D i a g n o s t i c A p p ro a c h

to Peripheral Arterial
Disease
Salman M. Azam, MDa, Teresa L. Carman, MDb,c,*

KEYWORDS
 Peripheral arterial disease  Vascular imaging
 Diagnostic testing  Angiography  Noninvasive testing

The peripheral arterial system includes all noncar- is equal.4 Disease prevalence increases with
diac arteries: the thoracic and abdominal aortas advancing age and cardiovascular risk factors. In
and their branches extending to visceral organs one study, lower extremity PAD was identified
and both upper and lower extremities as well as in 29% of patients older than 70 years or patients
the extracranial vessels. Although the awareness older than 50 years with a history of smoking or
of peripheral arterial disease (PAD) has increased diabetes.5 Patients older than 70 years in the
in the past decade, PAD remains underdiagnosed National Health and Nutrition Examination Survey
and undertreated. The development of PAD guide- and patients older than 65 years in the Framing-
lines has helped increase awareness and define ham Heart Study had an increased risk of devel-
diagnostics and treatment strategies in PAD.1,2 oping PAD, with a prevalence of 4.3% in patients
Atherosclerotic disease is the most common older than 40 years compared with 14.5% in
cause of PAD, but nonatherosclerotic vascular patients older than 70 years.6 African Americans
disease may cause similar symptoms and must and Hispanics have an increased risk of PAD
be considered in patients presenting with vascular compared with Caucasians.
insufficiency. The differential diagnosis of patients Most patients with lower extremity PAD are
presenting should therefore include entrapment asymptomatic, whereas others may experience
syndromes at the thoracic outlet or popliteal fossa, nondescript leg symptoms. Typical symptoms
cystic adventitial disease, fibromuscular dyspla- associated with PAD include claudication,
sia, endofibrosis of the iliac artery, embolism, ischemic rest pain, ischemic ulcerations, and
thromboangiitis obliterans (Buerger disease), and gangrene. Compared with age-matched controls,
vasculitis, such as Takayasu arteritis or giant cell patients with asymptomatic PAD have poorer
arteritis.3 Musculoskeletal syndromes associated functional performance and quality of life as well
with arthritis, compartment syndrome, myositis, as smaller calf muscle area and greater calf
or pseudoclaudication may also present in a similar muscle fat.7 In general, patients perform poorly
fashion. on health-related quality-of-life questionnaires
From epidemiologic studies, approximately 12% and have an increased rate of depression. These
of the adult population has PAD. At younger ages, patients are at risk for recurrent hospitalizations,
PAD is more prevalent in men than in women; revascularizations, as well as limb loss.2,8,9 More
however, with advancing age, gender distribution importantly, patients with PAD have a higher rate

The authors have nothing to disclose.

cardiology.theclinics.com

a
Harrington-McLaughlin Heart and Vascular Institute, University Hospitals Case Medical Center, 11100 Euclid
Avenue, Mailstop LKS 5038, Cleveland, OH 44106, USA
b
Vascular Medicine, Harrington-McLaughlin Heart and Vascular Institute, University Hospitals Case Medical
Center, 11100 Euclid Avenue, Mailstop LKS 5038, Cleveland, OH 44106, USA
c
Division of Cardiovascular Medicine, Case Western Reserve University School of Medicine, OH, USA
* Corresponding author. Vascular Medicine, Harrington-McLaughlin Heart and Vascular Institute, University
Hospitals Case Medical Center, 11100 Euclid Avenue, Mailstop LKS 5038, Cleveland, OH 44106.
E-mail address: teresa.carman@uhhospitals.org

