Epidemiology
Etiology
- Atherosclerosis in the aorta and peripheral arteries → insufficient tissue perfusion → PAD
- PAD usually coexists with coronary artery disease. Smoking is one of the most important risk factors for PAD!
Pathophysiology
Clinical features
- Intermittent claudication
- Femoropopliteal disease (most common): typically causes calf claudication
- Aortoiliac disease (Leriche syndrome)
- Level of the aortic bifurcation or bilateral occlusion of the iliac arteries
- Triad of bilateral buttock, hip, or thigh claudication, erectile dysfunction, and absent/diminished femoral pulses
- Worsens upon exertion
- Due to increased oxygen demand
Diagnostics
- Ankle-Brachial Index (ABI): The best initial test. It compares the systolic BP in the ankle to the systolic BP in the arm.
- Normal: 1.0 - 1.4.
- Diagnostic for PAD: < 0.9.
- Severe PAD: < 0.5 suggests severe disease; < 0.4 indicates CLI.
- > 1.4: Suggests non-compressible, calcified arteries, often seen in elderly or diabetic patients.
- Angiography (CTA/MRA): The gold standard for visualizing anatomy and planning revascularization.
Differential diagnostics
| Feature | Peripheral Artery Disease (PAD) | Thromboangiitis Obliterans |
|---|
| Etiology | Atherosclerosis | Inflammatory Vasculitis |
| Patient Profile | > 50 yrs with risk factors (HTN, DM, HLD) | < 45 yr heavy male smoker |
| Vessels | Large proximal arteries | Small/Medium distal arteries & veins |
| Key Finding | Intermittent claudication | Migratory thrombophlebitis, “Corkscrew collaterals” |
| Tx | Risk factor management, Revascularization | Complete smoking cessation |
Treatment
- Indications
- Intermittent claudication to improve symptoms and functional status
- May be considered after revascularization of femoropopliteal disease to reduce the risk of re-stenosis
- Agent: cilostazol (a phosphodiesterase type 3 inhibitor with vasodilatory, antiplatelet, and antithrombotic properties)