This article is a review of chronic infrainguinal atherosclerotic arterial occlusive disease caused by atherosclerosis involving the femoral, popliteal, and/or infrapopliteal arteries. Because chronic atherosclerotic disease may result in acute circulatory compromise, acute arterial occlusion is also covered. Less common etiologies of lower extremity arterial insufficiency, such as atheroembolism, Buerger disease, popliteal artery entrapment syndrome, and cystic adventitial disease, are briefly discussed.
Decision-making in the management of vascular disease changes frequently as new information becomes available and as new technologies emerge.1 Furthermore, therapeutic recommendations for a given population may not be applicable to individual patients with even slightly differing risk factors, co-morbidities, or vascular anatomy.2
Problem
Although most patients with infrainguinal disease are treated nonoperatively, over 100,000 vascular reconstructive procedures are performed yearly in the United States alone. Unfortunately, intervention fails in up to 50% of cases within 5 years.3
Frequency
Chronic atherosclerotic lower extremity disease is present in 20% of the population older than 55 years.7 Most affected persons are asymptomatic. In fact, estimates indicate that only approximately 20% of people with atherosclerotic lower extremity disease present to a physician because of symptoms. Another 20% are symptomatic but do not seek medical attention.
Risk Factors
Commonly accepted risk factors for both the occurrence and progression of atherosclerotic vascular disease include abnormal glucose tolerance, cigarette smoking, advanced age, hyperlipidemia, and hypertension.8
Certain biochemical factors have also been shown to be independent risk factors for atherosclerotic peripheral vascular disease. Such factors include increased plasma fibrinogen levels,9 hyperhomocysteinemia,10,11 and high-sensitivity C-reactive protein12 These factors may also increase the risk of bypass graft stenosis and reocclusion.
When more than one risk factor is present, the cumulative risk is often greater than individual risk factors combined. This is especially true of cigarette smoking, which, when accompanied by another risk factor (such as hypertension or hyperlipidemia) increases the disease risk to more than twice the sum of the individual risks.
Pathophysiology
Atherosclerotic occlusive disease
With atherosclerotic occlusion of a major lower extremity artery, the limb is perfused via collateral pathways. Although this alternate pathway may be adequate at rest, it becomes inadequate as the oxygen demands of the leg musculature increase with activity. This results in calf muscle pain or fatigue, a symptom known as intermittent claudication. As the degree of atherosclerotic occlusion worsens, blood flow, even at rest, may become impaired. This may cause ischemic pain at rest, ischemic ulceration, and gangrene.
Acute arterial occlusion
Acute occlusion of peripheral arteries commonly involves the infrainguinal segment. Underlying atherosclerotic disease may result in intraluminal strictures that impair blood flow and cause acute thrombosis. Emboli typically lodge at bifurcations and, hence, tend to occlude the distal common femoral artery (the most common site, comprising 34% of all arterial emboli) or distal popliteal artery (14%). Popliteal artery aneurysms may thrombose as a result of turbulent blood flow.
The clinical indications of acute occlusion of lower extremity arteries are the following classic 6 "P"s : -
Paresthesias
Pain
Poikilothermia (coolness)
Pallor
Pulselessness
Paralysis
The anatomic level at which pulse loss occurs helps identify the location of the occlusion.
Diagnosis
Physical examination discloses absent or diminished peripheral pulses below a certain level. Although diminished common femoral artery pulsation is characteristic of aortoiliac disease, infrainguinal disease alone is characterized by normal femoral pulses at the level of the inguinal ligament and diminished or absent pulses distally.
Specifically, loss of the femoral pulse just below the inguinal ligament occurs with a proximal superficial femoral artery occlusion. Loss of the popliteal artery pulse suggests superficial femoral artery occlusion, typically in the adductor canal. Loss of pedal pulses is characteristic of disease involving the distal popliteal artery or its trifurcation.
Importantly however, be aware that absence of the dorsalis pedis pulse may be a normal anatomic variant, noted in approximately 10% of the population. On the other hand, the posterior tibial pulse is present in 99.8% of persons aged 0-19 years. Hence, absence of both pedal pulses is a more specific indicator of peripheral arterial disease.
Other findings suggestive of atherosclerotic disease include a bruit heard overlying the iliac or femoral arteries, skin atrophy, loss of pedal hair growth, cyanosis of the toes, ulceration or ischemic necrosis, and, after 1-2 minutes of elevation above heart level, pallor of the involved foot followed by dependent rubor (see Image 2).