Cardiol Clin 29 (2011) 319–329

doi:10.1016/j.ccl.2011.04.004
0733-8651/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
320 Azam & Carman

of all-cause mortality and are at an increased risk dependent. Tissue loss includes the presence of
of cardiovascular events, including myocardial ischemic ulcerations or frank gangrene.
infarction (MI), stroke, and cardiovascular death, Physical examination includes measurement of
compared with those without PAD.10–13 This blood pressure in both arms, cardiac auscultation
finding highlights the importance of early diagnosis for heart rate and rhythm, auscultation for carotid,
of PAD and institution of treatment, both to limit subclavian, abdominal, and femoral artery bruits,
progression of PAD and reduce the risk of cardio- abdominal palpation for signs of aortic aneurysm,
vascular and all-cause mortalities. palpation of peripheral pulses in all 4 extremities;
and inspection of the 4 extremities to assess for any
DIAGNOSIS OF PAD signs of PAD.14 A blood pressure difference of more
than 15 mmHg between the 2 arm cuff measure-
A thorough history taking and physical examination ments indicates innominate, subclavian, or axillary
is the first step in diagnosing PAD before under- artery disease. The presence of arterial bruits
taking diagnostic testing. Any history of PAD, tran- warrants further investigation. One meta-analysis
sient ischemic attack, or stroke, prior diagnostic involving 17,295 patients showed that the yearly MI
studies, as well as interventions such as carotid rate and cardiovascular death were 2 times greater
endarterectomy, percutaneous stenting, or periph- in patients with carotid bruits than that in those
eral bypass surgery assist with formulating the next without carotid bruits.17 Peripheral pulses should be
step in the evaluation of the patient. The initial eval- described as bounding (31), normal (21), diminished
uation should include an assessment of the (11), or absent.7 Widened arterial pulsations in the
patient’s functional status and living situation, risk femoral or popliteal artery should be noted, which
factors, and comorbidities, such as cardiac, pul- may indicate the presence of a peripheral aneurysm.
monary, or renal diseases, which may influence Careful inspection of the extremities should include
the diagnostic and/or therapeutic strategy, and observation for ulcerations, calluses, tinea pedia,
gauge any decline in the patient’s activity level.14 trophic skin changes, infection, and pallor on eleva-
This evaluation allows the clinician to establish tion or temperature changes relative to the proximal
a preliminary diagnosis and determine the most and/or contralateral limb.
appropriate treatment. Most interventions are per- Noninvasive diagnostic testing should support
formed electively in patients with PAD, whereas the clinical diagnosis of PAD and supplement
more-urgent intervention may be required in the a thorough history taking and physical examina-
setting of critical limb ischemia. tion. In addition, noninvasive testing is useful to
Many patients with PAD are asymptomatic, and document the severity of disease, provides a base-
although patients do not have symptoms with their line for follow-up, and can help predict the potential
activities of daily living, they may have functional for ulcer/wound healing. Of the available noninva-
impairment on formal testing.3 PAD may not sive diagnostic tests, only the ankle-brachial index
present with classic claudication symptoms, and (ABI), segmental pressure measurement, and pulse
properly phrasing questions to obtain pertinent volume waveform analysis can provide physiologic
information from the patient is essential. Atypical information about perfusion of the extremities.
symptoms of PAD include lower extremity discom- Other noninvasive imaging techniques can assist
fort or fatigue that begins during exertion but is not with planning endovascular or surgical treatment.
reproducible with the same level of exertion and
may require a longer period of time to resolve.
Continuous Wave Doppler
Classic symptoms include pain, discomfort and
heaviness, tiredness, cramping, and burning The most basic assessment of arterial flow is per-
sensation in the muscles of the calf, hip, thigh, or formed using continuous wave Doppler (CWD).
buttocks, which is reproducible with a similar level CWD may be used in the office or at the bedside
of activity such as walking and disappears after to provide a qualitative assessment of arterial
several minutes of rest. The same symptoms recur vascular flow. The audible Doppler signal is quan-
once walking is resumed. The Rose Angina and tified in terms of strength and phasicity. CWD can
Claudication Questionnaire and the Edinburgh neither determine the depth of the vessel nor
Claudication Questionnaire can be used to assist assess the direction of flow. In a high-resistance
clinicians with screening patients for PAD at the vascular bed, such as the lower extremity, the
time of the initial history taking and physical normal Doppler signal is triphasic. A triphasic
examination.15,16 Critical limb ischemia includes signal has 3 audible components: forward flow of
symptoms of rest pain or tissue loss. Rest pain is systole, early reverse flow of diastole, and late
characterized by pain in the toes or distal forefoot forward flow of diastole.14 In a low-resistance
with elevation, which is relieved when the limb is vascular bed, such as the internal carotid artery
 PAD Diagnosis 321

