Peripheral Arterial Disease
Peripheral arterial disease (PAD) is the presence of stenosis or occlusion in the arteries of the lower limbs, usually due to atherosclerosis.
Patients with PAD are at increased risk of cardiovascular and cerebrovascular events, including myocardial infarction, stroke, and death.
Risk factors for PAD overlap those for atherosclerosis and include smoking, increasing age, hypertension, lipid disorders, and diabetes.
Symptoms of severe PAD include:
* Foot pain that does not go away when you stop exercising
* Foot or toe wounds that will not heal or heal very slowly
* A marked decrease in the temperature of your lower leg or foot particularly compared to the other leg or to the rest of your body.
The pain of PAD usually goes away when you stop exercising, although this may take a few minutes. When muscles are being used, they need more blood flow. That means if thereÕs a blockage due to plaque buildup, the muscles wonÕt get enough blood during exercise to meet their needs. ThatÕs what causes the pain, which is called Òintermittent claudicationÓ. The term comes from the Latin word meaning Òto limp.Ó
The ABI is a sensitive, noninvasive, cost-effective method for detecting PAD. It is calculated using the ratio of ankle systolic blood pressure divided by the systolic blood pressure at the arm. Measurements can be obtained in the office using a blood pressure cuff and a hand-held Doppler instrument. A toe-brachial index (TBI), which requires small cuffs and precise technique for accuracy, can be used in patients who have an elevated ABI (>1.3) but suspected PAD and in patients with noncompressible leg arteries, such as in the elderly or those with long-standing diabetes.
An ABI less than 0.9 is considered abnormal, values from 0.41-0.9 are classified as mild-to-moderate PAD, and values less than 0.4 are classified as severely decreased (7). The American Diabetes Association recommends that the ABI be performed in the following populations (2):
* Patients with diabetes who are aged 50 years and older
* Patients with diabetes who are younger than 50 years and have other atherosclerotic risk factors
* Patients who have had diabetes for more than 10 years
Additional vascular diagnostic tools may be used to localize occlusion, assess severity, and monitor treatment progress. These tests include segmental blood pressure and pulse volume recording, exercise stress testing, continuous wave Doppler and duplex ultrasonography, magnetic resonance angiography (MRA), contrast angiography, and CT angiography (CTA) (7).
Pulse volume recording is used to assess hemodynamic severity and to help localize arterial lesions in the leg. Exercise stress testing is used to differentiate claudication and pseudoclaudication and when resting ABI values are normal but PAD is suspected. A treadmill and a trained staff are required to perform exercise stress testing, and this diagnostic tool may not be feasible in specific patient populations, such as the elderly.
Continuous wave Doppler and duplex ultrasonography are noninvasive vascular tests that provide detailed information on the location and severity of vessel occlusion. MRA provides a detailed picture of the arteries without the use of ionizing radiation or an iodine-based contrast medium. As such, MRA can be used in patients with renal insufficiency. Contrast angiography and CTA are invasive evaluations requiring iodinated contrast medium and ionizing radiation and are generally reserved for extensive anatomical evaluation in patients who are candidates for revascularization. An abdominal ultrasonogram is indicated if any abnormalities are detected upon palpation.
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