Differential diagnoses
Pseudoclaudication
Although ischemic findings in the face of absent pulses clearly pinpoint arterial insufficiency as the culprit, intermittent claudication, even when associated with absent pulses, is not always due to arterial insufficiency.
If symptoms are not always reproducible (ie, the patient sometimes has "good days" when ambulation is not limited by claudication) or if the symptoms are associated with low back pain or radiculopathy, the clinician should consider the possibility of pseudoclaudication, which occurs as a result of spinal stenosis or cauda equina syndrome.
In that case, the pulse deficit may be an incidental finding of asymptomatic atherosclerosis. Noninvasive vascular laboratory testing (see Lab Studies), lumbosacral imaging, and neurologic evaluation all may contribute to distinguishing between these possibilities.
Two rather unusual conditions, venous claudication due to extensive iliofemoral venous thrombosis and chronic compartment syndrome due to calf muscle hypertrophy in athletes, result in a bursting type of pain in the calf with ambulation, which subsides slowly with elevation. In each case, the etiology is impaired venous outflow.
Atheroembolism
Patchy areas of ischemia involving the feet, especially in the presence of palpable pedal pulses, suggest the possibility of atheroembolism of plaque fragments from ulcerated, although nonocclusive, proximal atherosclerotic plaques or from thrombus lining the wall of an infrarenal aortic aneurysm (see Abdominal Aortic Aneurysm).14
Buerger disease
Severe ischemia of the toes with absent pedal pulses but normal proximal pulses in a man aged 35-50 years who smokes cigarettes may be the result of Buerger disease (thromboangiitis obliterans).15 Ischemia of the fingers may also be present. The digits are cool, moist, mottled, and sometimes have tender shallow ulcers. Migratory superficial phlebitis may occur.
Collagen-vascular disease must be excluded.16 See the eMedicine article Buerger Disease (Thromboangiitis Obliterans). Angiography reveals pathognomonic findings of "corkscrew" arteries. Treatment is discontinuation of smoking and good local wound care. Vascular surgery is rarely possible because of the poor quality of the distal arteries.
Complex regional pain syndromes (CRPSs) have been classified by the World Health Organization as CRPS II (ie, causalgia), which is associated with a demonstrable nerve injury, and as CRPS I (ie, mimocausalgia, reflex sympathetic dystrophy, Sudeck atrophy), which includes the remainder. Causalgia (ie, causos, heat; algos, pain) was first described in patients with arterial and nerve injuries sustained during the American Civil War. Both variants remain poorly understood and often misdiagnosed.
Although the exact pathophysiology is elusive, the sympathetic nervous system clearly plays a focal role. Therefore, surgical sympathectomy-perfected decades ago by vascular surgeons to manage nonreconstructible arterial disease (a common situation at the time)-was once the mainstay for treatment of the CRPSs.
Although surgical sympathectomy is now mostly notable only for historic purposes, sympathetic blockade is quite effective and is commonly performed for the CRPSs. Hence, currently the treatment of CRPSs is performed mainly by pain management specialists. Nonetheless, because the vascular surgeon has always been primarily responsible for the diagnosis of extremity symptoms, it is not uncommon for patients with CRPS to report to a vascular surgeon because of extremity pain.
Such pain may occur after extremity trauma but may seem disproportionate to the degree of injury.17 Pain may also manifest after delayed revascularization of an acutely ischemic extremity. The diagnosis is often one of exclusion and thus requires a high index of clinical suspicion. The diagnosis should be considered more strongly if severe superficial burning pain and agonizing hypersensitivity are present and are associated with vasomotor abnormalities such as edema, erythema, and hyperhidrosis. Radiographic studies may demonstrate relative and patchy osteopenia in the involved extremity.
In addition to symptomatic relief, management of the CRPSs requires sympathetic blockade. This is best performed during the early, acute stage when the clinical course may be reversible. As the disease progresses, the erythema gives way to cyanotic mottling, the acute edema transforms to brawny edema, and the pain becomes unrelenting and disabling. These findings occur at approximately the third month and represent the second, or dystrophic, stage. At this point, both plain radiographs and bone scans tend to demonstrate indicative findings.
