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Hirsch AT et al ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic InterSociety Consensus; and Vascular Disease Foundation Circulation 2006 Mar 21;113(11):e463 654 [PMID: 16549646] Sontheimer DL Peripheral vascular disease: diagnosis and treatment Am Fam Physician 2006 Jun 1;73(11):1971 6 [PMID: 16770929] WAVE Investigators The effects of oral anticoagulants in patients with peripheral arterial disease: rationale, design, and baseline characteristics of the Warfarin and Antiplatelet Vascular Evaluation (WAVE) trial, including a meta-analysis of trials Am Heart J 2006 Jan;151(1):1 9 [PMID: 16368284]

The ankle-brachial index (ABI) is reduced; levels below 05 suggest severe reduction in flow ABI readings depend on arterial compression Since the vessels may be calcified in diabetic patients and the elderly, ABIs can be misleading and must be accompanied by a wave-form analysis Pulse volume recordings with cuffs placed at the high thigh, mid thigh, calf, and ankle will delineate the levels of obstruction with reduced pressures and blunted wave-forms Angiography, CTA, or MRA all adequately show the anatomic location of the obstructive lesions Generally, these studies are only done if revascularization is planned

FIGURE 4-7

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undermines quality of life as well as overall cardiovascular health, intervention may be warranted All interventions require close postprocedure follow-up with ultrasound surveillance so that any recurrent narrowing can be treated promptly to prevent complete occlusion The patency rate of bypass grafts of the femoral artery, SFA, and popliteal artery may be as high as 70% at 3 years with patency for endovascular procedures somewhat lower Because of the associated coronary disease, 5-year survival among patients with lower extremity disease is approximately 50% However, with aggressive risk factor modification, substantial improvement in longevity has been reported

McDermott MM et al Lower extremity nerve function in patients with lower extremity ischemia Arch Intern Med 2006 Oct 9;166(18):1986 92 [PMID: 17030832] White C Intermittent claudication N Engl J Med 2007 Mar 22;356(12):1241 50 [PMID: 17377162]

As with aorto-iliac disease, conservative management has an important role for some patients, particularly those individuals with SFA occlusion and good profunda femoris collaterals For these patients conservative management as noted above can result in excellent outcomes with no intervention required

1 Bypass surgery Surgery is indicated if intermittent claudication is progressive, incapacitating or interferes significantly with essential daily activities Intervention is mandatory if there is rest pain or threatened tissue loss of the foot The most effective and durable treatment for lesions of the SFA is a femoral-popliteal bypass with autogenous saphenous vein Synthetic material, polytetrafluoroethylene (PTFE) can be done with relatively short bypasses with excellent distal vessels These grafts do not have the patency of vein but may have value in patients who have no vein available 2 Thromboendarterectomy Removal of the atherosclerotic plaque is now limited to the lesions of the common femoral and profunda femoris artery where bypass grafts and endovascular techniques have no role 3 Endovascular surgery Endovascular techniques have increased in popularity for lesions of the SFA There are several alternatives Angioplasty may be combined with stenting either with a bare metal stent or a PTFE-covered stent to form an endoluminal bypass Cyroplasty, angioplasty with balloon cooled to a 20 and endoluminal atherectomy also have their proponents These techniques have lower morbidity than bypass but also have a lower rate of success and durability The most favorable lesions for endovascular therapy are lesions that are less than 10 cm long and in patients who are undergoing aggressive risk factor modification After any of these procedures, the patient generally receives lifelong antiplatelet medication, with periprocedural treatment with clopidogrel (75 mg/day) and long-term maintenance therapy with aspirin

Rest pain of the forefoot relieved by dependency Pain or numbness of the foot with walking Ulceration or gangrene of the foot or toes Pallor when the foot is elevated

Occlusive processes of the lower leg and foot primarily involve the tibial vessels with only extensive disease involving the arteries of the foot There often is extensive calcification of the vessel wall This distribution of atherosclerosis is primarily seen in patients with diabetes mellitus

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