or lower extremity after exercise, the Doppler PAD. In the absence of PAD, treadmill exercise
signal demonstrates continuous forward flow and increases blood flow to the extremities; as such,
is biphasic because of the lack of diastolic the ABI increases slightly and remains elevated
reversal. The Doppler probe is also used for for several minutes. In patients with proximal
measuring segmental pressures and the ABI. PAD, exertional vasodilation of the lower extremity
vascular bed increases blood velocity across the
stenosis and decreases blood pressure distally, re-
ABI
sulting in decreasing ABI and a slower return to
The ABI is an addition to the physical examination baseline. Exercise testing also allows an objective
and is considered the single best initial screening assessment of symptom limitation in patients with
test in patients with suspected PAD. The ABI corre- claudication. This testing allows clinicians to better
lates well with the severity of obstruction; however, formulate individualized therapeutic exercise
it is poorly correlated with functional impairment programs. Motorized treadmills and standard fixed
because of PAD.3 The ABI is easy to perform and load or graded protocols are used in most labora-
can be done at the bedside. A handheld CWD tories. However, alternative forms of exercise
and a manual blood pressure cuff are the only such as active pedal plantar flexion, stair climbing,
required equipments. The Doppler probe is placed hallway walking, or a 6-minute walk test can also
over the arterial signal. The blood pressure cuff is be used.2,27,28 For patients in whom standard
inflated until the arterial signal disappears, the supine ABI testing is not possible, a protocol to
cuff is slowly deflated, and the pressure at first measure seated ABIs has been validated and can
return of an audible signal is recorded. The ABI is be used to assess for PAD as well.29
calculated as the ratio of highest ankle systolic The ABI alone does not provide information about
pressure, from either the dorsalis pedis or posterior the level of obstruction. Segmental blood pressure
tibial artery, to the highest arm systolic pressure measurement assists in anatomic localization of
recorded over the brachial artery. An ABI of obstruction and can help predict wound healing as
between 0.91 and 1.3 is considered normal. An well as limb survival. Segmental blood pressures
ABI of 0.71 to 0.90 indicates mild obstruction, may be performed using a 3- or 4-cuff method. In
0.41 to 0.70 is consistent with moderate obstruc- the 3-cuff method, appropriately sized blood pres-
tion, and 0.00 to 0.40 denotes severe ob- sure cuffs are placed at the level of the upper thigh,
struction.18,19 A low ABI, consistent with arterial proximal calf, and ankle. In the 4-cuff method,
occlusive disease, is an independent predictor of a fourth cuff is placed at the level of the distal thigh.
increased mortality.10,20–24 Patients with an ABI Similar to the ABI measurement, the cuff is pressur-
less than 0.90 have a 5-year mortality approaching ized to occlude the artery, and using a Doppler
25% and are twice as likely to have a history of MI, probe, the first return of audible Doppler signal is re-
angina, and heart failure as patients with ABI corded. Each cuff isolates the arterial segment prox-
greater than 1.00.23,25,26 An ABI greater than imal to the cuff. The pressure at the ankle should
1.30 suggests the presence of medial calcinosis be similar to the brachial pressure, and the pressure
and noncompressibility of the vessels. This situa- at the thigh is usually slightly higher. A pressure
tion is most commonly encountered in patients decrease between cuff segments of more than
with diabetes or renal failure. An ABI greater 20 mm Hg indicates obstructive disease. This nonin-
than 1.40 has been associated with increased vasive test may be useful for anatomic localization of
cardiovascular and all-cause mortalities.10 obstructive disease and may assist in planning
In patients with ABI greater than 1.3 and sus- further imaging or intervention (Fig. 1). Both the
pected medial calcinosis, the toe-brachial index ABI and segmental blood pressures are useful in
(TBI) is a better assessment of underlying vascular monitoring the success and patency of therapeutic
disease because the digital vessels of the toes are interventions. Although generally well tolerated,
often spared from the process and accurate some patients may find the inflation pressure
pressure measurements can be obtained. A 2-cm required to occlude the thigh cuff uncomfortable.
cuff is placed at the toe, and a photoplethysmogra- In addition, segmental blood pressures may be inac-
phy (PPG) sensor is placed at the tip. A TBI less than curate with extensively developed collateral flow.
0.7 is considered abnormal. TBIs can be used to
predict healing of wound and foot amputation sites.
Pulse Volume Recording
An open wound is unlikely to heal in patients with an
absolute toe pressure of less than 30 mm Hg. Air plethysmography (APG) and PPG are other
In patients with a normal resting ABI but typical noninvasive techniques used to assess PAD.
symptoms of claudication, exercise or treadmill These techniques require an appropriately sized
ABI can be helpful in unmasking the presence of blood pressure cuff, a transducer, and a recording
322 Azam & Carman

