Peripheral arterial disease overview
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Peripheral arterial disease Microchapters |
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Differentiating Peripheral arterial disease from other Diseases |
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Diagnosis |
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Treatment |
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Case Studies |
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AHA/ACC Guidelines on Management of Lower Extremity PAD |
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Guidelines for Structured Exercise Therapy for Lower Extremity PAD |
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Guidelines for Minimizing Tissue Loss in Lower Extremity PAD |
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Guidelines for Revascularization of Claudication in Lower Extremity PAD |
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Guidelines for Management of Acute Limb Ischemial in Lower Extremity PAD |
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Guidelines for Longitudinal Follow-up for Lower Extremity PAD |
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Peripheral arterial disease overview On the Web |
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American Roentgen Ray Society Images of Peripheral arterial disease overview |
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Directions to Hospitals Treating Peripheral arterial disease |
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Risk calculators and risk factors for Peripheral arterial disease overview |
Editors-in-Chief: C. Michael Gibson, M.D., Beth Israel Deaconess Medical Center, Boston, MA; Robert G. Schwartz, M.D. [1], Piedmont Physical Medicine and Rehabilitation, P.A.; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Rim Halaby
Overview
Peripheral arterial disease is commonly divided in the Fontaine stages, introduced by Dr René Fontaine in 1954[1]. A more recent classification by Rutherford consists of three grades and six categories[2]. In addition, the American College of Cardiology/American Heart Association (ACC/AHA) uses a symptoms-based classification (absence of symptoms, claudication, critical limb ischemia and acute limb ischemia), in their guidelines.
Classification
Peripheral artery occlusive disease is commonly divided in the Fontaine stages, introduced by Dr René Fontaine in 1954. The classification is as follows: class I is mild pain on walking ("claudication"), class II is severe pain on walking relatively shorter distances (intermittent claudication) , class III is pain while resting and class IV is tissue loss (gangrene).[3]
Pathophysiology
Causes
Causes in alphabetical order:
- Atherosclerosis
- Degenerative diseases: Marfan's Syndrome and Ehlers-Danlos syndrome, Neurofibromatosis, arteriomegaly
- Dysplastic disorders: Fibromuscular dysplasia
- In situ thrombosis
- Thromboembolism
- Vascular inflamation : Takayasu's Arteritis
Differentiation of Peripheral Artery Disease from other Disorders
The most important disorder that peripheral arterial disease and the associated symptom of claudication must be distinguished from is pseudoclaudication caused by lumbar spinal stenosis[4]. Intermittent claudication (IC) must also be differentiated from lower extremity pain caused by non-vascular etiologies that may include neurologic, musculoskeletal and venous pathologies. Given the diversity in and the severity of symptoms among patients with peripheral arterial disease, there is a long list of disorders that peripheral arterial disease must be distinguished from. In fact, the false-positive diagnosis rates of peripheral arterial disease are estimated to be around 44% and the false-negative rates are estimated to be around 19%.
Epidemiology and Demographics
The prevalence of peripheral arterial disease varies considerably depending on how PAD is defined, and the age of the population being studied.[5] The prevalence of peripheral arterial disease in the general population is 12–14%. Peripheral arterial disease is even more common among the elderly and affects up to 20% of patients over the age of 70 years [6]. Peripheral vascular disease affects 1 in 3 diabetics over the age of 50. Approximately 10 million Americans have peripheral arterial disease.
Risk Factors
The risk factors associated with peripheral artery disease are similar to those associated with coronary artery disease. They can be classified as traditional and non traditional. Another way to classify the risk factors is depending on their level of risk: high risk factors (tobacco and diabetes), moderate risk factors (hypertension and hyperhomocysteinemia) and low risk factors (hypercholesterolemia). Some risk factors are modifiable, like hypertension, whereas others are not.[4]
Screening
A resting ankle brachial index is the screening study of choice in a patient who has suspected lower extremity peripheral arterial disease. The ankle brachial index is defined as the ratio of the ankle blood pressure divided by the highest brachial blood pressure. An ankle branchial index should be obtained if a patient has one or more of the following characteristics: 1) exertional claudication; 2) the presence of nonhealing wounds; 3) age over 50 with a history of smoking or diabetes or 4) age over 65.
Prognosis
Most patients with peripheral arterial disease (PAD) have a benign course, with the majority of patients being asymptomatic. However, clinical manifestations may progress rapidly in smokers, patients with diabetes and patients with chronic renal failure. Peripheral arterial disease is associated with complications that include ischemic leg pain at rest, ulceration and gangrene. In addition, the mortality rate among patients with peripheral arterial disease is higher than that of the general population. Mortality is mainly due to concomitant coronary artery disease and cerebrovascular disease rather than to the peripheral arterial disease itself[7].
Diagnosis
History and Symptoms
Patients with peripheral arterial disease can be asymptomatic in 70% of cases, can have symptoms of intermittent claudication or can sometimes have critical symptoms that include ulceration and gangrene. The clinical presentation of peripheral arterial disease depends on the location and severity of stenosis of the vessel. The symptoms range from mild pain on exertion to severe ischemia at rest. The hallmark of peripheral arterial disease is the symptom of claudication which is an intermittent cramping pain in the leg that is induced by exercise and relieved by rest.
Physical Examination
Laboratory Findings
CT
When symptoms suggestive of peripheral artery disease are present, clinical evaluation along with non invasive testing are enough to establish the diagnosis. CT angiography, one of invasive diagnostic studies, provides anatomic evaluation of the vessels. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the structural details of the vessels.[8]
MRI
When symptoms suggestive of peripheral artery disease are present, clinical evaluation along with non invasive testing are enough to establish the diagnosis. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the anatomy of the vessels. The invasive diagnostic studies, which are basically anatomic studies that rely on imaging, include the following: conventional angiography, CT angiography, MRA, duplex ultrasound[9].
