Page 5 - Carotid and peripheral vascular interventions textbook

CHAPTER 12 • FEMOROPOPLITEAL ARTERIAL DISEASE

population (11). This disorder mainly impacts active and 4) to monitor the result of percutaneous and surgical
young athletes with no prior cardiovascular risk factors’ revascularization therapy. The ankle-brachial index
history. Patients usually present complain of intermittent (ABI) is both a reproducible and inexpensive way of
calf and foot pain which happens following exercise and evaluating lower extremity hemodynamics. The ABI is
disappears at rest. If left untreated, the PAES may cause the ratio of the highest systolic pressure within each leg,
distal arterial thromboembolism, popliteal artery thrombosis taken at the posterior tibial and dorsalis pedis arteries
(PAT), popliteal artery stenosis (PAS), as well as limb with a Doppler probe with the higher of the left or right
amputation. Screening for high-risk patients who need arm brachial artery pressure. ABI ratio less than 0.9 are
prompt surgical intervention is important to prevent these indicative of diagnosis of PAD and values below 0.5
complications. indicate severe PAD. When ABI has conf rmed PAD,
it is required to delineate the diseased lesion and assess
CLINICAL PRESENTATION revascularization therapy options. Several methods have

been applied to def ne the location of the affected arteries.
Intermittent claudication is the most common Each method has its strengths and limitations.
manifestation of isolated femoropopliteal arterial disease.
It is def ned as pain, cramping, discomfort or fatigue Segmental limb pressure and
within the calf muscles which is continually caused by pulse volume recordings
exercise, but rest relieves it within 10 minutes. If the PFA The location and extension of PAD may additionally
circulation is normal, there is possibility that patients may be def ned by using segmental limb pressure measurements,
be asymptomatic or if symptomatic, the claudication is recorded by a doppler instrument using plethysmographic
usually relieved with exercise training and intervention is cuffs covering the brachial arteries and different points
unnecessary. CLI (i.e., ischemic rest pain or non-healing on the lower limb, which need to include the upper thigh,
ulceration) is uncommon, and when it occurs, patients the lower thigh, the upper calf just below the knee, and
always have multi-level arterial occlusive disease the ankle. A pressure gradient of more than 20 mm Hg
involving infrapopliteal tibial arteries. Revascularization between the lower thigh and the upper calf suggests distal
of the femoropopliteal arteries to increase proximal SFA or popliteal artery disease. As noted, patients with
in-f ow might be enough to alleviate ischemic pain and well-formed collateral f ows might not show a signif cant
to promote wound healing. pressure gradient. Besides segmental limb pressure, pulse
Peripheral vascular examination should include volume recordings (PVRs) can evaluate changes within
palpation for all lower extremity pulses as well as each limb’s volume, in various leg segments, within
auscultation for vascular bruit, especially at the femoral every cardiac cycle. Using segmental limb pressures and
arteries. Absent or diminished pulses of popliteal artery PVRs measurements together, the accuracy rate is 95%
suggests femoropopliteal occlusive disease. In case of tibial in detecting and localizing occlusive disease compared 333
vessel involvement, other physical f ndings at the foot with angiography (12).
should be examined such as shiny skin, hair loss, muscle
atrophy, and non-healing wound or ulcers. Dependent Arterial duplex ultrasonography

rubor with elevation pallor can appear in advanced disease Duplex ultrasonography (DUS) is a precise method
which is caused by impaired autoregulation within dermal of determining the location and degree of stenosis of
arterioles and capillaries. femoropopliteal disease. The DUS combines doppler
velocities and doppler waveform analysis. Doppler
DIAGNOSTIC TESTS waveforms may change from a typical triphasic pattern
to a biphasic and, f nally, monophasic presentation in
Noninvasive vascular studies are used in many signif cant PAD patients (Fig. 12-3). DUS is increasingly
purposes, including 1) to conf rm PAD diagnosis in used to assess the hemodynamic effects of localized
patients with equivocal history or physical f ndings, 2) to stenoses and peripheral arterial anatomy with high
grade the severity and to determine the level of stenosis sensitivity and specif city. However, the accuracy of the
or occlusions, 3) to follow the progression of disease, study is highly operator dependent.