Fig. 1. Demonstration of segmental arterial pressures and pulse volume recording (PVR) of the lower extremities.
The ABI is normal on the right (ABI 5 1.02) and demonstrates moderate disease on the left (ABI 5 0.59). Both the
segmental pressure measurements and PVR waveforms suggest obstruction at the level of the left femoral and
popliteal arteries. Amp, amplitude; BP, blood pressure; DP, dorsalis pedis; PT, posterior tibial.

instrument. The pulse volume recording (PVR) is (catacrotic slope), which bows toward the base-
a form of APG. A blood pressure cuff is placed line. With increasing arterial obstruction, the PVR
on the lower extremity and inflated to a baseline tracing becomes progressively flattened and
pressure of approximately 65 mm Hg. Placement prolonged.14 The PVR only allows for qualitative
of the cuffs is similar to those used for segmental interpretation of the waveform. The PVR is useful
pressures, and the cuff is attached to the plethys- in predicting the outcome in critical limb ischemia
mograph. The lower extremity pulsatile flow and risk of amputation as well as in monitoring limb
causes small changes in limb volume, which are perfusion after revascularization. A severely flat-
recorded as arterial contours and provide indirect tened PVR tracing at the ankles suggests a limited
qualitative information about the arterial blood flow opportunity for wound healing. In patients with
and correspond to direct arterial pressure wave- noncompressible vessels, the PVR tracing is
form recording at that level. The normal PVR more reliable than segmental pressure or the
tracing has a sharp upstroke (anacrotic slope), ABI. Therefore, PVRs are often combined with
a distinct pulse peak, and a rapid decline segmental pressure measurement, particularly in
 PAD Diagnosis 323

