Updated: 7/14/2021

Arterial Insufficiency

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Questions
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Evidence
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Topic
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
  • 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
    • most commonly caused by atherosclerosis
      • peripheral artery disease
  • Pathogenesis
    • atherosclerotic disease can lead to progressive obstruction of the peripheral arteries
      • lack of blood flow ischemia, leading to pain
  • Associated conditions
    • Leriche syndrome
      • aortoiliac occlusion presents with
        • bilateral lower limb claudication
        • impotence
        • lower extremity muscular atrophy
    • coronary 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

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Questions (9)
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(M2.CV.17.4690) A 65-year-old man with a past medical history of anterior myocardial infarction, peripheral arterial disease, and known patent foramen ovale presents to the emergency department after being found down from a fall on the sidewalk in the middle of winter. He states that his right leg feels numb and painful at the same time. He insists that he did not slip on ice or snow, yet fell suddenly. He is taking aspirin, simvastatin, and cilostazol. Vital signs show T 98.0 F, BP 100/60, HR 100, RR 18. His pulse is irregularly irregular. His right leg appears pale with no dorsalis pedis and posterior tibial pulses compared to 2+ pulses on the left. He cannot discern soft or sharp touch in his right leg. Which intervention will most likely improve the viability of this patient's right leg?

QID: 107590
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Percutaneous transluminal stent implantation

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Rivaroxaban

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Warfarin

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4

Catheter-based thrombectomy / thrombolysis

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(0/0)

5

Heparin

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(0/0)

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(M2.CV.13.70) A 63-year-old man presents to the clinic complaining of burning bilateral leg pain which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. His past medical and surgical history are significant for hypertension, hyperlipidemia, diabetes, and a 40-pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 167/108 mm Hg, pulse is 88/min, respirations are 13/min, and oxygen saturation is 95% on room air. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally. Which of the following is the best initial treatment for this patient's symptoms?

QID: 100586
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Balloon angioplasty with stenting

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(72/86)

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Exercise and smoking cessation

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(6/86)

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Femoral-popliteal bypass

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(1/86)

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Lisinopril and atorvastatin

1%

(1/86)

5

Lovenox and atorvastatin

6%

(5/86)

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Evidence (4)
EXPERT COMMENTS (20)
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