Peripheral arterial disease

Abstract

The major cause of peripheral arterial disease (PAD) is atherosclerosis. It may present with typical ischemic pain, atypical pain, or with no symptoms. The risk factors for the development of peripheral arterial atherosclerosis are diabetes mellitus, hyperlipidemia, hypertension, and cigarette smoking. The symptoms of peripheral arterial disease can be typical (claudication) or atypical. Intermittent claudication is defined as a reproducible discomfort of a defined group of muscles, which is induced by exercise and relieved with rest. The severity of symptoms of claudication depends on the amount of stenosis, the collateral circulation and the vigor of exercise. Atypical symptoms are often the result of comorbidities, physical inactivity and alterations in pain perception. Detection of asymptomatic PAD is important because it identifies patients at an increased risk of atherosclerosis at other sites. Noninvasive tests include the ankle-to-brachial index, exercise treadmill test, segmental limb pressures, ultrasonography and segmental volume plethysmography. Therapy of patients with claudication involves risk modification including exercise program and medical, percutaneous and/or surgical approaches. The evidence of benefit is convincing only for antiplatelet agents, usually aspirin, and cilostazol. Two important criteria for revascularization, either percutaneous intervention or surgery, are severe disability that limits the patient's ability to work or to perform other activities that are important to the patient, and failure (or predicted failure) to respond to exercise rehabilitation and pharmacological therapy. About 25 percent of patients with critical limb ischemia undergo amputation within one year. The vast majority of patients presenting with even critical ischemia can be offered a reasonable attempt for limb salvage.