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{{Peripheral arterial disease}}
{{Peripheral arterial disease}}
 
{{CMG}} {{AOEIC}} [[User:Maheep Sangha|Maheep Singh Sangha, M.B.B.S.]]; {{CZ}}; [[User:Rim Halaby|Rim Halaby]]
'''Editors-in-Chief: [[C. Michael Gibson]], M.D., Beth Israel Deaconess Medical Center, Boston, MA; [[User:Bobby Schwartz|Robert G. Schwartz, M.D.]] [mailto:RGSHEAL@aol.com], [http://www.piedmontpmr.com Piedmont Physical Medicine and Rehabilitation, P.A.]; '''Associate Editor-In-Chief:''' {{CZ}}; [[User:Rim Halaby|Rim Halaby]]


==Overview==
==Overview==
 
The term peripheral arterial disease refers to a group of disorders characterized by progressive stenosis and altered structure and function of non coronary arteries that supply the [[brain]], visceral organs and limbs. [[Peripheral arterial disease]] (PAD) are most commonly of atherosclerotic type and hence this term is generally used to refer to the atherosclerotic peripheral arterial lesions in lower extremities. However, PAD also includes aneurysmal and thromboembolic lesions of [[arteries]].
In contrast, peripheral vascular disease (PVD) refers to all vascular disorders affecting not only arteries but also veins and lymphatics. Peripheral arterial occlusive diseases (PAOD) are part of the peripheral arterial diseases but they exclude aneurysmal disorders, and hence only include atherosclerotic and and thromboembolic arterial lesions. PAD is a systemic disease most commonly caused by [[atherosclerosis]]. It is usually present with other [[atherosclerosis]] related diseases like [[coronary artery disease]] and [[cerebrovascular disease]]. PAD is associated with decrease quality of life and increase risk of mortality.


==Classification==
==Classification==
Peripheral artery occlusive disease is commonly divided in the Fontaine stages, introduced by Dr René Fontaine in 1954. The classification is as follows: class I is mild [[pain]] on walking ("[[claudication]]"), class II is  severe pain on [[walking]] relatively shorter distances ([[intermittent claudication]]) , class III is pain while resting and class IV is [[biological tissue|tissue]] loss ([[gangrene]]).<ref>{{cite journal | author=Fontaine R, Kim M, Kieny R | title=Die chirugische Behandlung der peripheren Durchblutungsstörungen. (Surgical treatment of peripheral circulation disorders) | journal=Helvetica Chirurgica Acta | year=1954 | volume=21 | issue=5/6 | pages=499&ndash;533 | language=German | pmid=14366554}}</ref>
[[Peripheral arterial disease]] is commonly divided in the Fontaine stages, introduced by Dr. René Fontaine in 1954. A more recent classification by Rutherford consists of three grades and six categories. In addition, the American College of Cardiology/American Heart Assocommon iliac arterytion (ACC/AHA) uses a symptoms-based classification (absence of symptoms, [[claudication]], critical limb ischemia and acute limb ischemia) in their guidelines. TASC (Trans Atlantic Inter-Society Consensus) morphological consensus is used to guide the choice between endovascular and surgical revarscularization in the management of patients with [[peripheral artery disease]].


==Pathophysiology==
==Pathophysiology==
 
[[Peripheral arterial disease]] is characterized by a narrowing of the peripheral blood vessels leading to decreased blood flow to the limbs. The most common underlying cause of PAD is atherosclerosis. As the atherosclerosis progresses with time beyond the ability of the vessels to compensate for it, mainly upon increased blood demand in exercise, symptoms of [[claudication]] start.


==Causes==
==Causes==
''Causes in alphabetical order:''
[[Peripheral arterial disease]] (PAD) is most commonly a manifestation of [[atherosclerosis]] resulting from vascular inflammation. Other uncommon causes should be suspected when the PAD occurs occurs at a young age and in the context of a positive history. Uncommon causes include degenerative diseases ([[marfan's syndrome]] and [[Ehlers-Danlos syndrome|ehlers-danlos syndrome]]), dysplastic disorders ([[fibromuscular dysplasia]]), inflammatory diseases (arteritis) and hypercoagulable states.
* [[Atherosclerosis]]
* Degenerative diseases: [[Marfan's Syndrome]] and [[Ehlers-Danlos syndrome]], [[Neurofibromatosis]], arteriomegaly
* Dysplastic disorders: [[Fibromuscular dysplasia]]
* In situ thrombosis
* Thromboembolism
* Vascular inflamation : [[Takayasu's Arteritis]]


