Snapshot A 65-year-old man presents with buttock and hip pain, particularly during exercise. He has no pain at rest. He also reports having chronic erectile dysfunction. His past medical history includes hyperlipidemia and coronary artery disease. He has a 20-pack-year smoking history. On physical exam, there are bilateral diminished +1 femoral pulses. His ankle-brachial index is 0.6 on the left and 0.7 on the right. Introduction Clinical definition a syndrome resulting from chronic peripheral artery disease of the aortic bifurcation, characterized by in claudication of the buttocks, absent femoral pulses, and sexual impotence Associated conditions coronary artery disease Epidemiology Demographics affects older patients men > women Risk factors smoking diabetes renal disease hyperlipidemia Etiology Atherosclerosis Pathogenesis atherosclerotic disease can lead to obstruction of the arteries aortoiliac obstruction leads to arterial insufficiency in the lower extremities, resulting in claudication Presentation Symptoms buttock and hip claudication exertional pain in early disease rest pain in more severe disease erectile dysfunction in men Physical exam absent or diminished femoral pulses can be unilateral or bilateral may have ischemic ulcers Imaging Doppler ultrasonography indication the diagnostic gold standard for arterial occlusion findings low-velocity flow through the artery Computed tomography (CT) indications confirms diagnosis pre-operative evaluation findings occlusion of the arteries collateral circulation Studies Ankle-brachial index less than or equal to 0.9 is diagnostic for peripheral artery disease best initial test Making the diagnosis based on clinical presentation Differential Sciatica distinguishing factor normal ankle-brachial index pain is not necessarily correlated with exertion Treatment Management approach initial management includes anti-platelet therapy as well as optimizing treatment for underlying conditions, such as hypertension and hyperlipidemia Conservative cessation of smoking indication all patients exercise regimen indications all patients as this encourage the development of collateral circulation Medical antiplatelet agents indication all patients drugs aspirin clopidogrel cilostazol dipyramidole Operative aortoiliac angioplasty or stenting indication significant aortoiliac disease refractory to medical management aortoiliac bypass surgery indication contraindication to angioplasty amputation indication most severe cases in which limb is not salvageable Complications Acute ischemia immediately threatened limb managed with intravenous heparin and embolectomy Distal limb amputation