Peripheral Artery Disease Clinical Signs

Manifestations and Diagnosis

• The American Heart Association recommends that intermittent claudication, rest pain, pallor, absence of pulses, poikilothermia, paresthesias, paralysis, non-healing ulcers, and gangrene are indicative of different degrees of arterial ischemia 1, 2
• Fatigue, discomfort, cramps, or pain of vascular origin in the lower extremities that occurs constantly with exercise and is relieved by rest (generally in less than 10 minutes) is a characteristic of claudication 1, 2
• The location of the pain can indicate the site of arterial obstruction: aortoiliac occlusion causes pain in the buttocks, hip, and thigh 3, 4, femoral-popliteal occlusion causes pain in the calf (most common) 4, and tibial occlusion causes pain in the calf or, more rarely, in the foot 3
• Critical limb ischemia (CLI) is characterized by chronic ischemic rest pain (≥2 weeks), non-healing ulcers/wounds, or gangrene in one or both legs attributable to objectively proven atherosclerotic occlusive disease 1, 2
• Objective signs of CLI include a very low ankle-brachial index (ABI) 3, decreased transcutaneous oxygen pressure (TcPO2) 5, and reduced cutaneous perfusion pressure 2, 6
• Acute limb ischemia (ALI) is characterized by severe acute hypoperfusion (<2 weeks) with the "6 P's": pain 3, pallor 2, pulselessness 2, poikilothermia 2, paresthesias 2, and paralysis 1, 2, 5
• ALI is classified into three categories based on severity: viable, threatened, and irreversible 2, 6
• The viable category has no immediate threat to the limb, with no sensory loss and no muscle weakness; the threatened category has mild to moderate sensory or motor loss; and the irreversible category has major tissue loss or permanent nerve damage 2, 6
• Tissue loss is classified as minor (non-healing ulcer, focal gangrene with diffuse pedal ischemia) or major (extends above the transmetatarsal level; functional foot no longer salvageable) 2, 6
• Decreased or absent peripheral pulses (femoral, popliteal, posterior tibial, pedal) are indicative of peripheral artery disease 3
• Femoral bruits (indicative of focal stenosis) are a sign of aortoiliac disease 3
• Delayed capillary refill and elevation dependence (pallor with elevation and rubor with dependence) are signs of significant ischemia 5
• Aortoiliac disease is characterized by decreased or absent femoral pulses and bruits in the femoral or iliac region 4
• Femoropopliteal disease is characterized by a decreased or absent popliteal pulse and claudication predominantly in the calf 4
• Infrapopliteal disease is characterized by absent distal pulses (tibial posterior and pedal) and a higher association with critical ischemia due to a lack of collateral vessels 4
• The differential diagnosis of claudication should include severe venous obstructive disease 5, chronic compartment syndrome 5, spinal stenosis and lumbar disease 3, osteoarthritis 1, and inflammatory muscle diseases 3
• A program of structured exercise (supervised or community/home-based) is recommended for patients with intermittent claudication 2