Peripheral Artery Disease (PAD)

Question 1

PAD Definition

Answer 1

• Atherosclerosis of the extremities (virtually always detected first in the lower, but can also be upper) causing ischemia
• Affects aorta-iliac or infra-iguinal arteries
• partially occluding blood flow, primarily to lower extremity

Question 2

Give a Patient Description of PAD

Answer 2

• PAD is a common circulatory problem in which narrowed arteries reduce blood flow to limbs
• Legs don’t received enough blood flow to keep up with demand
• This may cause symptoms such as leg pain when walking (claudication)
• Peripheral artery disease is also likely to be a sign of a buildup of fatty deposits in your arteries (atherosclerosis)

Question 3

Mild PAD Symptoms + Signs

Answer 3

• may be asymptomatic or cause intermittent claudication
• exertional discomfort - most commonly in the calf - relieved by rest
• cold dry skin
• hair loss
• diminished or absent pulses
• slow brittle toenail growth
• unremitting pain at night relieved by dangling foot out of bed or standing on a cold floor
• skin pallor
• dependent rubor

Question 4

Severe PAD Symptoms + Signs

Answer 4

• ulcerations can develop in later stages of the disease
• cyanosis
• muscle wasting
• poor wound healing
• gangrene

Question 5

What is Ischaemia?

Answer 5

Inadequate oxygen supply to tissues due to decreased blood supply

Question 6

What is Necrosis?

Answer 6

Unprogrammed cell death

Question 7

What is Gangrene?

Answer 7

Death of tissue specifically due to inadequate blood supply

Question 8

What are the Stages of PAD?

Answer 8

Stage 1: asymptomatic
Stage 2: intermittent claudication
Stage 3: rest pain/nocturnal pain
Stage 4: necrosis/gangrene

Question 9

How do you diagnose of PAD?

Answer 9

• case history
• physical examination
• measurement of the ankle-brachial index
• ultrasonography
• angiography before surgery

Question 10

What is the treatment of PAD?

Answer 10

• risk factor modification
• exercise
• anti-platelet drugs
• cilostazol or pentoxifylline as needed for symptoms
• angioplasty (balloon into artery + stent)
• surgical bypass
• amputation

Question 11

What are the PAD Risk factors (modifiable)?

Answer 11

• smoking
• alcohol
• poor diet
• sedentary lifestyle
• obesity
• poor sleep
• stress

Question 12

What are the PAD Medical co-morbidities?

Answer 12

• diabetes
• hypercholesterolemia
• hypertension
• chronic kidney disease
• inflammatory condition e.g. rheumatoid arthritis
• atypical antipsychotic medications

Question 13

What would you do in a PAD Osteopathic Exam?

Answer 13

• reduced skin temperature
• reduced sensation
• prolonged capillary refill time (more than 2 seconds)
• pulses (character, rate, rhythm)
• blood pressure of brachial/ankle (Ankle Brachial Plexus Index - ABPI)
• CV examination (blood pressure, heart sounds)
• check feet/legs for ulcers
• muscle atrophy
• skin changes - thin, shiny, discoloured, dependent rubor, elevation pallor, tissue loss on the heel or between the toes and hair loss

Question 14

What advice and education can you give PAD patients?

Answer 14

• lifestyle support and advice e.g. smoking, alcohol, diet
• optimise medical treatment of comorbidities
• exercise

Question 15

What PAD tests/examinations available for referral?

Answer 15

• refer!
• contrast MRI
• common medications - atorvastatin, clopidogrel, naftidrofuryloxalate

Question 16

What is the Differential Diagnosis of PAD?

Answer 16

• acute limb ischaemia is a commonly missed diagnosis as it is often not considered
• conditions that mimic arterial occlusion include:
  —>chronic peripheral neuropathy (diabetic neuropathy) - pulses are present, unless there is also chronic arterial occlusive disease or vasospasm and skin temperature is normal (unlike in acute limb ischaemia)

—> acute compressive peripheral neuropathy (compartment syndrome) — tense muscle compartments (not present in actuate limb ischaemia)

—> acute deep veins thrombosis — pulses are usually palpable (unless chronic arterial occlusive disease, vasospasm, or significant oedema is also present) and oedema does not usually occur with acute limb ischaemia

—> low cardiac output in conjunction with chronic lower extremity peripheral artery disease

• intermittent claudication has a number of differential diagnosis including:

—> nerve root compression — sharp lancing pain, radiating down the leg, exacerbated by sitting, standing, walking and improved by change of position

—> hip arthritis — aching discomfort in the lateral hip and thigh after exercise, not quickly relieved, but may improve when not weight bearing

—> spinal stenosis — often bilateral pain and weakness affecting the buttocks and posterior leg. Worse on standing, relieved by flexing the lumbar spine

—> foot and ankle arthritis — aching pain in the ankle and foot arch. Symptoms may be influenced by activity level, not quickly resolving, but may be relieved by not weight bearing.

—> less commonly, chronic compartment syndrome, venous claudication, symptomatic Baker’s cyst

• chronic limb-threatening ischaemia can be missed if symptoms are confused with other causes of foot pain, for example:

—> plantar fasciitis

—> cellulitis

—> gout

—> arthritis

Question 17

What are the differential diagnosis for claudication?

Answer 17

• arthritis
• chronic compartment syndrome
• muscle strain
• baker’s cyst
• nerve entrapment
• nerve root compression
• spinal stenosis
• DVT
• Vasculitis