Peripheral Arterial Disease

A common condition known as peripheral artery disease, or just peripheral arterial disease, is when the blood flow to the arms and legs is reduced due to narrowed arteries. When a person has peripheral artery disease (PAD), their blood flow is insufficient in the legs, arms, or both to meet their body's needs. Walking-related leg pain (claudication) and other symptoms could result from this. Atherosclerosis, or the accumulation of fatty deposits in the arteries, is typically indicated by peripheral artery disease. Narrowing of the arteries brought on by atherosclerosis may lessen blood flow to the arms and legs.

Signs and Symptoms of Peripheral Arterial Occlusion 

These are characterized by 5Ps:

• Pain
• Pallor
• Paresthesia
• Paralysis
• Pulselessness
• Poikilothermic

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Causes of Peripheral Arterial Disease

• Atherosclerosis
• Borges disease
• Takayasu arthritis
• Systemic lupus erythematosus
• Post-traumatic
• Radiation Injury- The radiation injury can lead to obliterative and arthritis and hence causes arterial occlusion.

Pathophysiology of Causes of Peripheral Arterial Disease

• Atherosclerosis
  • It is the most common cause of peripheral arterial disease and it occurs mainly in the 6^th to 7^th decade of life.
  • The main arteries involved are the aorta, iliac artery, femoral artery, and popliteal artery. It mainly involves the lower limb.
  • The manifestation of peripheral arterial diseases depends on the site of occlusion of the artery. The tissue that is distal to the artery occlusion becomes ischemic and if that artery is supplying the muscles, it will lead to intermittent claudication.
  • The manifestations depend on the site of obstruction. In aortoiliac disease, there will be intermittent claudication of the buttock, thigh, and calf. Some of the patients can experience erectile dysfunction and impotence and this disease is called Leriche syndrome.
  • In the case of common femoral artery involvement, thigh and calf claudication occurs.
  • In the case of superficial femoral artery and popliteal artery obstruction, calf claudication will occur.
• Thromboangitis Obliterans or Buerger’s disease
  • It is seen in young and male smokers.
  • It generally involves small and medium-sized vessels like the Tibial artery, plantar artery, and radial artery.
  • The lower limb is involved more than the upper limb.

The clinical features of Buerger’s disease can be remembered by any mnemonic RIM:

• Raynaud’s phenomenon
• Intermittent claudication
• Migratory superficial thrombophlebitis
• It is very important to note that when the disease progresses over a particular period of time, the claudication distance decreases.
• Buerger’s disease is diagnosed by Four limb angiography and due to the chronic nature of the disease, there is the development of collaterals known as Corkscrew collaterals.
• The ankle-brachial pressure index is assessed in this condition and the interpretations are as follows:
  • 0.1-0.4 – Critical Limb Ischemia
  • 0.5-0.9- Intermittent Claudication
  • 1.0-1.2- Normal
  • >1.2- Calcified Vessels

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Treatment of Peripheral Arterial Disease

• The most important advice that the patient should be given is abstinence from smoking completely.
• Vasodilators are not very helpful but can be given.
• Lumbar sympathectomy is performed if there is rest pain because the rest pain is caused by cutaneous ischemia and the blood supply to the muscle is not under sympathetic control, and is not used for intermittent claudication.
• Omental transposition can be performed.
• For a patient with gangrene, amputation is the only option.
• Embolic occlusion
  • The embolus is a thrombus which is detached from the heart or proximal vessels.
  • The most common source of embolus is left atrium and it is mainly seen in patients with atrial fibrillation.
  • The second most common source of embolus is mural thrombus which is a thrombus in myocardial infarction patients.
  • The manifestation in embolic occlusion is dependent on the organs involved.
  • If the brain is involved then the symptoms of transient ischemic attack or stroke will be present.
  • There is a term called as amaurosis fugax which is a temporary loss of vision when the embolic occlusion is present in retinal artery.
  • If Mesenteric vessels are involved then ischemia and gangrene of small bowl will occur.
  • If kidney vessels are involved then the patient will present with symptoms of loin pain and hematuria.
  • Diagnosis of embolic occlusion is made clinically because it is an emergency.

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The Diagnosis of Embolic Occlusion is Characterized By

• No history of claudication.
• The patient will have evidence of the source of the emboli.
• The distal pulses are not palpable.
• The movements become difficult and painful.
• The patient will have severe pain and numbness in the limb.

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Management of Embolic Occlusion

• The patient will be started on intravenous heparin as it is an emergency, it will help to reduce the extension of the thrombus and it will maintain the patency of the vessel.
• Embolectomy or thrombectomy should be performed using a Fogarty balloon catheter.

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