Chapter 9 Lower Extremity Peripheral Artery Diseasevascular specialty care is always required. As well,
one additional “clinical presentation” (prior limb
arterial revascularization) is highlighted for care
focus, recognizing that PAD is never “fi xed” by any
revascularization procedure. PAD care must delib-
erately continue after any individual revasculariza-
tion “episode of care” via use of graft or PTA site
surveillance and prescription of risk reduction
therapies.Clinical presentations
Asymptomatic PAD
Class I
1 A history of walking impairment, claudication,
ischemic rest pain, and/or nonhealing wounds is
recommended as a required component of a stan-
dard review of systems for adults 50 years and older
who have atherosclerosis risk factors and for adults
70 years and older. (Level of Evidence: C)
2 Individuals with asymptomatic lower extremity
PAD should be identifi ed by examination and/or
measurement of the ankle-brachial index (ABI) so
that therapeutic interventions known to diminish
their increased risk of myocardial infarction (MI),
stroke, and death may be offered. (Level of Evidence:
B)
3 Smoking cessation, lipid lowering, and diabetes
and hypertension treatment according to current
national treatment guidelines are recommended for
individuals with asymptomatic lower extremity
PAD. (Level of Evidence: B)
4 Antiplatelet therapy is indicated for individuals
with asymptomatic lower extremity PAD to reduce
the risk of adverse cardiovascular ischemic events.
(Level of Evidence: C)Table 9.1 The vascular physical examination
Key components of the vascular physical examination are as
follows:
- Measurement of blood pressure in both arms and notation of
any interarm asymmetry. - Palpation of the carotid pulses and notation of the carotid
upstroke and amplitude and presence of bruits. - Auscultation of the abdomen and fl ank for bruits.
- Palpation of the abdomen and notation of the presence of the
aortic pulsation and its maximal diameter. - Palpation of pulses at the brachial, radial, ulnar, femoral,
popliteal, dorsalis pedis, and posterior tibial sites. Perform Allen’s
test when knowledge of hand perfusion is needed. - Auscultation of both femoral arteries for the presence of bruits.
- Pulse intensity should be assessed and should be recorded
numerically as follows: 0, absent; 1, diminished; 2, normal; and 3,
bounding. - The shoes and socks should be removed; the feet inspected; the
color, temperature, and integrity of the skin and intertriginous areas
evaluated; and the presence of ulcerations recorded. - Additional fi ndings suggestive of severe PAD, including distal
hair loss, trophic skin changes, and hypertrophic nails, should be
sought and recorded.
Fig. 9.1 Risk of developing lower extremity PAD.
with the disease. This guideline defi nes fi ve distinct
lower extremity clinical syndromes that should be
used to guide the appropriateness of diagnostic and
therapeutic efforts: Asymptomatic, atypical leg pain,
claudication, chronic critical limb ischemia, and
acute limb ischemia. Individuals with both chronic
critical limb ischemia or acute limb ischemia repre-
sent a cohort with the highest cardiovascular mor-
bidity and mortality, and for whom immediate
Table 9.2 Individuals at risk for lower extremity peripheral artery
disease- Age less than 50 years, with diabetes and one other
atherosclerosis risk factor - Age 50 to 69 years and history of smoking or diabetes
- Age 70 years and older
- Leg symptoms with exertion (suggestive of claudication) or
ischemic rest pain - Abnormal lower extremity pulse examination
- Known atherosclerotic coronary, carotid, or renal artery disease