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Peripheral obliterative arteriopathy

Peripheral obliterative arteriopathy, or peripheral arterial occlusive disease (PAOD) is a disease characterised by a reduced blood flow of the lower limbs during physical exercise or at rest, mainly due to an ongoing atherosclerotic process.

Atherosclerotic plaques cause narrowing or obstruction of the arteries by reducing blood flow to the lower limbs. PAOD can manifest itself in different ways, with different intensity based on the degree to which vessels are affected and the development of collateral circulation: asymptomatic arterial insufficiency, intermittent claudication (claudicatio intermittens), and pain when at rest.

In more severe forms of PAOD, patients develop critical ischemia of the lower limbs, with a deterioration of their function, which can require surgical revascularization procedures, or even amputation. As the disease is in most cases the expression of a severe and widespread atherosclerotic process, affected patients present a high risk of cardiac and cerebrovascular complications, especially without appropriate treatment.

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Risk factors

Risk factors for peripheral artery disease are similar to risk factors for atherosclerosis in other parts of the body. The three main risk factors associated with peripheral artery disease are age (over 60), cigarette smoke, and diabetes mellitus (DM). Peripheral artery disease is most common among the elderly, and the risk of developing it doubles with every 10 years of aging. Smoking or DM increase the risk of peripheral artery disease independently by at least three times compared to the rest of the population. Smoking also has a synergic action on other risk factors, and a number of smoked packs/year is associated with the severity of the disease. Smokers have twice as big a risk of mortality, disease progression, and limb amputation compared to non smokers when affected by peripheral artery disease. Diabetic patients are also severely affected by this condition, and the diffusion and progression of peripheral artery disease appears to be related to the duration of diabetes in time rather than to the glycemic index. Other important risk factors are dyslipidemia (increased values of total cholesterol, low density lipoproteins [LDL], triglycerides [TG], lipoprotein (a)) and arterial hypertension.

Physio-pathology

Arteriosclerosis accounts for over 90% of cases of peripheral artery disease, whilst the remaining 10% is associated with less common vascular pathologies. Atherosclerotic lesions are plaques made of a lipid nucleus, central connective tissue, inflammatory cells and smooth muscle cells, all covered with a fibrous membrane. Plaques tend to be located on the bifurcation or proximal segments of large and medium sized arteries. Femoral and popliteal arteries are affected in 80% – 90% of cases of peripheral artery disease; tibial and peroneal arteries account for 40% – 50% of cases, aortoiliac arteries for 30%.

Signs and symptoms

Most patients with PAD are asymptomatic or have atypical symptoms with the typical intermittent claudication.

Symptomatic patients can report:

Atypical leg pain
Intermittent claudication in 10-30% of cases.

Patient with claudicatio refer a stringent pain, cramping, or a feeling of tiredness affecting on or more muscle groups of the lower limbs. Symptoms usually worsen with walking and are relieved by resting. The site of claudicatio is distal to the arterial tract affected. For example, claudicatio of the gluteus, hips and thighs are associated with an aortoiliac condition, and so on. In severe cases of PAD, patients may show signs and symptoms of acute ischemia. These include pain at rest, coldness or numbness of the feet, with or without tissue loss (ulcers or gangrene)

Signs and symptoms of acute ischemia:

Pain
Pale skin
Absence of pulse
Coldness of the affected limb
Paralysis
Paraesthesia

Laboratory tests are useful to detect the presence of dyslipidemia, diabetes, or severe metabolic imbalances (e.g. renal or hepatic insufficiency). A basal electrocardiogram (ECG) should be performed at the time of diagnosis, as well as a cardiac stress test for selected patients.

Diagnostic tools to evaluate patients with critical ischemia:

Medical history and a physical examination, including brain and coronary circulation
Complete blood count and blood chemistry exams
Electrocardiogram at rest
Blood pressure measurement at the ankle and foot
X-ray imaging of lower limb arteries (in patients eligible for endovascular surgery)
A doppler ultrasonography of the carotid arteries may be indicated for high-risk patients
A more accurate assessment of the coronary arteries

Diagnosis

PAD can accurately and easily be diagnosed calculating the ankle-brachial index (ABI). The ABI is the ratio of the blood pressure at the ankle to the higher blood pressure in the brachial arteries measured using a doppler ultrasound device. The ABI test is useful for the following reasons:

Most PAD sufferers are asymptomatic or they have atypical leg symptoms.

Patients with asymptomatic PAD are at high risk of cardiovascular events (e.g. myocardial infarction, stroke, cardiovascular mortality), comparable to that of patients with symptomatic coronary disease.

The severity of PAD (as determined by an ABI threshold value or the presence of symptoms) can determine the outcome for the limbs and survival of the patient.

ABI is an accurate measurement (an ABI lower than 0.9 is 95% sensitive and 100% specific in detecting PAD), it is not invasive, inexpensive, easy to perform in outpatients clinics, and it can be performed efficiently by your primary care physician or medical staff.

Who should undergo the ankle-brachial index test?

People suffering with claudicatio or other symptoms associated with more severe ischemia
Age ≥ 70 or over
Age = 50-69 but with a history of diabetes or cigarette smoke
Age < 49 with diabetes and another risk factor (smoking, diabetes, hypertension, high cholesterol levels)
Abnormal lower limb impulse test
Known atherosclerosis in other location (coronary, carotid, or renal arteries)

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