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Updated: Dec 17 2021

Arterial Insufficiency

Images arteriosclerosis.jpg
  • 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
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