==Differentiation of Peripheral Artery Disease from other Disorders==
==Differentiating Peripheral Artery Disease from other Disorders==
The most important disorder that peripheral arterial disease and the associated symptom of '''claudication''' must be distinguished from is '''pseudoclaudication''' caused by [[lumbar spinal stenosis]]<ref name="Spittel">Spittel P. Chapter 44. Peripheral vascular Disease. In Murphy J, Lloyd M,Mayo Clinic Cardiology Concise Textbook. Fourth edition.Mayo clinic scientific press.2013</ref>. [[Intermittent claudication]] (IC) must also be differentiated from lower extremity pain caused by non-vascular etiologies that may include neurologic, musculoskeletal and venous pathologies.  Given the diversity in and the severity of symptoms among patients with peripheral arterial disease, there is a long list of disorders that peripheral arterial disease must be distinguished from.  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 disorder that peripheral arterial disease and the associated symptom of claudication must be distinguished from is pseudoclaudication caused by [[lumbar spinal stenosis]]. [[Intermittent claudication]] (IC) must also be differentiated from lower extremity pain caused by non-vascular etiologies that may include neurologic, musculoskeletal and venous pathologies.  Given the diversity in and the severity of symptoms among patients with peripheral arterial disease, there is a long list of disorders that peripheral arterial disease must be distinguished from.  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%.


==Epidemiology and Demographics==
==Epidemiology and Demographics==
The prevalence of peripheral arterial disease varies considerably depending on how PAD is defined, and the age of the population being studied.<ref name="3rx" /> The prevalence of peripheral arterial disease in the general population is 12–14%.  Peripheral arterial disease is even more common among the elderly and affects up to 20% of patients over  the age of 70 years <ref name="pmid17580733">{{cite journal |author=Shammas NW |title=Epidemiology, classification, and modifiable risk factors of peripheral arterial disease |journal=[[Vascular Health and Risk Management]] |volume=3 |issue=2 |pages=229–34 |year=2007 |pmid=17580733 |pmc=1994028 |doi= |url=}}</ref>.   Peripheral vascular disease affects 1 in 3 diabetics over the age of 50.  Approximately 10 million Americans have peripheral arterial disease.
The prevalence of peripheral arterial disease varies considerably depending on how PAD is defined, and the age of the population being studied. The prevalence of peripheral arterial disease in the general population is 12–14%.  Peripheral arterial disease is even more common among the elderly and affects up to 20% of patients over  the age of 70 years. Peripheral vascular disease affects 1 in 3 diabetics over the age of 50.  Approximately 10 million Americans have peripheral arterial disease.


==Risk Factors==
==Risk Factors==
The risk factors associated with [[peripheral artery disease]] are similar to those associated with [[coronary artery disease]]. They can be classified as traditional and non traditional. Another way to classify the risk factors is depending on their level of risk: high risk factors (tobacco and [[diabetes]]), moderate risk factors ([[hypertension]] and hyperhomocysteinemia) and low risk factors (hypercholesterolemia). Some risk factors are modifiable, like [[hypertension]], whereas others are not.<ref name="Spittel">Spittel P. Chapter 44. Peripheral vascular Disease. In Murphy J, Lloyd M. Mayo Clinic Cardiology Concise Textbook. Fourth edition.Mayo clinic scientific press.2013</ref>
The risk factors associated with [[peripheral artery disease]] are similar to those associated with [[coronary artery disease]]. They can be classified as traditional and non traditional. Another way to classify the risk factors is depending on their level of risk: high risk factors (tobacco and [[diabetes]]), moderate risk factors ([[hypertension]] and hyperhomocysteinemia) and low risk factors (hypercholesterolemia). Some risk factors are modifiable, like [[hypertension]], whereas others are not.


