Peripheral arterial disease
Summary
Definition
History and exam
Key diagnostic factors
- asymptomatic
- intermittent claudication
- thigh or buttock pain with walking that is relieved with rest
- diminished or absent pulse
- sudden onset of severe leg pain accompanied by numbness, weakness, pale and cold leg
Other diagnostic factors
- erectile dysfunction
- leg pain at rest
- gangrene
- nonhealing wound/ulcer
- muscle atrophy
- dependent rubor
- pallor when the leg is elevated
- loss of hair over the dorsum of the foot
- thickened toenails
- shiny/scaly skin
- pale extremity
- nerve loss
Risk factors
- smoking
- diabetes
- hypertension
- elevated C-reactive protein (CRP)
- hyperlipidemia
- age >40 years
- history of coronary artery disease/cerebrovascular disease
- hyperhomocysteinemia
- low levels of exercise
- vasculitis/inflammatory conditions
- arterial fibrodysplasia
Diagnostic tests
1st tests to order
- ankle-brachial index (ABI)
Tests to consider
- toe-brachial index (TBI)
- segmental pressure examination
- pulse volume recording
- duplex ultrasound
- continuous wave Doppler ultrasound
- exercise ankle-brachial index (ABI)
- catheter angiography
- CT angiogram
- magnetic resonance angiography (MRA)
Treatment algorithm
acute limb ischemia
claudication (not lifestyle-limiting)
claudication (lifestyle-limiting)
chronic severe limb ischemia (critical limb ischemia)
Contributors
Authors
Leila Mureebe, MD, MPH, MMCi, FACS
Associate Professor of Surgery
Duke University Health Care
VA Mid Atlantic Healthcare System
Durham
NC
Disclosures
LM declares that she has no competing interests.
Acknowledgements
Dr Leila Mureebe would like to gratefully acknowledge Dr Ehrin Armstrong and Dr Kosmas I. Paraskevas, previous contributors to this topic.
Disclosures
EA is an advisory board member for Abbott Vascular, Boston Scientific, Medtronic, and Philips. EA and KIP are both authors of references cited in this topic.
Peer reviewers
Khaled Ziada, MD
Assistant Professor
Division of Cardiovascular Medicine
University of Kentucky
Lexington
KY
Disclosures
KZ declares that he has no competing interests.
Debabrata Mukherjee, MD
Gill Foundation Professor of Interventional Cardiology
Director of Cardiac Catheterization Laboratories
Gill Heart Institute
Division of Cardiovascular Medicine
University of Kentucky
Lexington
KY
Disclosures
DM declares that he has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Eur Heart J. 2018 Mar 1;39(9):763-816.Full text Abstract
Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: executive summary. Circulation. 2017 Mar 21;135(12):e686-725.Full text Abstract
Norgren L, Hiatt WR, Dormandy JA, et al; TASC II Working Group. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007;45(suppl S):S5-67.Full text Abstract
Mills JL Sr, Conte MS, Armstrong DG, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg. 2014 Jan;59(1):220-34;e1-2.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Spinal stenosis
- Arthritis
- Venous claudication
More DifferentialsGuidelines
- ACR Appropriateness Criteria: sudden onset of cold, painful leg
- Canadian Cardiovascular Society guidelines for peripheral arterial disease
More GuidelinesPatient information
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Peripheral arterial disease
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