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| {{Infobox_Disease |
| | #REDIRECT [[Peripheral arterial disease]] |
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| Image = Arterial_insufficiency.jpg|
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| Caption = Arterial insufficiency|
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| {{SI}}
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| {{CMG}}
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| ==Overview==
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| In [[medicine]], '''peripheral artery occlusive disease''' (PAOD, also known as '''peripheral vascular disease''' (PVD) and '''peripheral artery disease '''(PAD) is a collator for all [[disease]]s caused by the obstruction of large peripheral [[artery|arteries]], which can result from [[atherosclerosis]], [[inflammation|inflammatory]] processes leading to [[stenosis]], an [[embolism]] or [[thrombus]] formation. It causes either [[Acute (medical)|acute]] or [[chronic (medicine)|chronic]] [[ischemia]].
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| ==Classification==
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| Peripheral artery occlusive disease is commonly divided in the Fontaine stages:<ref>{{cite journal | author=Fontaine R, Kim M, Kieny R |
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| title=Die chirugische Behandlung der peripheren Durchblutungsstörungen.
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| (Surgical treatment of peripheral circulation disorders) | journal=Helvetica Chirurgica Acta, Basel | year=1954 | volume=21 | issue=5/6 | pages=499–533 | language=German }}</ref>
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| * I: mild [[Pain and nociception|pain]] on walking ("[[claudication]]")
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| * II: severe pain on [[walking]] relatively shorter distances ([[intermittent claudication]])
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| * III: pain while resting
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| * IV: loss of sensation to the lower part of the extremity
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| * V: [[biological tissue|tissue]] loss ([[gangrene]])
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| ==Diagnosis==
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| ==Causes==
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| * Smoking - tobacco use in any form is the single most important modifiable cause of PAD internationally. Smokers have up to a tenfold increase in relative risk for PAOD in a dose-related effect. Exposure to second-hand smoke from environmental exposure has also been shown to promote changes in blood vessel lining (endothelium) which is a precursor to atherosclerosis.
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| * [[Diabetes Mellitus]] - increased risk of PAOD 2-4X by causing endothelial and smooth muscle cell dysfunction in peripheral arteries. Diabetics account for up to 70% of nontraumatic amputations performed, and a known diabetic who smokes runs an approximately 30% risk of [[amputation]] within 5 years.
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| * Dyslipidemia - elevation of total [[cholesterol]], LDL cholesterol, and [[triglyceride]] levels each have been correlated with accelerated PAOD. Correction of dyslipidemia by diet and/or medication is associated with a major improvement in short-term rates of heart attack and stroke. This benefit is gained even though current evidence does not demonstrate a major reversal of peripheral and/or coronary atherosclerosis.
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| * [[Hypertension]] - elevated blood pressure is correlated with an increase in the risk of developing PAD, as well as in associated coronary and cerebrovascular events (heart attack and stroke).
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| * Other risk factors which are being studied include levels of various inflammatory mediators such as C-reactive protein, homocysteine, and fibrinogen.
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| * Risk of PAOD also increases if the patient is: over the age of 50, African American, male, [[obese]], or has a personal history of [[vascular disease]], [[myocardial infarction|heart attack]], or [[stroke]].
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| Upon suspicion of PAOD, the first-line test is the [[ankle brachial pressure index]] (''ABPI''/''ABI'') which is a measure of the fall in blood pressure in the arteries supplying the legs. A reduced ABPI (less than 0.9) is consistent with PAOD. Values of ABPI below 0.8 indicate moderate disease and below 0.5 severe disease.It is possible for conditions which stiffen the vessel walls to produce incorrect readings and high values(>1.3) would also merit investigation.
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| If ABI's are abnormal the next step is generally a lower limb [[Medical ultrasonography#Doppler sonography|doppler ultrasound]] examination to look at site and extent of [[atherosclerosis]] at the [[femoral artery]]. Other imaging can be performed by [[angiogram|angiography]], where a catheter is inserted into the femoral artery and selectively guided to the artery in question and then used to inject [[Radiodensity|radiodense]] contrast agent whilst an [[X-ray]] is taken. Any [[stenosis]] of the arteries can be identified and treated at the same time by balloon [[Angioplasty#Peripheral angioplasty|angioplasty]] if the stenosis is over a short segment (<3cm). However if the artery is occluded or there is diffuse disease present, then [[Bypass (surgical)|arterial bypass surgery]] may be required.