Other Diagnostic Findings
When symptoms suggestive of peripheral artery disease are present, clinical evaluation along with non invasive testing are enough to establish the diagnosis. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the anatomy of the vessels.The non invasive modality mostly used in the diagnosis of peripheral artery disease is the measurement of the ankle brachial index (ABI) at rest and after exercise testing.
The non invasive diagnostic studies are functional studies and they include the following: measurement of ABI at rest and after exercise, pulse volume recording,transcutaneous oxygen pressure measurement and laser doppler fluximetry.
The invasive diagnostic studies are anatomic studies and they include the following: conventional angiography, CT angiography, MRA and duplex ultrasound.[7]
Treatment
Medical Therapy
Despite its prevalence and cardiovascular risk implications, only 25 percent of patients with peripheral arterial disease are actively being treated[10]. The medical therapy aims to reduce the atherosclerotic risk factors which include diabetes mellitus, hypertension, dyslipidemia and smoking, to improve walking time and distance and to prevent the progression of the peripheral arterial disease and the need of invasive surgical procedures. All patients with peripheral arterial disease should be prescribed an antiplatelet agent[4].
Surgery
Guidelines for Management
2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)- Recommendations for Management of Femoral Artery Aneurysms (DO NOT EDIT)[11]
| Class I |
| "1. Patients with a palpable popliteal mass should undergo an ultrasound examination to exclude popliteal aneurysm. (Level of Evidence: B)" |
| "2. Patients with popliteal aneurysms 2.0 cm in diameter or larger should undergo repair to reduce the risk of thromboembolic complications and limb loss. (Level of Evidence: B)" |
| "3. Patients with anastomotic pseudoaneurysms or symptomatic femoral artery aneurysms should undergo repair. (Level of Evidence: A)" |
| Class IIa |
| "1. Surveillance by annual ultrasound imaging is suggested for patients with asymptomatic femoral artery true aneurysms smaller than 3.0 cm in diameter.(Level of Evidence: C)" |
| "2. In patients with acute ischemia and popliteal artery aneurysms and absent runoff, catheter-directed thrombolysis or mechanical thrombectomy (or both) is suggested to restore distal runoff and resolve emboli. (Level of Evidence: B)" |
| "3. In patients with asymptomatic enlargement of the popliteal arteries twice the normal diameter for age and gender, annual ultrasound monitoring is reasonable. (Level of Evidence: C)" |
| "4. In patients with femoral or popliteal artery aneurysms, administration of antiplatelet medication may be beneficial. (Level of Evidence: C)" |
2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)- Recommendations for Management of Catheter-Related Femoral Artery Pseudoaneurysms (DO NOT EDIT)[11]
| Class I |
| "1. Patients with suspected femoral pseudoaneurysms should be evaluated by duplex ultrasonography. (Level of Evidence: B)" |
| "2. Initial treatment with ultrasound-guided compression or thrombin injection is recommended in patients with large and/or symptomatic femoral artery pseudoaneurysms. (Level of Evidence: B)" |
| Class IIa |
| "1. Surgical repair is reasonable in patients with femoral artery pseudoaneurysms 2.0 cm in diameter or larger that persist or recur after ultrasound-guided compression or thrombin injection. (Level of Evidence: B)" |
| "2. Re-evaluation by ultrasound 1 month after the original injury can be useful in patients with asymptomatic femoral artery pseudoaneurysms smaller than 2.0 cm in diameter. (Level of Evidence: B)" |
References
- ↑ Fontaine R, Kim M, Kieny R (1954). "Die chirugische Behandlung der peripheren Durchblutungsstörungen. (Surgical treatment of peripheral circulation disorders)". Helvetica Chirurgica Acta (in German). 21 (5/6): 499&ndash, 533. PMID 14366554.
- ↑ Christopher W. Advances in interventional cardiology. Circulation November 6, 2007 vol. 116 no. 19 2203-2215
- ↑ Fontaine R, Kim M, Kieny R (1954). "Die chirugische Behandlung der peripheren Durchblutungsstörungen. (Surgical treatment of peripheral circulation disorders)". Helvetica Chirurgica Acta (in German). 21 (5/6): 499&ndash, 533. PMID 14366554.
- ↑ 4.0 4.1 4.2 Spittel P. Chapter 44. Peripheral vascular Disease. In Murphy J, Lloyd M,Mayo Clinic Cardiology Concise Textbook. Fourth edition.Mayo clinic scientific press.2013
- ↑
- ↑ Shammas NW (2007). "Epidemiology, classification, and modifiable risk factors of peripheral arterial disease". Vascular Health and Risk Management. 3 (2): 229–34. PMC 1994028. PMID 17580733.
- ↑ 7.0 7.1 Wennberg PW, Rooke TW. Chapter 109. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst's The Heart. 13th ed. New York: McGraw-Hill; 2011.
- ↑ Wennberg PW, Rooke TW. Chapter 109. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst's The Heart. 13th ed. New York: McGraw-Hill; 2011.
- ↑ Wennberg PW, Rooke TW. Chapter 109. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst's The Heart. 13th ed. New York: McGraw-Hill; 2011.
- ↑ A. Richey Sharrett, MD, DRPH (2007). "Peripheral arterial disease prevalence". Peripheral Arterial Disease. Retrieved 2007-12-03. Unknown parameter
|publsiher=ignored (|publisher=suggested) (help); Unknown parameter|month=ignored (help) - ↑ 11.0 11.1 Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B (2006). "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. 113 (11): e463–654. doi:10.1161/CIRCULATIONAHA.106.174526. PMID 16549646. Retrieved 2012-10-09. Unknown parameter
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