==Screening==
==Screening==
A resting ankle brachial index is the screening study of choice in a patient who has suspected lower extremity peripheral arterial disease.  The ankle brachial index is defined as the ratio of the ankle blood pressure divided by the highest brachial blood pressure.  An ankle branchial index should be obtained if a patient has one or more of the following characteristics: 1) exertional claudication; 2) the presence of nonhealing wounds; 3) age over 50 with a history of smoking or diabetes or 4) age over 65.
A resting ankle brachial index is the screening study of choice in a patient who has suspected lower extremity peripheral arterial disease.  The ankle brachial index is defined as the ratio of the ankle blood pressure divided by the highest brachial blood pressure.  An ankle branchial index should be obtained if a patient has one or more of the following characteristics: 1) exertional claudication; 2) the presence of nonhealing wounds; 3) age over 50 with a history of smoking or diabetes or 4) age over 65.


==Prognosis==
==Natural History, Complications and Prognosis==
Most patients with [[peripheral arterial disease]] (PAD) have a benign course, with the majority of patients being asymptomatic. However, clinical manifestations may progress rapidly in [[smoking|smokers]], patients with [[diabetes]] and patients with [[chronic renal failure]]. [[Peripheral arterial disease]] is associated with complications that include ischemic leg pain at rest, ulceration and [[gangrene]]. In addition, the mortality rate among patients with [[peripheral arterial disease]] is higher than that of the general population. Mortality is mainly due to concomitant [[coronary artery disease]] and [[cerebrovascular disease]] rather than to the [[peripheral arterial disease]] itself<ref name="Wennberg">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.</ref>.
Most patients with [[peripheral arterial disease]] (PAD) have a benign course, with the majority of patients being asymptomatic. However, clinical manifestations may progress rapidly in [[smoking|smokers]], patients with [[diabetes]] and patients with [[chronic renal failure]]. [[Peripheral arterial disease]] is associated with complications that include ischemic leg pain at rest, ulceration and [[gangrene]]. In addition, the mortality rate among patients with [[peripheral arterial disease]] is higher than that of the general population. Mortality is mainly due to concomitant [[coronary artery disease]] and [[cerebrovascular disease]] rather than to the [[peripheral arterial disease]] itself.


==Diagnosis==
==Diagnosis==
==History and Symptoms==
===History and Symptoms===
Patients with [[peripheral arterial disease]] can be asymptomatic in 70% of cases, can have symptoms of [[intermittent claudication]] or can sometimes have critical symptoms that include ulceration and [[gangrene]]. The clinical presentation of peripheral arterial disease depends on the location and severity of stenosis of the vessel. The symptoms range from mild [[pain]] on exertion to severe [[ischemia]] at rest. The hallmark of peripheral arterial disease is the symptom of claudication which is an intermittent cramping pain in the leg that is induced by exercise and relieved by rest.
Patients with [[peripheral arterial disease]] can be asymptomatic in 70% of cases, can have symptoms of [[intermittent claudication]] or can sometimes have critical symptoms that include ulceration and [[gangrene]]. The hallmark of peripheral arterial disease is the symptom of claudication which is an intermittent cramping pain in the leg that is induced by exercise and relieved by rest. The clinical presentation of peripheral arterial disease depends on the location and severity of stenosis of the vessel; in fact, calf cramping in the upper 2/3 of the calf is usually due to superficial femoral disease, while cramping in the lower 1/3 of the calf is due to popliteal disease. Buttock, thigh, calf or foot claudication, can occur either singly or in combination. The most frequently affected artery in intermittent claudication is the [[popliteal artery]]. Leg pain occurs in one leg in 40% of patients and in both legs in 60% of patients. Patients may also experience fatigue or pain in the thighs and buttocks.
 
==Physical Examination==
 
 
==Laboratory Findings==


===Physical Examination===
The patient's lower legs and feet should be examined with shoes and socks off, with attention to pulses, hair loss, skin color, and trophic skin changes. Patients with [[PAD]] might have [[cyanosis]], atrophic changes like loss of hair, shiny skin, decreased temperature, decreased [[pulse]] or redness when limb is returned to a dependent position. The location of the symptoms depends on the nature of the involved arteries.


