Revision 28 for 'Peripheral arterial disease'

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Peripheral arterial disease

Peripheral arterial disease is a common and debilitating condition.

Epidemiology

The age-adjusted prevalence of peripheral arterial disease is approximately 12% 3.

Pathology

Atherosclerosis is the leading cause of occlusive arterial disease of the extremities in patients over 40 years of age with the highest incidence in the sixth and seventh decades of life.

Risk factors

The risk factors for PAD are basically the same as for coronary artery disease:

Clinical classification

The Rutherford classification
  • stage 0 - asymptomatic
  • stage 1 - mild claudication
  • stage 2 - moderate claudication : the distance that delineates mild, moderate and severe claudication is not specified in the Rutherford classification, but is mentioned in the Fontaine classification as 200 meters.
  • stage 3 - severe claudication
  • stage 4 - rest pain
  • stage 5 - ischemic ulceration not exceeding ulcer of the digits of the foot
  • stage 6 - severe ischemic ulcers or frank gangrene
The Fontaine classification
  • stage I - asymptomatic.
  • stage II - intermittent claudication.
    • stage IIa : intermittent claudication  after more than 200 meters of pain free walking.
    • stage IIb : intermittent claudication after less than 200 meters of walking
  • stage III - rest pain.
  • stave IV - ischemic ulcers or gangrene
TASC II classification of femoral and popliteal lesions 4
  • type A lesions
    • single stenosis ≤ 10 cm in length
    • single occlusion ≤ 5 cm in length
  • type B lesions
    • multiple lesions (stenoses or occlusions), each ≤ 5 cm
    • single stenosis or occlusion ≤ 15 cm not involving the infrageniculate popliteal artery
    • single or multiple lesions in the absence of continous tibial vessels to improve inflow for a distal bypass
    • heavily calcified occlusion ≤ 5cm in length
    • single popliteal stenosis
  • type C lesions
    • multiple stenoses or occlusions totaling > 15 cm with or without heavy calcification
    • recurrent stenoses or occlusions that need treatment after two endovascular interventions
  • type D lesions
    • chronic total occlusion of the common or superficial femoral artery (> 20 cm, involving the popliteal artery)
    • chronic total occlusion of the popliteal artery and proximal trifurcation vessels

Radiographic features

Plain film

May show calcified atherosclerotic plaques along vessels

Angiography

In angiogramms (DSA [gold standard], CT, MRI) you can identifiy and quantify the stenoses.

Treatment and prognosis

Primary treatment strategy according TASC severity

  • TASC A - endovascular therapy
  • TASC B - endovascular therapy
  • TASC C - surgical therapy (if patient is able to be operated, otherwise endovascular therapy)
  • TASC D - surgical therapy

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