PERIPHERAL ARTERIAL DISEASE - idb.hr

1 Key words: PERIPHERAL ARTERIAL DISEASE , atherosclerosis, intermittent claudication,noninvasive diagnostic tests, therapy, diabetes mellitusSUMMARYThe major cause of PERIPHERAL ARTERIAL DISEASE (PAD)is atherosclerosis. It may present with typical ischemicpain, atypical pain, or with no symptoms. The riskfactors for the development of PERIPHERAL arterialatherosclerosis are diabetes mellitus, hyperlipidemia,hypertension, and cigarette smoking. The symptoms ofperipheral ARTERIAL DISEASE can be typical(claudication) or atypical. Intermittent claudication isdefined as a reproducible discomfort of a definedgroup of muscles, which is induced by exercise andrelieved with rest.

2 The severity of symptoms ofclaudication depends on the amount of stenosis, thecollateral circulation and the vigor of symptoms are often the result of comorbi-dities, physical inactivity and alterations in painperception. Detection of asymptomatic PAD isimportant because it identifies patients at an increasedrisk of atherosclerosis at other sites. Noninvasive testsinclude the ankle-to-brachial index, exercise treadmilltest, segmental limb pressures, ultrasonography andsegmental volume plethysmography. Therapy ofpatients with claudication involves risk modificationincluding exercise program and medical,percutaneous and/or surgical approaches.

3 Theevidence of benefit is convincing only for antiplateletagents, usually aspirin, and cilostazol. Two importantcriteria for revascularization, either percutaneousintervention or surgery, are severe disability that limitsthe patient s ability to work or to perform otheractivities that are important to the patient, and failure(or predicted failure) to respond to exerciserehabilitation and pharmacological therapy. About 25percent of patients with critical limb ischemia undergoamputation within one year. The vast majority ofpatients presenting with even critical ischemia can beoffered a reasonable attempt for limb major cause of PERIPHERAL ARTERIAL DISEASE (PAD)is atherosclerosis.

4 Patients with compromise of bloodflow to the extremities as a consequence of peripheralarterial DISEASE may present with typical ischemicpain, atypical pain, or with no symptoms. Intermittent67 Diabetologia Croatica 39-2, 2010 Vuk Vrhovac University ClinicDugi dol 4a, HR-10000 Zagreb, CroatiaReviewReceived: July 5, 2010 Accepted: July 12, 2010 PERIPHERAL ARTERIAL DISEASEJozo Boras, Neva Brklja i , Antonela Ljubi i , Spomenka Ljubi Corresponding author:Jozo Boras, MD, PhD, Vuk Vrhovac UniversityClinic, Dugi dol 4a, HR-10000 Zagreb, is defined as a reproducible discomfort ofa defined group of muscles, which is induced byexercise and relieved with rest. ETIOLOGYThe etiology of leg pain can be divided intocategories that include vascular, neurogenic andmusculoskeletal causes.

5 Vascular pain includes classicclaudication, atypical claudication and rest pain. Themain cause of intermittent claudication is peripheralatherosclerosis. Neurologic pain is predominantly dueto neurospinal ( , disk DISEASE , spinal stenosis,tumor) or neuropathic causes ( , diabetes, alcoholabuse). Musculoskeletal pain derives from the bones,joints, ligaments, tendons and fascial elements oflower clinical history can help distinguish some of theless common causes of this disorder. Nonarterialpathologic conditions should also be considered ondifferential diagnosis of limb discomfort: deep venousthrombosis, musculoskeletal disorders, peripheralneuropathy, and spinal stenosis (pseudoclaudication)(Table 1).

6 RISK FACTORSThe risk factors for the development of peripheralarterial atherosclerosis are diabetes mellitus,hyperlipidemia, hypertension, and cigarette from Framingham Heart Study (1) and NHANES(2) analysis confirm that PAD was significantlyincreased in current smokers and patients withdiabetes, hypertension or patients have worse ARTERIAL DISEASE and apoorer outcome than nondiabetics (3).Patients at risk of lower extremity PAD (based uponthe American College of Cardiology/American HeartAssociation (ACC/AHA) guidelines on PAD 2005)are: age 70; age 50-69 with a history of smoking ordiabetes; age 40-49 with diabetes and at least one otherrisk factor for atherosclerosis; leg symptomssuggestive of claudication on exertion or ischemicpain at rest; and abnormal lower extremity pulseexamination or known atherosclerosis at other sites( , coronary, carotid or renal ARTERIAL DISEASE ).

7 Current cigarette smoking, the ratio of total to HDLcholesterol, hs-CRP and Lp(a) were statisticallyimportant predictors for the largest fall in ankle-to-brachial index (ABI) (large vessel cohort), whereasdiabetes was the only significant predictor ofprogression among patients with the largest fall in toeto brachial index (TBI), small vessel DISEASE (4).CLINICAL PRESENTATIONP atients with PAD may present with typicalsymptoms such as pain, atypical symptoms, or may beasymptomatic. The 2005 ACC/AHA guidelines onPAD suggest the following distribution of clinicalpresentation of PAD in patients aged 50:asymptomatic 20%-50%, atypical leg pain 40%-50%, classic claudication 10%-35%, and criticallimb ischemia 1%-2% (5).

8 Two classification systems,Fontaine s stages and Rutherford s categories, havebeen used for lower extremity PAD based upon theseverity of symptoms and the presence of markers forsevere DISEASE such as ulceration and gangrene (6)(Table 2). 68J. Boras, N. Brklja i , A. Ljubi i , S. Ljubi / PERIPHERAL ARTERIAL DISEASEM ajor causeAtherosclerosis (arteriosclerosis obliterans)Other causesAcute ARTERIAL DISEASE Adventitial cystic diseaseAortic coarctationArterial fibrodysplasiaArterial tumorErgot toxicityIliac endofibrosis in athletesOccluded limb aneurysmsPopliteal-artery entrapmentPseudoxanthoma elasticumRadiation fibrosisRetroperitoneal fibrosisTakayasu s arteritisTemporal arteritisThoracic outlet obstructionThromboangiitis obliterans (Buerger s DISEASE )VasospasmTable 1.

9 Causes of claudicationSYMPTOMATIC DISEASES ymptoms of PERIPHERAL ARTERIAL DISEASE can betypical (claudication) or atypical. The severity ofsymptoms of claudication depends upon the amount ofstenosis, the collateral circulation and the vigor ofexercise. Patients with claudication can present withbuttock and hip, thigh, calf or foot pain, single or incombination. Patients with aortoiliac occlusive DISEASE (Leriche syndrome) present with buttock, hip andsometimes thigh claudication and may be associatedwith weakness of the hip and thigh on aortoiliac DISEASE can cause erectiledysfunction in men. Physical examination revealsbilateral diminished or absent pulses at the level of thegroin, occasionally with bruits over the iliac andfemoral arteries and muscle atrophy and slow woundhealing in legs.

10 Atherosclerotic occlusion of thecommon femoral artery may include claudication inthe thigh, calf or both. These patients have normalgroin pulses but decreased pulses distally. Calfclaudication is the most common complaint. It isdescribed as cramping pain that is consistentlyreproduced with exercise and relieved with in the upper-third of the calf is usually dueto superficial femoral artery stenosis, whereascramping in the lower third of the calf is due topopliteal DISEASE . Foot claudication is oftenaccompanied by occlusive DISEASE of the tibial andperoneal vessels. Isolated foot claudication is rarelyseen with atherosclerotic occlusive DISEASE , but iscommonly seen with thromboangiitis obliterans(Buerger s DISEASE ).