Over time, disuse leads to atrophy, soft tissue fibrosis, and joint contractures. Radiographs confirm ankylosis and severe osteoporosis. This signals the third, or atrophic, stage. Note that atrophy can also occur because of intentional disuse for anticipated secondary gain. Such patients reportedly do not respond to treatment until litigation has concluded.
Typically, the clinician does not even consider the diagnosis of a CRPS until the second stage. At that point, a dramatic clinical response to sympathetic blockade may confirm the diagnosis. Unfortunately, too much damage may have already occurred for sympathetic ablation to be effective and to break the vicious cycle of pain, sympathetic overactivity, and pain; the progression of the CRPS may be inexorable and irreversible.
One other caveat is that in the face of coexisting arterial disease, the vascular surgeon who may attribute the symptoms to ischemia and thereby may consider bypass should be aware that a surgical incision tends to exacerbate the pain in an extremity afflicted with a CRPS.
For more information, also see the eMedicine article Complex Regional Pain Syndrome.
Popliteal artery entrapment syndrome
Intermittent claudication occurring in younger persons (from the teens to approximately age 45 y), particularly males, raises the possibility of popliteal artery entrapment syndrome.18
In this unusual condition, the artery follows an aberrant course around the gastrocnemius muscle, usually medial to the medial head instead of between the 2 heads of this muscle. Ambulation causes the muscle to compress the artery and results in transient loss of distal blood flow. Over time, the artery may thrombose or become aneurysmal.
Prior to complete thrombosis, this condition can sometimes be confirmed clinically by noting loss of the pedal pulse upon active plantar flexion or passive dorsiflexion of the foot. CT scanning or MRI can reveal the muscular abnormality, and angiography with stress views can confirm the diagnosis.
Treatment entails sectioning the aberrant muscle fibers. Bypass grafting is needed if the occlusion is chronic in nature. Assessing the contralateral side is important because one third of cases are bilateral.
Cystic adventitial disease of the popliteal artery
Intermittent claudication of abrupt onset occurring in a relatively young male also may be the result of cystic adventitial disease of the popliteal artery.19
This rare congenital anomaly is the result of ganglionlike cysts, perhaps from an adjacent synovium, compressing the artery. This compression may eventually lead to thrombosis of the artery.
Prior to occlusion, pedal pulses may be found to disappear with flexion of the knee joint. Ultrasonography, CT scanning, or MRI may demonstrate the cyst, while angiography may demonstrate a characteristic hourglass deformity, which has been termed the scimitar sign.
Cystic adventitial disease of the popliteal artery is treated surgically by removing the cyst. Vascular bypass is required if occlusion has occurred.20
Indications
Indications for lower extremity revascularization include gangrene, pain at rest, nonhealing arterial ulcer, and disabling claudication.
Imaging Studies
Conventional Angiography : - If surgical treatment is contemplated, angiography is needed to delineate the extent and significance of atherosclerotic disease. Major risks associated with conventional contrast-injection angiography are related to the puncture and to the use of contrast agents.
Technique : - Typically, a catheter is inserted retrograde via a femoral puncture, and contrast is power-injected into the infrarenal aorta. Films are taken as the contrast is followed down to both feet. In certain cases, as with aortic occlusion, a femoral approach to the aorta may not be possible. In this case, the radiologist may use an alternate entry such as via an axillary artery or even directly into the infrarenal aorta via a translumbar approach.
Puncture-related complications : - The arterial catheter is usually passed through a 5-F sheath that is 1.6 mm in diameter. This is a sizable hole in the femoral artery, which may be only 6-10 mm in diameter. After the catheter is removed, gentle pressure must be applied to the puncture site for approximately 30 minutes, and the radiologist must balance the need for hemostasis against the possibility of arterial occlusion. Risks include hemorrhage, pseudoaneurysm formation, and clotting or dislodgement of an intimal flap, which may acutely occlude the artery at or near the entry site. Currently, newer methods of percutaneous closure of the puncture sites have significantly reduced the site complication rates.
