and short-term determinants of walking capacity in patients with intermittent claudication. J Vasc Surg 2010; 51:886.
- Frederick M, Newman J, Kohlwes J. Leriche syndrome. J Gen Intern Med 2010; 25:1102.
- Leriche R, Morel A. The Syndrome of Thrombotic Obliteration of the Aortic Bifurcation. Ann Surg 1948; 127:193.
- Cranley JJ. Ischemic rest pain. Arch Surg 1969; 98:187.
- DeWeese JA, Leather R, Porter J. Practice guidelines: lower extremity revascularization. J Vasc Surg 1993; 18:280.
- McGee SR, Boyko EJ. Physical examination and chronic lower-extremity ischemia: a critical review. Arch Intern Med 1998; 158:1357.
- Khan NA, Rahim SA, Anand SS, et al. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA 2006; 295:536.
- Brueseke TJ, Macrino S, Miller JJ. Lack of lower extremity hair not a predictor for peripheral arterial disease. Arch Dermatol 2009; 145:1456.
- Insall RL, Davies RJ, Prout WG. Significance of Buerger's test in the assessment of lower limb ischaemia. J R Soc Med 1989; 82:729.
- Collins KA, Sumpio BE. Vascular assessment. Clin Podiatr Med Surg 2000; 17:171.
- Fisher DFJ. Toe and foot amputation. In: Current Therapy in Vascular Surgery, Ernst CB, Stanley JC (Eds), Mosby, St. Louis, MO 1995. p.672.
- Vierron E, Halimi JM, Giraudeau B. Ankle-brachial index and peripheral arterial disease. N Engl J Med 2010; 362:471; author reply 471.
- Mahé G, Le Faucheur A, Noury-Desvaux B. Ankle-brachial index and peripheral arterial disease. N Engl J Med 2010; 362:470.
- Parmenter BJ, Raymond J, Dinnen PJ, et al. Preliminary evidence that low ankle-brachial index is associated with reduced bilateral hip extensor strength and functional mobility in peripheral arterial disease. J Vasc Surg 2013; 57:963.
- Wang JC, Criqui MH, Denenberg JO, et al. Exertional leg pain in patients with and without peripheral arterial disease. Circulation 2005; 112:3501.
- Ankle Brachial Index Collaboration, Fowkes FG, Murray GD, et al. Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA 2008; 300:197.
- 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.
- O'Hare AM, Katz R, Shlipak MG, et al. Mortality and cardiovascular risk across the ankle-arm index spectrum: results from the Cardiovascular Health Study. Circulation 2006; 113:388.
- Allison MA, Laughlin GA, Barrett-Connor E, Langer R. Association between the ankle-brachial index and future coronary calcium (the Rancho Bernardo study). Am J Cardiol 2006; 97:181.
- Szilagyi DE, Schwartz RL, Reddy DJ. Popliteal arterial aneurysms. Their natural history and management. Arch Surg 1981; 116:724.
- Varga ZA, Locke-Edmunds JC, Baird RN. A multicenter study of popliteal aneurysms. Joint Vascular Research Group. J Vasc Surg 1994; 20:171.
- Motaganahalli RL, Pennell RC, Mantese VA, Westfall SG. Cystic adventitial disease of the popliteal artery. J Am Coll Surg 2009; 209:541.
- Kim SH, Lee CE, Park HO, et al. Adventitial cystic disease of the common femoral artery: a case report and literature review. Korean J Thorac Cardiovasc Surg 2013; 46:150.
- Drac P, Köcher M, Utikal P, et al. Cystic adventitial disease of the popliteal artery: report on three cases and review of the literature. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2011; 155:309.
- Schep G, Bender MH, van de Tempel G, et al. Detection and treatment of claudication due to functional iliac obstruction in top endurance athletes: a prospective study. Lancet 2002; 359:466.
- 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.
- 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