LowerLower ExtremityExtremity VascularVascular DiseaseDisease LowerLower ExtremityExtremity VascularVascular DiseaseDisease PoplitealPopliteal arteryartery FibrodysplasiaFibrodysplasia entrapmententrapment PseudoxanthomaPseudoxanthoma MucinousMucinous cysticcystic elasticumelasticum degenerationdegeneration PersistentPersistent sciaticsciatic arteryartery Buerger'sBuerger's diseasedisease IliacIliac arteryartery syndromesyndrome ofof AbdominalAbdominal aorticaortic cyclistcyclist coarctationcoarctation PrimaryPrimary arterialarterial tumorstumors EmboliEmboli AtherosclerosisAtherosclerosis LowerLower ExtremityExtremity VascularVascular DiseaseDisease ClaudicationClaudication CriticalCritical LimbLimb IschemiaIschemia ClaudicationClaudication ““Doc,Doc, mymy legslegs hurt.hurt.”” ClaudereClaudere -- ““toto limp.limp.”” Transient,Transient, exerciseexercise inducedinduced ischemicischemic myalgiamyalgia TheThe localitylocality ofof painpain usuallyusually correlatescorrelates withwith thethe locationlocation ofof thethe occlusion.occlusion. IntermittentIntermittent ClaudicationClaudication 13%13% ofof patientspatients overover 5050 havehave abnormalabnormal ABIABI - Partner’s Program. Vasc Med 2001 ABIABI rangingranging fromfrom 0.50.5 toto 0.950.95 RelativelyRelatively fewfew patientspatients whowho presentpresent withwith claudicationclaudication everever requirerequire revascularizationrevascularization toto preventprevent limblimb loss.loss. AmputationAmputation raterate ofof 1%1% toto 7%7% atat 55 toto 1010 yearsyears RevascularizationsRevascularizations totaledtotaled lessless thanthan 20%20% atat 1010 years.years. IntermittentIntermittent ClaudicationClaudication InterventionIntervention controversialcontroversial 233233 consecutiveconsecutive patientspatients (90%(90% endovascular)endovascular) MeanMean followfollow--upup ofof almostalmost 77 yearsyears PrimaryPrimary patencypatency atat 55 yearsyears waswas 27%27% 50%50% secondarysecondary interventionsinterventions 12%12% ofof limbslimbs ultimatelyultimately developeddeveloped CLICLI Jamsen et al. J Vasc Surg 2003 ProsPros andand ConsCons BenignBenign naturalnatural historyhistory DiminishedDiminished qualityquality ofof GraftGraft failurefailure andand lifelife potentialpotential limblimb threatthreat InabilityInability toto rehabrehab M&MM&M ofof revascularizationrevascularization SmokingSmoking 8%8% ofof patientspatients whowho diddid notnot smokesmoke oror quitquit smokingsmoking withinwithin 11 yearyear ofof diagnosisdiagnosis ofof PADPAD developeddeveloped restrest painpain 21%21% whowho smokedsmoked oror quitquit moremore thanthan 11 yearyear afterafter diagnosisdiagnosis DiabetesDiabetes alsoalso hashas beenbeen associatedassociated withwith increasedincreased developmentdevelopment ofof CLICLI CriticalCritical LimbLimb IschemiaIschemia InadequateInadequate arterialarterial bloodblood flowflow toto accommodateaccommodate thethe metabolicmetabolic needsneeds ofof restingresting tissue.tissue. RestRest painpain oror pedalpedal necrosisnecrosis RiskRisk factorsfactors includeinclude age,age, smoking,smoking, andand diabetesdiabetes CriticalCritical LimbLimb IschemiaIschemia AnkleAnkle pressurepressure lessless thanthan 5050 toto 7070 mmmm HgHg ToeToe pressurepressure lessless thanthan 3030 toto 5050 mmmm HgHg TranscutaneousTranscutaneous partialpartial pressurepressure ofof oxygenoxygen atat thethe footfoot lessless thanthan 3030 toto 5050 mmmm HgHg RestRest painpain BurningBurning dysesthesiadysesthesia ofof thethe foot.foot. AggravatedAggravated byby elevationelevation andand relievedrelieved withwith dependencydependency IncreaseIncrease inin arterialarterial pressurepressure fromfrom gravitygravity NonfunctioningNonfunctioning venoarteriolarvenoarteriolar reflexreflex TissueTissue LossLoss IschemicIschemic ulcerationsulcerations oror gangrenegangrene SpontaneousSpontaneous AfterAfter minorminor traumatrauma oror surgicalsurgical incisionsincisions CriticalCritical LimbLimb IschemiaIschemia EstimatedEstimated 500,000500,000 toto 11 millionmillion newnew casescases perper yearyear CLICLI progressesprogresses directlydirectly fromfrom FontaineFontaine II toto stagestage IIIIII oror IVIV 50%50% ofof patientspatients werewere asymptomaticasymptomatic 66 monthsmonths beforebefore majormajor amputationamputation forfor CLICLI - Dormandy. Br J Surg 1994 CoCo--morbiditiesmorbidities maskmask symptomssymptoms ofof claudicationclaudication.. CriticalCritical LimbLimb IschemiaIschemia Major risk factors - age, smoking, and diabetes. The incidence of major amputation increases with age. Smoking:PAD > Smoking: CAD Major amputation is 10 times more frequent in diabetic patients Diabetic smokers need amputation earlier