An in-depth report on the causes, diagnosis, and treatment of peripheral artery disease (PAD).
Peripheral arterial disease; PAD; Peripheral vascular disease;
PAD is greatly underdiagnosed. Many patients do not report symptoms, or may not even have symptoms. People should be checked for peripheral artery disease if they have risk factors for heart disease, leg pain during walking, or ulcers on their legs.
The doctor should check for high blood pressure, heart abnormalities, blockage(s) in the artery in the neck, and abdominal aneurysms. The doctor should also examine the skin of the legs and feet for color changes, ulcers, infection, or injuries, and check the pulse of the arteries in the leg.
Intermittent claudication caused by peripheral artery disease is typically diagnosed using a calculation called the ankle-brachial index. This method also helps to diagnose PAD in patients without symptoms of intermittent claudication.
The procedure is done as follows:
The doctor divides the systolic pressure in the ankle by the systolic pressure in the arm. The result is called the ankle-brachial index (ABI), also called ankle-arm pressure index (API).
What the results mean:
Doppler ultrasound imaging is commonly the first imaging test of the arteries performed and also may be used to follow patients. It is able to provide an anatomic view of the arteries and report on velocity and flow characteristics. It is non-invasive and is performed usually in an outpatient setting.
Before considering invasive procedures to treat peripheral artery disease, the surgeon needs a better understanding of which arteries are involved, how severe the blockage is, and the state of the blood vessels surrounding the blockage. In the past, invasive or conventional angiography was typically performed. This type of angiogram uses dye, which is injected through a catheter that is inserted in the groin.
Magnetic resonance angiography (MRA) is a type of magnetic resonance imaging (MRI). It provides a non-invasive alternative to a traditional angiogram. The MRA uses a magnetic field and radiofrequency waves to provide pictures of arteries and blood vessels. Patients are given gadolinium (a contrast material) through an IV to improve the image quality. In many medical centers, MRA is considered almost or as accurate as invasive angiography and will frequently be the only test required.
A new technology called computed tomography angiography (CTA) uses x-rays to visualize blood flow in arteries throughout the body. This technique is also highly effective in diagnosing PAD. While it involves more radiation exposure than an MRA, it can be used in patients who have contraindications to magnetic resonance imaging.
A patient is often given a treadmill test if the ankle-brachial index is questionable. Patients with claudication have a 50 - 60% reduction in peak performance, which is comparable to that in patients with heart failure. The treadmill test is also useful for determining the severity of the pain while walking and assessing the effectiveness of treatments.
A test called a wave form analysis may be used to confirm an abnormal API or pressure reading. The patient lies on their back for at least 10 minutes in a warm room (so that the blood vessels will not narrow). The leg is turned outward, and the knee is slightly bent. The doctor passes a handheld scanner over the leg, which picks up sound waves coming from the arteries. These signals are recorded, and the wave forms are traced to detect abnormal blood flow.
Patients with suspected PAD should have an electrocardiogram (ECG. EKG) and other tests that can detect heart problems.
A number of other tests may be ordered to rule out disorders with similar symptoms. Such disorders include:
Aboyans V, Criqui MH, Denenberg JO, Knoke JD, Ridker PM, Fronek A. Risk factors for progression of peripheral arterial disease in large and small vessels. Circulation. 2006 Jun 6;113(22):2623-9.
Arain FA, Cooper LT Jr. Peripheral arterial disease: diagnosis and management. Mayo Clin Proc. 2008 Aug;83(8):944-49; quiz 949-50.
Aung PP, Maxwell HG, Jepson RG, Price JF, Leng GC. Lipid-lowering for peripheral arterial disease of the lower limb. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD000123.
Collins R, Burch J, Cranny G, Aguiar-Ibáñez R, Craig D, Wright K, et al. Duplex ultrasonography, magnetic resonance angiography, and computed tomography angiography for diagnosis and assessment of symptomatic, lower limb peripheral arterial disease: systematic review. BMJ. 2007 Jun 16;334(7606):1257. Epub 2007 Jun 4
Creager MA and Libby P. Peripheral arterial disease. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007:chap 57.
Garg PK, Tian L, Criqui MH, Liu K, Ferrucci L, Guralnik JM, et al. Physical activity during daily life and mortality in patients with peripheral arterial disease. Circulation. 2006 Jul 18;114(3):242-8.
Kikano GE, Brown MT. Antiplatelet therapy for atherothrombotic disease: an update for the primary care physician. Mayo Clin Proc. 2007 May;82(5):583-93.
McDermott MM, Ades P, Guralnik JM, Dyer A, Ferrucci L, Liu K, et al. Treadmill exercise and resistance training in patients with peripheral arterial disease with and without intermittent claudication: a randomized controlled trial. JAMA. 2009 Jan 14;301(2):165-74.
Met R, Bipat S, Legemate DA, Reekers JA, Koelemay MJ. Diagnostic performance of computed tomography angiography in peripheral arterial disease: a systematic review and meta-analysis. JAMA. 2009 Jan 28;301(4):415-24.
Saw J, Bhatt DL, Moliterno DJ, Brener SJ, Steinhubl SR, Lincoff AM, et al. The influence of peripheral arterial disease on outcomes: a pooled analysis of mortality in eight large randomized percutaneous coronary intervention trials. J Am Coll Cardiol. 2006 Oct 17;48(8):1567-72.
Sobel M, Verhaeghe R; American College of Chest Physicians; American College ofChest Physicians. Antithrombotic therapy for peripheral artery occlusive disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun;133(6 Suppl):815S-843S.
Steg PG, Bhatt DL, Wilson PWF, D’Agostino R, Ohman EM, Rother, J. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA. Mar 21 2007;29(11)7:1197-1206.
Warfarin Antiplatelet Vascular Evaluation Trial Investigators, Anand S, Yusuf S, Xie C, Pogue J, Eikelboom J, et al. Oral anticoagulant and antiplatelet therapy and peripheral arterial disease. N Engl J Med. 2007 Jul 19;357(3):217-27.
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