creation date: 2026-05-14 16:54
tags: Pathologies
Peripheral Artery Disease
Background
Definitions
Peripheral artery disease (PAD) refers to atherosclerotic disease leading to peripheral artery obstruction.
Older terminology include arteriosclerotic disease and peripheral artery occlusive disease. The current use of PAD refers to atherosclerosis of noncoronary (peripheral) vasculature.
The disease generally affects the lower extremities (aortoiliac > femoropopliteal > infrapopliteal). The upper extremities are much less frequently affected (left subclavian most common amongst upper extremity).
Pathogenesis
Atherosclerosis results in the progressive narrowing of arteries. Should the arteries narrow to the point the blood supply fails to meet ongoing metabolic requirements, symptoms will occur.
Poor blood flow results in ischemia of the limb and also reduced healing.
Clinical Presentation
Signs & Symptoms
Most patients with PAD have no complaints (20-50% asymptomatic).
Manifestation include:
- Exertional pain (claudication or atypical)
- Ischemic rest pain (localized to forefoot/toes)
- Skin discolouration
- Nonhealing wounds
Acute limb ischemia may present with the 6 Ps:
- Pain (acute onset, progressive)
- Pulselessness
- Pallor
- Paresthesia
- Paralysis
- Poikilothermia (extreme coolness)
History & Physical Exam
History should include:
- Walking impairment
- Extremity pain that seem ischemic in nature
- Presence of nonhealing wounds
Physical exam should include:
- Temperature
- Pulses
- Neurologic assessment (sensation)
Buerger’s test can be used to test for PAD. Patient is supine and leg raised to 45 degrees for 1-2 minutes, then patients sit up and let down legs to hang over the edge
- Elevation pallor: foot turns pale during elevation phase
- Rubor dependency: during dependent phase, foot takes longer to return to normal and turns a dusky, dark red (compensation from previous ischemia during elevation)
Risk Factors
Risk factors are those consistent with atherosclerosis:
- Older age
- Hypertension
- Male sex
- Known atherosclerosis at other sites
- Family history of atherosclerosis
- Diabetes
- Hyperlipidemia
- Homocysteinemia
Diagnosis
Criteria
Diagnosis can be made clinically with consistent risk factors and physical exam findings.
Ankle-branchial index, which compares the blood pressure of ankle to arm) can also be diagnostic.
- ABI ≤ 0.9
Work-up
Laboratory studies
Routine studies include:
- CBC with differential
- Metabolic panel
- Lipids
- Homocysteine
- Lipoprotein (a)
- CRP
Plain radiograph
May demonstrate arterial calcification.
Differential
Other sources of arterial stenosis/occlusion causing pain include:
- Arterial thrombosis due to aneurysm
- Arterial injury
- Arterial dissection
- Thromboembolism
Red Flags / Complications
Complications include:
- Ischemia and gangrene
- Infection
- Osteomyelitis
- Acute limb ischemia
- Compartment syndrome
- Amputation
- Erectile dysfunction
Management
The goal of management is to relieve symptoms, improve quality of life, and reduce risk of disease progression.
Lifestyle Modifications
Consist of:
- Smoking cessation
- Diet, exercise, and weight loss
- Glycemic control
Exercise should be done to point of pain to encourage angiogenesis.
Medical Therapy
Long term antithrombotic therapy is indicated for secondary prevention.
- Aspirin 75 mg, 81 mg, or 325 mg PO once daily
- Clopidogrel 75 mg PO once daily
Lipid-lowering therapy should be initiated with at least a moderate-intensity statin. Antihypertensive therapy should be initiated to control hypertension.