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| Modern multislice [[computerized tomography]] ('''CT''') scanners provide direct imaging of the arterial system as an alternative to angiography. CT provides complete evaluation of the [[aorta]] and lower limb arteries without the need for an angiogram's arterial injection of contrast agent.
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| ==Symptoms==
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| * [[Claudication]] - pain, weakness, or cramping in muscles due to decreased blood flow
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| * Sores, wounds, or ulcers that heal slowly or not at all
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| * Noticeable change in color (blueness or paleness) or temperature (coolness) when compared to the other limb
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| * Diminished hair and nail growth on affected limb and digits.
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| ===Physical Examination===
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| ==== Extremities ====
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| [[Image:Arterial_insufficiency.jpg|thumb|center|Arterial insufficiency<ref>http://images.google.com/imgres?imgurl=http://lh3.google.com/_p163cKQmQ3k/RqBEn-ukrPI/AAAAAAAAAY8/v2CX9vPz7B4/s800/roth-spot%2B(white-centered%2Bhemorrhage%2B-%2Bendocarditis).jpg&imgrefurl=http://picasaweb.google.com/lh/photo/uugpiqwnGqw04cE42LS_-g&h=262&w=360&sz=19&hl=en&start=19&um=1&tbnid=F2wEexJaxk3GEM:&tbnh=88&tbnw=121&prev=/images%3Fq%3DEndocarditis%26um%3D1%26hl%3Den%26client%3Dfirefox-a%26rls%3Dorg.mozilla:en-US:official%26sa%3DN</ref>]]
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| ==Therapy==
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| Dependent on the severity of the disease, the following steps can be taken:
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| * Conservative measures include [[Smoking cessation]] (cigarettes promote PAOD and are a risk factor for [[cardiovascular disease]]). Regular exercise for those with claudication helps open up alternative small vessels ('''collateral flow''') and the limitation in walking often improves. Medication with [[aspirin]], [[clopidogrel]] and [[statins]], which reduce clot formation and cholesterol levels, respectively can help with disease progression and address the other cardiovascular risks that the patient is likely to have.
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| * [[Angioplasty]] (PTA or percutaneous transluminal angioplasty) can be done on solitary lesions in large [[artery|arteries]], such as the [[femoral artery]].
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| * Plaque excision, in which the plaque is scraped off of the inside of the vessel wall.
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| * Occasionally, [[Bypass (surgical)|bypass]] grafting is needed to circumvent a seriously stenosed area of the arterial vasculature. Generally, the [[saphenous vein]] is used, although artificial (Gore-Tex) material is often used for large tracts when the veins are of lesser quality.
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| * Rarely, [[sympathectomy]] is used - removing the nerves that make arteries contract, effectively leading to vasodilatation.
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| * When [[gangrene]] of toes has set in, [[amputation]] is often a last resort to stop infected dying tissues from causing [[septicemia]].
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| [[Arterial thrombosis]] or embolism has a dismal prognosis, but is occasionally treated successfully with [[thrombolysis]].
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| ==Associations==
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| Many PAOD patients also have [[angina pectoris]] or have had [[myocardial infarction]]. There is also an increased risk for [[stroke]].
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| ==Guidelines==
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| * {{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, ''et al'' |title=ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary 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 |journal=J. Am. Coll. Cardiol. |volume=47 |issue=6 |pages=1239-312 |year=2006 |pmid=16545667 |doi=10.1016/j.jacc.2005.10.009 |issn= |url=http://www.guideline.gov/summary/summary.aspx?doc_id=8503&nbr=4740}}
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| == External references ==
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| [http://www.merck.com/mmpe/sec07/ch080/ch080f.html Peripheral Arterial Disease: Peripheral Arterial Disorders: Merck Manual Professional Edition] Accessed on 27 March 2007
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| == Footnotes ==
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| <references/>
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| [[Category:Cardiovascular diseases]]
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| [[Category:Angiology]]
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| [[Category:Cardiology]]
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