==CT==
===CT===
When symptoms suggestive of [[peripheral artery disease]] are present, '''clinical evaluation''' along with '''non invasive testing''' are enough to establish the diagnosis. CT [[angiography]], one of '''invasive''' diagnostic studies, provides '''anatomic ''' evaluation of the vessels. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the structural details of the [[vessels]].<ref>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.</ref>
When symptoms suggestive of [[peripheral artery disease]] are present, clinical evaluation along with non invasive testing are enough to establish the diagnosis. CT [[angiography]], one of invasive diagnostic studies, provides anatomic evaluation of the vessels. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the structural details of the [[vessels]].


==MRI==
===MRI===
When symptoms suggestive of [[peripheral artery disease]] are present, '''clinical evaluation''' along with '''non invasive testing''' are enough to establish the diagnosis. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the anatomy of the [[vessels]]. The '''invasive''' diagnostic studies, which are basically '''anatomic studies''' that rely on imaging, include the following: conventional [[angiography]], CT angiography, [[MRA]], duplex [[ultrasound]]<ref>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.</ref>.
When symptoms suggestive of [[peripheral artery disease]] are present, clinical evaluation along with non invasive testing are enough to establish the diagnosis. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the anatomy of the [[vessels]]. The invasive diagnostic studies, which are basically anatomic studies that rely on imaging, include the following: conventional [[angiography]], CT angiography, [[MRA]] and duplex [[ultrasound]].


==Other Diagnostic Findings==
=== Ultrasound ===
When symptoms suggestive of [[peripheral artery disease]] are present, '''clinical evaluation''' along with '''non invasive testing''' are enough to establish the diagnosis. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the anatomy of the [[vessels]].The non invasive modality mostly used in the diagnosis of [[peripheral artery disease]] is the measurement of the [[ankle brachial index]] (ABI) at rest and after exercise testing.
[[Ultrasound]] is somewhat insensitive in making the diagnosis of PVD.


The '''non invasive''' diagnostic studies are '''functional studies''' and they include the following: measurement of [[ABI]] at rest and after exercise, pulse volume recording,transcutaneous oxygen pressure measurement and laser doppler fluximetry.
=== Other Imaging findings ===
When symptoms suggestive of [[peripheral artery disease]] are present, clinical evaluation along with non invasive testing are enough to establish the diagnosis. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the anatomy of the [[vessels]].
The invasive diagnostic studies, which are basically anatomic studies that rely on imaging, include conventional [[angiography]], CT angiography, [[MRA]] and duplex [[ultrasound]].


The '''invasive''' diagnostic studies are '''anatomic studies''' and they include the following: conventional [[angiography]], CT angiography, [[MRA]] and duplex [[ultrasound]].<ref name="Wennberg">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.</ref>
===Other Diagnostic Findings===
When symptoms suggestive of [[peripheral artery disease]] are present, clinical evaluation along with non invasive testing are enough to establish the diagnosis. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the anatomy of the [[vessels]].The non invasive modality mostly used in the diagnosis of [[peripheral artery disease]] is the measurement of the [[ankle brachial index]] (ABI) at rest and after exercise testing. The non invasive diagnostic studies are functional studies and they include the following: measurement of [[ABI]] at rest and after exercise, pulse volume recording, transcutaneous oxygen pressure measurement and laser doppler fluximetry. The invasive diagnostic studies are anatomic studies and they include the following: conventional [[angiography]], CT angiography, [[MRA]] and duplex [[ultrasound]].


==Treatment==
==Treatment==
===Medical Therapy===
===Medical Therapy===
Despite its prevalence and cardiovascular risk implications, only 25 percent of patients with peripheral arterial disease are actively being treated<ref name=health.am>{{cite web | author = A. Richey Sharrett, MD, DRPH  | title =Peripheral arterial disease prevalence| work =Peripheral Arterial Disease | url=http://www.health.am/vein/more/peripheral-arterial-disease-prevalence/ | year = 2007 | month= Sep 21 | publsiher=Armenian Health Network, Health.am | accessdate=2007-12-03}}</ref>. The medical therapy aims to reduce the atherosclerotic risk factors which include [[diabetes|diabetes mellitus]], [[hypertension]], dyslipidemia and smoking, to improve walking time and distance and to prevent the progression of the [[peripheral arterial disease]] and the need of invasive surgical procedures. All patients with [[peripheral arterial disease]] should be prescribed an antiplatelet agent<ref name="Spittel">Spittel P. Chapter 44. Peripheral vascular Disease. In Murphy J, Lloyd M,Mayo Clinic Cardiology Concise Textbook. Fourth edition.Mayo clinic scientific press.2013</ref>.
Despite its prevalence and cardiovascular risk implications, only 25 percent of patients with peripheral arterial disease are actively being treated. The medical therapy aims to reduce the atherosclerotic risk factors which include [[diabetes|diabetes mellitus]], [[hypertension]], dyslipidemia and smoking, to improve walking time and distance and to prevent the progression of the [[peripheral arterial disease]] and the need of invasive surgical procedures. All patients with [[peripheral arterial disease]] should be prescribed an antiplatelet agent.