in life than nondiabetic smokers EvaluationEvaluation RelevantRelevant HistoryHistory ElapsedElapsed timetime afterafter exerciseexercise isis stoppedstopped beforebefore thethe painpain isis relievedrelieved TypeType ofof restrest oror positionposition ofof patientpatient (standing(standing atat rest,rest, sitting,sitting, lying)lying) necessarynecessary toto relieverelieve thethe painpain WhetherWhether thethe painpain returnsreturns afterafter thethe samesame timetime andand distancedistance ifif exerciseexercise isis thenthen resumedresumed TASC Working Group: Management of peripheral arterial disease. J Vasc Surg 31(Pt 2):S56, 2000 RelevantRelevant HistoryHistory LocationLocation ofof thethe painpain oror discomfortdiscomfort DurationDuration ofof thethe symptomsymptom WhetherWhether itit worsensworsens oror improvesimproves withwith timetime andand whetherwhether conservativeconservative therapytherapy hashas hadhad anan effecteffect DistanceDistance thethe patientpatient cancan nownow walkwalk beforebefore (1)(1) experiencingexperiencing thethe discomfortdiscomfort andand (2)(2) beingbeing forcedforced toto stopstop TASC Working Group: Management of peripheral arterial disease. J Vasc Surg 31(Pt 2):S56, 2000 SymptomSymptom PatternPattern ClaudicationClaudication generallygenerally resultsresults fromfrom aa singlesingle levellevel ofof arterialarterial occlusionocclusion ThreeThree majormajor patternspatterns ofof arterialarterial obstructionobstruction 1)1) InflowInflow obstructionobstruction 2)2) OutflowOutflow obstructionobstruction 3)3) CombinationCombination LocationLocation ofof symptomssymptoms correlatescorrelates withwith levellevel ofof obstruction.obstruction. InflowInflow ObstructionObstruction AorticAortic andand IliacIliac stenosisstenosis oror occlusion.occlusion. ButtockButtock andand thighthigh claudicationclaudication VasculogenicVasculogenic erectileerectile dysfunctiondysfunction MayMay exhibitexhibit classicclassic symptomssymptoms ofof intermittentintermittent calfcalf claudicationclaudication resultingresulting fromfrom inadequateinadequate perfusionperfusion ofof thethe entireentire legleg OutflowOutflow ObstructionObstruction SuperficialSuperficial femoralfemoral arteryartery stenosisstenosis oror occlusionocclusion isis thethe mostmost commoncommon lesionlesion associatedassociated withwith intermittentintermittent claudicationclaudication NoNo specificspecific thighthigh oror footfoot symptoms.symptoms. PoplitealPopliteal andand tibialtibial arterialarterial occlusionsocclusions areare associatedassociated moremore commonlycommonly withwith limblimb--threateningthreatening ischemiaischemia owingowing toto thethe paucitypaucity ofof collateralcollateral vascularvascular pathwayspathways beyondbeyond thesethese lesions.lesions. MultilevelMultilevel ObstructionObstruction BroadBroad symptomssymptoms ofof intermittentintermittent claudicationclaudication affectingaffecting thethe buttock,buttock, hip,hip, thigh,thigh, andand calf.calf. CLICLI requiresrequires atat leastleast twotwo oror moremore levelslevels PatternPattern ofof occlusionocclusion isis usuallyusually inin adjacentadjacent vascularvascular beds,beds, butbut maymay bebe inin parallelparallel bedsbeds LimitLimit flowflow throughthrough thethe collateralcollateral bedsbeds RiskRisk FactorFactor AssesmentAssesment HTNHTN –– riskrisk ofof ICIC 2.5x2.5x inin men,men, 3.9x3.9x inin womenwomen DiabetesDiabetes SmokingSmoking -- severityseverity ofof arterialarterial occlusiveocclusive diseasedisease proportionalproportional toto thethe numbernumber ofof cigarettescigarettes smokedsmoked EachEach additionaladditional riskrisk factorfactor independentlyindependently increasesincreases thethe riskrisk ofof developingdeveloping symptomaticsymptomatic PADPAD RiskRisk FactorsFactors Downloaded from: Vascular Surgery 6/e (on 20 April 2006 01:40 AM) © 2 005 El se vie r PhysicalPhysical ExamExam LossLoss ofof hairhair Thin,Thin, drydry skinskin ThickenedThickened nailsnails UlcersUlcers EdemaEdema GangreneGangrene PhysicalPhysical ExamExam PulsesPulses BruitsBruits PulsatilePulsatile massesmasses HematologicHematologic EvaluationEvaluation CompleteComplete bloodblood count,count, includingincluding whitewhite bloodblood cellscells andand plateletsplatelets FastingFasting bloodblood glucoseglucose SerumSerum creatininecreatinine FastingFasting lipidlipid profileprofile FibrinogenFibrinogen levellevel UrinalysisUrinalysis TASC Working Group: Management of peripheral arterial disease. J Vasc Surg 31(Pt 2):S59, 2000. HypercoaguableHypercoaguable StateState Thrombin/Thrombin/prothrombinprothrombin timetime ActivatedActivated partialpartial thromboplastinthromboplastin timetime ProteinProtein