patients with noncompressible vessels (see proximal intrathoracic vessels, such as the aortic
Fig. 1).30 PVR waveforms may be abnormal in arch, supra-aortic trunk, and distal cervical and
patients with low cardiac output or influenced by intracranial carotid arteries, are not amendable to
technologist inexperience with cuff placement. ultrasound imaging.14
Although not yet approved by the Food and
Drug Administration (FDA), the newly developed
Duplex Ultrasonography
ultrasound contrast agents show promise in the
Duplex ultrasonography combines B-mode imaging of lower extremities and renal arteries as
imaging and pulsed wave Doppler imaging. Duplex well as for endograft surveillance.35–39 Several
ultrasonography is an accurate, cost-effective, other imaging advances stand to change the
noninvasive method to localize stenosis and differ- current ultrasound imaging technology. Three-
entiate stenosis from occlusion. This technique dimensional ultrasound imaging and ultrasonic
does not require any intravenous contrast adminis- computed tomography for precisely determining
tration or radiation. Gray-scale or B-mode imaging the location, extent, and configuration of vascular
creates a 2-dimensional (D) image of the arterial disease are under development.40,41
wall and lumen, which allows the operator to iden-
tify morphologic changes in the arterial wall,
Magnetic Resonance Angiography
including atherosclerotic plaque and other abnor-
malities, such as aneurysms or cystic adventitial Magnetic resonance angiography (MRA) provides
disease, that may be the source of ischemic symp- excellent-quality images of the aorta and the
toms. Pulsed wave Doppler imaging, which may be peripheral vasculature, including identification of
augmented by the use of color flow Doppler, allows small runoff vessels in the foot. In many centers,
an estimation of the degree of stenosis based on MRA meets or exceeds the quality of traditional
the blood flow velocity. In the peripheral arteries, catheter-based angiography and has replaced
a peak systolic velocity greater than 200 cm/s or angiography as the procedure of choice for
a systolic velocity ratio greater than 2.5 across planning intervention or surgical therapy.42,43
the stenosis correlates with an obstruction of Gadolinium-enhanced 3D MRA affords the oppor-
more than 50% (Fig. 2). Using the combined tunity to acquire angiographic-like images.44–47
modalities of B-mode imaging and pulsed wave Compared with conventional digital subtraction
Doppler, duplex ultrasonography allows for the angiography (DSA), contrast-enhanced 3D MRA
assessment of the degree of stenosis as well as has a sensitivity and specificity of more than 90%
the character and length of stenosis in the periph- and 97%, respectively, for detecting hemody-
eral arteries.31–33 Duplex ultrasonography is also namically significant lower extremity disease.3,34
used to diagnose renal artery stenosis, mesenteric Magnetic resonance imaging (MRI) also provides
occlusive disease, carotid disease, and aortic excellent soft tissue imaging, vessel wall informa-
and/or aneurysmal disease. Duplex ultrasono- tion, and qualitative aspects of plaque, including
graphy is frequently used in surveillance programs lipid-rich plaque, intraplaque hemorrhage, and so
after endovascular therapy or surgical revasculari- forth. Combining MRI and MRA allows simulta-
zation. Recurrent leg symptoms or significant neous visualization of muscular and tendinous
decrease in ABI of more than 0.15 detects a failing structures and can help determine the cause of
bypass graft in only 50% of cases, which under- popliteal artery entrapment.
scores the importance of routine surveillance. Some of the limitations of MRA include claustro-
Serial monitoring to assess for recurrent stenosis phobia and inability to perform the technique in
or preocclusive lesions allows for repeat interven- patients with pacemakers and intracranial arterial
tion before the primary repair fails.34 aneurysm clips.48 Increased venous contamina-
Although duplex ultrasonography provides tion used to be a problem in patients with critical
excellent anatomic and physiologic information, limb ischemia or diabetic foot ulcers owing to rapid
some of the imaging studies are quite time- arterial-venous transit.49 However, this problem
consuming. Accuracy is operator dependent, and has been largely circumvented by the use of venous
studies should be performed by an experienced cuffs and judicious use of timing techniques.
vascular technologist. Obesity and overlying Although use of gadolinium-based contrast does
bowel gas can interfere with the visualization of not have strong propensity to cause contrast
the aorta and renal, mesenteric, and iliac arteries. nephropathy compared with iodinated contrast
Severe calcification, overlying skin disorders, or agents used for computed tomographic angio-
edema of the lower extremities can also interfere graphy (CTA) and catheter-based angiography,
with the imaging of the tibial arteries. Ultrasound the recent FDA warnings regarding nephrogenic
cannot penetrate bony structures; therefore, the systemic fibrosis after gadolinium administration
324 Azam & Carman

Fig. 2. Duplex ultrasonographic image of the proximal anastomosis of a femoropopliteal bypass graft. (A) Inflow
from the native common femoral artery with biphasic arterial Doppler signals. At the anastomosis (B), a velocity
shift is noted. Systolic velocity ratio is (487 cm/s:66 cm/s) 7.4, which is consistent with severe stenosis.
 PAD Diagnosis 325