===Surgery===
===Surgery===
Revascularization, whether endovascular or surgical, is reserved for patients with intermittent [[claudication]] symptoms refractory to medical therapy, critical limb ischemia and acute limb ischemia. The choice between endovascular and surgical intervention is done on case-to-case basis; however, endovascular intervention is usually chosen first and surgery is done when the non surgical intervention fails. In addition, the anatomic characteristics of the PAD lesions guides the management plan. [[Amputation]] might be required in severe cases of critical limb [[ischemia]].


==Guidelines for Management==
===Primary Prevention===
===2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)- Recommendations for Management of Femoral Artery Aneurysms (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>===
As [[atherosclerosis]] is the major cause of [[peripheral artery disease]], its risk factors are the same as those of other atherosclerotic diseases. [[Diabetes|Diabetes mellitus]], [[hypertension]], dyslipidemia and smoking are considered as some of the most important modifiable risk factors. Hence, the primary prevention of PAD can be mainly achieved by smoking cessation as well as by the appropriate control of diabetes, blood pressure and lipid profile.
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]]
 
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Patients with a palpable popliteal mass should undergo an ultrasound examination to exclude popliteal aneurysm. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Patients with popliteal aneurysms 2.0 cm in diameter or larger should undergo repair to reduce the risk of thromboembolic complications and limb loss. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Patients with anastomotic pseudoaneurysms or symptomatic femoral artery aneurysms should undergo repair. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIa]]
 
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''  Surveillance by annual ultrasound imaging is suggested for patients with asymptomatic femoral artery true aneurysms smaller than 3.0 cm in diameter.''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
 
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' In patients with acute ischemia and popliteal artery aneurysms and absent runoff, catheter-directed thrombolysis or mechanical thrombectomy (or both) is suggested to restore distal runoff and resolve emboli. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' In patients with asymptomatic enlargement of the popliteal arteries twice the normal diameter for age and gender, annual ultrasound monitoring is reasonable. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
 
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' In patients with femoral or popliteal artery aneurysms, administration of antiplatelet medication may be beneficial. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
===2005 ACC/AHA Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)- Recommendations for Management of Catheter-Related Femoral Artery Pseudoaneurysms (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]]
 
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Patients with suspected femoral pseudoaneurysms should be evaluated by duplex ultrasonography. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Initial treatment with ultrasound-guided compression or thrombin injection is recommended in patients with large and/or symptomatic femoral artery pseudoaneurysms. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIa]]
 
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''  Surgical repair is reasonable in patients with femoral artery pseudoaneurysms 2.0 cm in diameter or larger that persist or recur after ultrasound-guided compression or thrombin injection. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Re-evaluation by ultrasound 1 month after the original injury can be useful in patients with asymptomatic femoral artery pseudoaneurysms smaller than 2.0 cm in diameter. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
==References==
{{reflist|2}}


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Guidelines for Structured Exercise Therapy for Lower Extremity PAD

Guidelines for Minimizing Tissue Loss in Lower Extremity PAD

Guidelines for Revascularization of Claudication in Lower Extremity PAD

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-In-Chief: Maheep Singh Sangha, M.B.B.S.; Cafer Zorkun, M.D., Ph.D. [2]; Rim Halaby

Overview

The term peripheral arterial disease refers to a group of disorders characterized by progressive stenosis and altered structure and function of non coronary arteries that supply the brain, visceral organs and limbs. Peripheral arterial disease (PAD) are most commonly of atherosclerotic type and hence this term is generally used to refer to the atherosclerotic peripheral arterial lesions in lower extremities. However, PAD also includes aneurysmal and thromboembolic lesions of arteries. In contrast, peripheral vascular disease (PVD) refers to all vascular disorders affecting not only arteries but also veins and lymphatics. Peripheral arterial occlusive diseases (PAOD) are part of the peripheral arterial diseases but they exclude aneurysmal disorders, and hence only include atherosclerotic and and thromboembolic arterial lesions. PAD is a systemic disease most commonly caused by atherosclerosis. It is usually present with other atherosclerosis related diseases like coronary artery disease and cerebrovascular disease. PAD is associated with decrease quality of life and increase risk of mortality.