Contrast-related risks : - Angiographic contrast material is nephrotoxic. The risk of precipitating acute renal failure is highest in patients with underlying renal insufficiency and those patients with diabetes. Patients with both of these risk factors have a 30% rate of acute renal failure following contrast angiography. Hence, an acceptable serum creatinine level must be confirmed prior to elective angiography. Avoid contrast angiography (if possible) for patients with any significant degree of renal impairment. If contrast angiography is absolutely required despite renal impairment, use a minimal volume of contrast material. In addition, providing adequate hydration prior to, during, and after the procedure is essential. Oral administration of the antioxidant acetylcysteine (Mucomyst) the night prior to and then just before angiography may be protective of renal function for patients at risk of contrast-induced nephropathy.23
Metformin warning : - To prevent the possibility of fatal lactic acidosis, patients with diabetes who are taking metformin (Glucophage) must not take this medication immediately following contrast angiography. Patients may resume taking the medication when normal renal function is confirmed 1-2 days after contrast exposure.
Alternatives to conventional angiography
Magnetic resonance angiography : - Magnetic resonance angiography (MRA) is an alternative both for patients for patients who are allergic to iodinated contrast material. MRA is not innocuous. Gadolinium chelates, the contrast agents used in MRA, have been linked recently to three potentially serious side-effects in patients with renal insufficiency: acute renal injury, pseudohypocalcemia, and nephrogenic systemic fibrosis.24 MRA is contraindicated in patients with implanted hardware such as a hip prostheses or pacemakers. The resolution may be inadequate for the vascular surgeon in planning reconstructive procedures, particularly in the smaller infrapopliteal arteries, although MRA technology and contrast agents continue to improve.25
Multidetector computed tomographic angiography (MDCT) : - MDCT avoids arterial puncture. By using precisely timed intravenous contrast injection, multidetector (16 or 64 channel) CT scanners can generate angiographic images of excellent resolution and at a relatively high acquisition speed. MDCT carries the contrast-related risks described above.26
Carbon dioxide angiography : - Carbon dioxide angiography is an alternative for patients with renal insufficiency; however, it is not widely available and requires some iodinated contrast material in addition to the carbon dioxide gas in order to provide useful images.
Plain radiography : - Plain radiographs are not routinely obtained in the workup of peripheral arterial occlusive disease. This is because arterial calcification seen on plain radiographs is not a specific indicator of severe atherosclerotic disease. Calcification of the arterial media is not diagnostic of atherosclerosis, and even calcification of the arterial intima, which is diagnostic of atherosclerotic disease, does not necessarily imply hemodynamically significant stenosis.
Treatment
Medical Therapy
Most patients with atherosclerotic lower extremity disease do not undergo surgical treatment. In fact, only 25% of patients presenting with intermittent claudication eventually require invasive treatment of limb-threatening ischemia or intractable symptoms, and only 5-10% do so within 5 years of the onset of claudication.
The cornerstones of medical management of intermittent claudication are walking and elimination or control of medical risk factors.27,28 For further reading, see the eMedicine articles Atherosclerosis and Coronary Artery Atherosclerosis.
Walking
Encourage walking.29 Regular walking of approximately 1 hour per day usually results in a significant increase in walking distance over time. This increase in walking distance has been noted to range from 80% to more than 200%. Improvement results from improved flow in collateral pathways.
Risk factor management
Discontinue cigarette smoking. A major factor contributing to progressive and intractable atherosclerotic disease is cigarette smoking. One study noted an 85% chance of improvement if smoking is stopped versus only a 20% chance of improvement if the patient continues smoking.
Control medical risk factors. Other risk factors that must be assessed and controlled are obesity, hypertension, hyperlipidemia30
Ensure meticulous foot care. Because an ischemic foot is at risk for developing limb-threatening ulceration from even minor trauma, good foot hygiene and appropriately fitting shoes are important. This is even more vital for patients with diabetes, who are also at risk for neuropathic foot ulcers.
Surgical Therapy
Surgical or endovascular intervention is indicated for intractable and disabling claudication, for ischemic pain at rest, and for ischemic necrosis (see Image 1). Surgery also may be useful for nonhealing ischemic ulceration.
Before considering surgical intervention, the clinician must address the possibility of coexisting atherosclerotic heart and cerebrovascular disease, which are extremely common in patients with atherosclerotic peripheral arterial disease. One study found that only 14% of patients with peripheral arterial disease had normal coronary arteries, while 15% had severe coronary artery disease that required surgical correction. See the eMedicine article Atherosclerosis for the cardiologic workup.
Obtain appropriate imaging studies. Before surgical intervention, the exact extent of the atherosclerotic disease is mapped using high-quality contrast angiography (see Imaging Studies).
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