Snapshot A 50-year-old man presents to his primary care physician for pain in his lower legs with long walks. He reports walking 10 blocks before feeling the pain and that it resolves with rest. His medical history includes hyperlipidemia, hypertension, and diabetes. His blood pressure is 145/80 mmHg, pulse is 90/min, and respirations are 18/min. On physical exam, his distal pulses are faint. His bilateral calves are dry and hairless with no peripheral ulcers. His skin is cool to the touch, especially in his feet. An ankle-brachial index is performed. Introduction Clinical definition ischemia resulting from obstruction of the peripheral arteries Associated conditions Leriche syndrome aortoiliac occlusion presents with bilateral lower limb claudication impotence lower extremity muscular atrophy coronary artery disease Epidemiology Demographics affects older patients male > female Location most commonly affects the popliteal artery Risk factors smoking hypertension hyperlipidemia family history renal disease diabetes Etiology Pathogenesis atherosclerotic disease can lead to progressive obstruction of the peripheral arteries lack of blood flow ischemia, leading to pain Most commonly caused by atherosclerosis peripheral artery disease Presentation Symptoms progressive severity asymptomatic intermittent claudication pain at rest nonhealing wounds ulceration gangrene and threatened limb calves are the most commonly affected area Physical exam may have ischemic ulcers often starts as a traumatic wound that fails to heal often involves the foot may have skin changes pale or red dry, shiny, and hairless in severe disease cool to touch Imaging Doppler ultrasound indication further evaluation of extent of vascular disease findings low-velocity flow through the artery 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 Arterial aneurysm distinguishing factors normal ankle-brachial index aneurysm seen on imaging Embolism (pain, pallor, paresthesias, poikilothermia, paralysis, pulselessness) distinguishing factor acute progression of symptoms treatment heparin vascular surgery 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 regular exercise regimen indication all patients Medical anti-platelet agents indication all patients drugs aspirin clopidogrel Operative revascularization indication claudication refractory to medical therapy modalities bypass surgery angioplasty and stenting amputation indication most severe cases in which limb is not salveagable Complications Osteomyelitis Loss of limb Cardiovascular event