Peripheral Arterial Disease

Causes of Peripheral Arterial Disease include:

• Atherosclerosis
• Borges disease
• Takayasu arteritis
• Systemic lupus erythematosus
• Post-traumatic injury
• Radiation injury, which can cause obliterative arthritis and arterial occlusion

Pathophysiology of Causes of Peripheral Arterial Disease

• Atherosclerosis
  • Atherosclerosis is the predominant cause of peripheral arterial disease, typically occurring between the sixth and seventh decades of life.
  • Major arteries affected include the aorta, iliac artery, femoral artery, and popliteal artery, primarily affecting the lower limbs.
  • Manifestations of peripheral arterial disease depend on the location of arterial occlusion. Ischemia affects tissues distal to the occluded artery, leading to intermittent claudication when muscles are supplied by the affected artery.
  • Depending on the site of obstruction:
    • Aortoiliac disease causes intermittent claudication in the buttock, thigh, and calf, sometimes accompanied by erectile dysfunction (Leriche syndrome).
    • Common femoral artery involvement leads to thigh and calf claudication.
    • Obstruction of the superficial femoral artery and popliteal artery results in calf claudication.
• Thromboangitis Obliterans (Buerger’s Disease)
  • Found predominantly in young male smokers.
  • Primarily affects small and medium-sized vessels such as the tibial artery, plantar artery, and radial artery, with a higher incidence in the lower limbs.
  Clinical features of Buerger’s disease are remembered by the mnemonic "RIM":
  • Raynaud’s phenomenon
  • Intermittent claudication
  • Migratory superficial thrombophlebitis
  • Progressive decrease in claudication distance over time.
  Diagnosis involves:
  • Four-limb angiography to assess disease extent.
  • Development of collateral vessels known as "Corkscrew collaterals" due to chronicity.
  • Ankle-brachial pressure index (ABPI) interpretation:
    • 0.1-0.4: Critical Limb Ischemia
    • 0.5-0.9: Intermittent Claudication
    • 1.0-1.2: Normal
    • >1.2: Calcified Vessels

Treatment of Peripheral Arterial Disease

The primary recommendation for patients is to completely abstain from smoking. Vasodilators may not provide substantial benefits but can still be prescribed. Lumbar sympathectomy is considered in cases of rest pain due to cutaneous ischemia. It is not suitable for intermittent claudication because sympathetic control of muscle blood supply remains unaffected. Omental transposition is an option for surgical intervention. Amputation is the final recourse for patients presenting with gangrene. Embolic occlusion:

• An embolus, detached from the heart or proximal vessels, typically originates as a thrombus.
• The left atrium is the primary source of emboli, often observed in patients with atrial fibrillation.
• Mural thrombi in patients with myocardial infarction constitute the second most common source of emboli.
• Symptoms of embolic occlusion vary depending on the affected organ.
• Brain involvement may present as transient ischemic attack or stroke symptoms.
• Amaurosis fugax describes temporary vision loss when embolic occlusion affects the retinal artery.
• Mesenteric vessel involvement leads to ischemia and potential gangrene of the small bowel.
• Renal vessel involvement manifests as loin pain and hematuria.
• Clinical diagnosis of embolic occlusion is crucial due to its emergent nature.

The Diagnosis of Embolic Occlusion is Characterized By

Diagnosing embolic occlusion typically involves the following clinical features:

• Absence of claudication history.
• Identification of the embolic source.
• Non-palpable distal pulses.
• Painful and difficult limb movements.
• Severe limb pain and numbness.

Management of Embolic Occlusion

In the management of embolic occlusion:

• Intravenous heparin is initiated urgently to limit thrombus extension and maintain vessel patency.
• Embolectomy or thrombectomy with a Fogarty balloon catheter is indicated for treatment.

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