Classification

Peripheral arterial disease is commonly divided in the Fontaine stages, introduced by Dr. René Fontaine in 1954. A more recent classification by Rutherford consists of three grades and six categories. In addition, the American College of Cardiology/American Heart Assocommon iliac arterytion (ACC/AHA) uses a symptoms-based classification (absence of symptoms, claudication, critical limb ischemia and acute limb ischemia) in their guidelines. TASC (Trans Atlantic Inter-Society Consensus) morphological consensus is used to guide the choice between endovascular and surgical revarscularization in the management of patients with peripheral artery disease.

Pathophysiology

Peripheral arterial disease is characterized by a narrowing of the peripheral blood vessels leading to decreased blood flow to the limbs. The most common underlying cause of PAD is atherosclerosis. As the atherosclerosis progresses with time beyond the ability of the vessels to compensate for it, mainly upon increased blood demand in exercise, symptoms of claudication start.

Causes

Peripheral arterial disease (PAD) is most commonly a manifestation of atherosclerosis resulting from vascular inflammation. Other uncommon causes should be suspected when the PAD occurs occurs at a young age and in the context of a positive history. Uncommon causes include degenerative diseases (marfan's syndrome and ehlers-danlos syndrome), dysplastic disorders (fibromuscular dysplasia), inflammatory diseases (arteritis) and hypercoagulable states.

Differentiating Peripheral Artery Disease from other Disorders

The most important disorder that peripheral arterial disease and the associated symptom of claudication must be distinguished from is pseudoclaudication caused by lumbar spinal stenosis. Intermittent claudication (IC) must also be differentiated from lower extremity pain caused by non-vascular etiologies that may include neurologic, musculoskeletal and venous pathologies. Given the diversity in and the severity of symptoms among patients with peripheral arterial disease, there is a long list of disorders that peripheral arterial disease must be distinguished from. 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%.

Epidemiology and Demographics

The prevalence of peripheral arterial disease varies considerably depending on how PAD is defined, and the age of the population being studied. The prevalence of peripheral arterial disease in the general population is 12–14%. Peripheral arterial disease is even more common among the elderly and affects up to 20% of patients over the age of 70 years. Peripheral vascular disease affects 1 in 3 diabetics over the age of 50. Approximately 10 million Americans have peripheral arterial disease.

Risk Factors

The risk factors associated with peripheral artery disease are similar to those associated with coronary artery disease. They can be classified as traditional and non traditional. Another way to classify the risk factors is depending on their level of risk: high risk factors (tobacco and diabetes), moderate risk factors (hypertension and hyperhomocysteinemia) and low risk factors (hypercholesterolemia). Some risk factors are modifiable, like hypertension, whereas others are not.

Screening

A resting ankle brachial index is the screening study of choice in a patient who has suspected lower extremity peripheral arterial disease. The ankle brachial index is defined as the ratio of the ankle blood pressure divided by the highest brachial blood pressure. An ankle branchial index should be obtained if a patient has one or more of the following characteristics: 1) exertional claudication; 2) the presence of nonhealing wounds; 3) age over 50 with a history of smoking or diabetes or 4) age over 65.

Natural History, Complications and Prognosis

Most patients with peripheral arterial disease (PAD) have a benign course, with the majority of patients being asymptomatic. However, clinical manifestations may progress rapidly in smokers, patients with diabetes and patients with chronic renal failure. Peripheral arterial disease is associated with complications that include ischemic leg pain at rest, ulceration and gangrene. In addition, the mortality rate among patients with peripheral arterial disease is higher than that of the general population. Mortality is mainly due to concomitant coronary artery disease and cerebrovascular disease rather than to the peripheral arterial disease itself.

