Peripheral arterial disease differential diagnosis: Difference between revisions
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== Differentiating Peripheral Arterial Disease from Other Diseases == | == Differentiating Peripheral Arterial Disease from Other Diseases == | ||
* Patients with peripheral arterial disease can be asymptomatic, can have symptoms of intermittent claudication or can sometimes have critical symptoms that include ulceration and gangrene. This diversity of presentation, as well as the spectrum of severity of symptoms with which patients present, lead to the presence of a long list of differential diagnosis. The diagnosis requires a good clinical history and physical exam. | * Patients with peripheral arterial disease can be asymptomatic, can have symptoms of intermittent [[claudication]] or can sometimes have critical symptoms that include ulceration and [[gangrene]]. This diversity of presentation, as well as the spectrum of severity of symptoms with which patients present, lead to the presence of a long list of differential diagnosis. The diagnosis requires a good clinical history and physical exam. | ||
*The typical presentation | *The typical presentation of [[claudication]] is: | ||
**Cramp- like pain is always induced by exercise at a constant distance that the patient walks. | **Cramp- like pain is always induced by exercise at a constant distance that the patient walks. | ||
**The pain might be unilateral or bilateral. | **The pain might be unilateral or bilateral. | ||
Revision as of 22:31, 30 October 2012
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Peripheral arterial disease Microchapters |
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Differentiating Peripheral arterial disease from other Diseases |
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Diagnosis |
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Case Studies |
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AHA/ACC Guidelines on Management of Lower Extremity PAD |
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Guidelines for Structured Exercise Therapy for Lower Extremity PAD |
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Guidelines for Minimizing Tissue Loss in Lower Extremity PAD |
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Guidelines for Revascularization of Claudication in Lower Extremity PAD |
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Guidelines for Management of Acute Limb Ischemial in Lower Extremity PAD |
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Guidelines for Longitudinal Follow-up for Lower Extremity PAD |
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Editors-in-Chief: C. Michael Gibson, M.D., Beth Israel Deaconess Medical Center, Boston, MA; Robert G. Schwartz, M.D. [1], Piedmont Physical Medicine and Rehabilitation, P.A.; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Patients with peripheral arterial disease can be asymptomatic, can have symptoms of intermittent claudication or can sometimes have critical symptoms that include ulceration and gangrene. This diversity of presentation, as well as the spectrum of severity of symptoms with which patients present, lead to the presence of a long list of differential diagnosis. In fact, the false-positive diagnosis rates of peripheral arterial disease are estimated to be around 44% and the false-negative rates are estimated to be around 19%.
The most important differential diagnosis of claudication caused by the peripheral arterial disease is pseudoclaudication caused by lumbar spinal stenosis[1]. Intermittent claudication (IC) must be differentiated from lower extremity pain caused by non-vascular etiologies that may include neurologic, musculoskeletal and venous pathologies.
Differentiating Peripheral Arterial Disease from Other Diseases
- Patients with peripheral arterial disease can be asymptomatic, can have symptoms of intermittent claudication or can sometimes have critical symptoms that include ulceration and gangrene. This diversity of presentation, as well as the spectrum of severity of symptoms with which patients present, lead to the presence of a long list of differential diagnosis. The diagnosis requires a good clinical history and physical exam.
- The typical presentation of claudication is:
- Cramp- like pain is always induced by exercise at a constant distance that the patient walks.
- The pain might be unilateral or bilateral.
- The pain is relievd by rest.
- Most importantly, claudication caused by the peripheral arterial disease must be differentiated from the pseudoclaudication caused by lumbar spinal stenosis[1].
Nonatherosclerotic Conditions that Mimic Intermittent Claudication:
Lumbar Spinal Stenosis
- It is generally attributable to nerve root compression by herniated disks or osteophytes and typically follows the dermatome of the affected root.
- It might result from spinal cord compression from narrowing secondary to lumbar spine osteoarthritis.
Typical presentation
- Pain usually begins immediately upon walking and may be felt in the calf or lower leg.
- Pain is not quickly relieved by rest and may even be present at rest.
- A sensation of pain running down the back of the leg as well as a history of back problems may be present.
- In patients with cauda equina syndrome, upright positioning aggravates the narrowing of the spinal canal, therefore causing symptoms.
- Upright standing may produce pain, weakness or discomfort in the hips, thighs and buttocks, and sometimes a sensation of numbness and paresthesias, although symptoms are usually associated with walking.
- Symptoms are alleviated by sitting or flexing the lumbar spine forward as opposed to standing, which alleviates pain caused by IC.
Venous Claudication
- Venous claudication occurs in patients with chronic venous insufficiency and those who develop post-thrombotic syndrome after deep venous thrombosis.
- Baseline venous hypertension in the obstructed veins worsens with exercise.
Typical presentation
- Venous claudication produces a tight bursting pressure in the limb following exercise, usually worse in the thigh and uncommonly in the calf.
- It is usually associated with venous edema in the leg.
- Venous claudication tends to improve with cessation of exercise but total resolution takes much longer than the resolution of intermittent claudication (IC).
- Leg elevation relieves the symptoms.
Chronic compartment syndrome
- Chronic compartment syndrome is an uncommon cause of exercise-induced leg pain.
- It results from thickened fascia, muscular hypertrophy or when external pressure is applied to the leg.
- It tends to occur in young athletes who develop increased pressure within a fixed compartment which compromises the perfusion and the function of the tissues within that space.
- Intracompartmental pressure testing before and after exercise is the diagnostic test of choice.
Typical presentation
- Chronic compartment syndrome presents as tight bursting pressure in the calf or foot following participation in endurance sports or other robust exercise.
- Pain subsides slowly with rest.
Hip and knee osteoarthritis
Typical presentation
- Osteoarthritis in joints is typically worse in the morning or at the initiation of movement
- Degree of pain varies day to day, does not cease upon stopping exercise or standing
- Pain improves after sitting, lying down, or leaning against an object to alleviate weight-bearing on the joint.
- Pain may be affected by weather changes, and may be present at rest
Differential Diagnosis
In alphabetical order[2]
- Arteritis (Takayasu, giant cell)
- Aortic coarctation
- Aortic dissection
- Atherosclerosis obliterans
- Baker cyst
- Chronic compartment syndrome
- Cystic adventitial disease
- Deconditioning
- Degenerative joint disease (hip, back, knee)
- Embolic disease
- Fibromuscular dysplasia
- Myopathy
- Popliteal artery entrapment syndrome
- Retroperitoneal fibrosis
- Spinal stenosis
- Thromboangiitis obliterans
- Venous claudication
References
- ↑ 1.0 1.1 Spittel P. Chapter 44. Peripheral vascular Disease. In Murphy J, Lloyd M,Mayo Clinic Cardiology Concise Textbook. Fourth edition.Mayo clinic scientific press.2013
- ↑ Wennberg PW, Rooke TW. Chapter 109. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst's The Heart. 13th ed. New York: McGraw-Hill; 2011.