Peripheral Arterial Disease: A Case Report From the Henry Ford Hospital

Abstract

A.T. is a 65-year-old black female with claudication secondary to peripheral arterial disease (PAD). She has a history of coronary artery disease, myocardial infarction, heart failure, endarterectomy, hypertension, hyperlipidemia, type 1 diabetes mellitus, and asthma. She was referred to the Division of Vascular Surgery at Henry Ford Hospital complaining of fatigue and heaviness in her lower thighs and calves during walking. Resting ankle-brachial index (ABI) was 0.50 and 0.70 at the right and left dorsalis pedis, respectively. She was prescribed cilo-stazol and encouraged to "…walk through the pain as much as possible." Due to worsening claudication, A.T. underwent an abdominal aortogram with arteriogram of the lower extremities. Results showed aortoiliac disease with multiple steno-ses of varying degrees. Areas of calcification were noted from the lower aorta and iliac artery to the anterior tibial artery affecting both the left and right limbs. Results from a stress echocardiogram showed cardiac wall motion abnormalities consistent with exercise-induced ischemia. She exercised for 5.8 minutes on the Bruce protocol , limited by general fatigue. The electrocardiogram displayed left bundle branch block, resting ejection fraction was 40%, peak blood pressure was 160/80 mmHg, and peak heart rate was 120 b·min −1. No symptoms were reported. Her medications are cilostazol, carvedilol, amlodipine, isosor-bide dinitrate, clopidogrel, simvastatin, potassium, triam-cinolone, ipratropium, and pirbuterol. She began supervised exercise training in cardiac rehabilitation following a hospitalization for angina. At rest her blood pressure was 120/50 mmHg, heart rate was 79 b·min −1 , blood glucose was 6.89 mmol·L −1 (266 mg·dL −1) and her HbA1c was 8.0%. Her initial exercise sessions were limited by bilateral claudication of her thighs and calves. Moderate pain occurred after 9 minutes of walking on day 1. A pain-rest walking program was initiated and followed for 12 weeks. She then joined the Henry Ford PREVENT program, which provides patients with a low-cost, long-term supervised exercise environment. She now exercises at least 3 d·wk −1 for 60 minutes each session. She splits her exercise time between a seated step-per and a treadmill. On most days she is now able to walk 30 continuous minutes without limiting claudication pain. DISCUSSION The natural history of arteriosclerosis involves an intimal plaque that progressively develops until it eventually causes a significant flow limiting occlusion of the vessel and reduction of blood supply relative to demand. Arteriosclerosis is a systemic disorder affecting the major circulations, with the intimal plaque occurring segmentally in multiple locations. When the plaque occurs in the distal aorta or in the arteries of the lower extremities, it is referred to as PAD. Epidemiology More than 8 million individuals in the United States above the age of 40 are estimated to have PAD (1). The prevalence of PAD per ABI is 4.3% in persons older than 40 years and up (2) and 29% in those 70 years and older (3). Thus PAD afflicts more than 4 million Americans and more than 200 million people worldwide. The age-adjusted prevalence of PAD increases to approximately 12% when more sensitive vascular imaging studies are used. Unlike coronary artery disease, the incidence of PAD is similar in men and women. Coronary artery disease occurs in 60% to 90% of patients