Diagnosis

History and Symptoms

Patients with peripheral arterial disease can be asymptomatic in 70% of cases, can have symptoms of intermittent claudication or can sometimes have critical symptoms that include ulceration and gangrene. The hallmark of peripheral arterial disease is the symptom of claudication which is an intermittent cramping pain in the leg that is induced by exercise and relieved by rest. The clinical presentation of peripheral arterial disease depends on the location and severity of stenosis of the vessel; in fact, calf cramping in the upper 2/3 of the calf is usually due to superficial femoral disease, while cramping in the lower 1/3 of the calf is due to popliteal disease. Buttock, thigh, calf or foot claudication, can occur either singly or in combination. The most frequently affected artery in intermittent claudication is the popliteal artery. Leg pain occurs in one leg in 40% of patients and in both legs in 60% of patients. Patients may also experience fatigue or pain in the thighs and buttocks.

Physical Examination

The patient's lower legs and feet should be examined with shoes and socks off, with attention to pulses, hair loss, skin color, and trophic skin changes. Patients with PAD might have cyanosis, atrophic changes like loss of hair, shiny skin, decreased temperature, decreased pulse or redness when limb is returned to a dependent position. The location of the symptoms depends on the nature of the involved arteries.

CT

When symptoms suggestive of peripheral artery disease are present, clinical evaluation along with non invasive testing are enough to establish the diagnosis. CT angiography, one of invasive diagnostic studies, provides anatomic evaluation of the vessels. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the structural details of the vessels.

MRI

When symptoms suggestive of peripheral artery disease are present, clinical evaluation along with non invasive testing are enough to establish the diagnosis. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the anatomy of the vessels. The invasive diagnostic studies, which are basically anatomic studies that rely on imaging, include the following: conventional angiography, CT angiography, MRA and duplex ultrasound.

Ultrasound

Ultrasound is somewhat insensitive in making the diagnosis of PVD.

Other Imaging findings

When symptoms suggestive of peripheral artery disease are present, clinical evaluation along with non invasive testing are enough to establish the diagnosis. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the anatomy of the vessels. The invasive diagnostic studies, which are basically anatomic studies that rely on imaging, include conventional angiography, CT angiography, MRA and duplex ultrasound.

Other Diagnostic Findings

When symptoms suggestive of peripheral artery disease are present, clinical evaluation along with non invasive testing are enough to establish the diagnosis. Invasive diagnostic studies are anatomic studies that are not used for diagnosis but rather for preoperative evaluation of the anatomy of the vessels.The non invasive modality mostly used in the diagnosis of peripheral artery disease is the measurement of the ankle brachial index (ABI) at rest and after exercise testing. The non invasive diagnostic studies are functional studies and they include the following: measurement of ABI at rest and after exercise, pulse volume recording, transcutaneous oxygen pressure measurement and laser doppler fluximetry. The invasive diagnostic studies are anatomic studies and they include the following: conventional angiography, CT angiography, MRA and duplex ultrasound.

Treatment

Medical Therapy

Despite its prevalence and cardiovascular risk implications, only 25 percent of patients with peripheral arterial disease are actively being treated. The medical therapy aims to reduce the atherosclerotic risk factors which include diabetes mellitus, hypertension, dyslipidemia and smoking, to improve walking time and distance and to prevent the progression of the peripheral arterial disease and the need of invasive surgical procedures. All patients with peripheral arterial disease should be prescribed an antiplatelet agent.

Surgery

Revascularization, whether endovascular or surgical, is reserved for patients with intermittent claudication symptoms refractory to medical therapy, critical limb ischemia and acute limb ischemia. The choice between endovascular and surgical intervention is done on case-to-case basis; however, endovascular intervention is usually chosen first and surgery is done when the non surgical intervention fails. In addition, the anatomic characteristics of the PAD lesions guides the management plan. Amputation might be required in severe cases of critical limb ischemia.

Primary Prevention

As atherosclerosis is the major cause of peripheral artery disease, its risk factors are the same as those of other atherosclerotic diseases. Diabetes mellitus, hypertension, dyslipidemia and smoking are considered as some of the most important modifiable risk factors. Hence, the primary prevention of PAD can be mainly achieved by smoking cessation as well as by the appropriate control of diabetes, blood pressure and lipid profile.


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