in patients with severe renal insufficiency (glomer- measurements, such as pressure gradients across
ular filtration rate <30–35 mL/min) have limited the stenotic lesions; investigate the vessel wall using
use of contrast-enhanced MRA in this patient intravascular ultrasound (IVUS); and perform a ther-
population.14,50 Noncontrast MRA discussed in apeutic intervention in the same setting.56,57
this issue by Mihai and colleagues can be particu- Advances in IVUS technology, such as 3D recon-
larly advantageous in the setting of advanced struction, virtual histology, and color flow, can
chronic kidney disease or in patients on dialysis. provide information regarding plaque characteriza-
tion and may influence intervention strategy.40,58
CTA Intravascular optical coherence tomography is
a developing technology that has proved useful in
Current multidetector CTA scanners can generate
coronary imaging and intervention. Although not
high-resolution arterial images at an isotropic voxel
well studied, this technology may have a role in
resolution of 500 m, which allows superb delinea-
monitoring disease progression and outcomes of
tion of small vessels in the foot.51 The volumetric
therapeutic intervention in PAD.59–61
acquisition of axial images and software-based re-
Limitations of this technique include exposure
formatting allows the practitioner to visualize the
to ionizing radiation, use of iodinated contrast
anatomy from multiple angles and in multiple
agents, and risk of complications from vascular
planes after a single acquisition. Postprocessing
access and catheterization. Carbon dioxide
software can be used to create 3D reconstructions;
(CO2) can be used as a nonnephrotoxic contrast
multiplanar reconstruction in coronal, sagittal, and
agent in the evaluation of PAD below the dia-
axial images; as well maximum-intensity projection
phragm. Injection of compressed CO2 results in
images. Unlike DSA, CTA provides improved
displacement of blood, creating negative contrast
visualization of the arterial wall and surrounding
within the target vessel. CO2 is rapidly absorbed
soft tissues as well as other adjacent anatomic
in the blood and therefore limits the evaluation
structures. Arterial calcification, plaque ulceration,
of tibial vessels. Faster frame acquisition rates
intravascular thrombus, stent fracture, in-stent
and specialized injection equipment are neces-
restenosis, or intimal hyperplasia, which may influ-
sary for CO2 angiography. Therefore, this tech-
ence endovascular or surgical procedures, can
nique may not be applicable to all imaging
also be assessed by CTA. This technique is less
centers.62,63
invasive, with fewer complications than conven-
tional angiography.34,52,53
Positron Emission Tomography
CTA has a sensitivity and specificity of greater
than 95% for identifying greater than 50% steno- Positron emission tomography (PET) is a nuclear
ses or occlusion in the peripheral vessels.54,55 medicine functional imaging modality that
Most surgeons have acquired considerable expe- analyzes nutrient flow and uptake into perfused
rience with both preoperative planning and post- tissues, including the brain, lungs, and heart.
operative surveillance for endovascular aneurysm Recent studies have demonstrated the utility of
repair using CTA.14 Limitations of CTA are expo- fludeoxyglucose F 18 and water labeled with
sure to radiation as well as administration of intra- oxygen O 15 in evaluating skeletal muscle tissue
venous contrast and risk of contrast nephropathy. and quantifying regional muscle blood flow in
For a typical CTA, visualization of the vasculature patients with lower extremity PAD.64–66 PET has
is obtained using 100 to 150 mL of iodinated not been studied as a diagnostic modality.
contrast. Once again, timing of the contrast bolus However, the role of PET in monitoring changes
is the key to providing adequate visualization of the for disease severity over time and after therapeutic
vasculature. Extensive vascular calcification can interventions has been examined. Further investi-
obscure the lumen and overestimate the degree of gation is needed to establish the utility and cost-
stenosis. CTA techniques are covered in more detail effectiveness of PET imaging in relation to other
in a subsequent article by Walls and colleagues. imaging modalities for diagnosing PAD.

DSA and Intravascular Ultrasonography Other Imaging Technologies

In many centers, duplex ultrasonography, CTA, Hyperspectral imaging is a noninvasive tech-
and MRA have replaced traditional catheter- nology that relies on scanning spectroscopy
based imaging in the initial evaluation of PAD. based on local chemical composition and can
However, traditional DSA still plays a vital role create a 2D anatomic oxygenation map of imaged
in the management of patients with PAD. One tissue. Although still in the early stages of
major advantage of DSA is the ability to selectively development, hyperspectral imaging may prove
evaluate individual vessels; obtain physiologic useful in following the outcomes of intervention,
326 Azam & Carman

managing medical therapies for PAD, as well referral to a vascular specialist is also warranted.
as assessing wound healing.59,67,68 Molecular There are numerous modalities available to clini-
imaging of plaques by administering traceable cians to evaluate patients with suspected PAD. All
molecules, such as magnetic nanoparticles and the different imaging techniques play a role in the
radionuclides, into the body and subsequently evaluation, management, and follow-up of patients
imaging them could potentially identify high-risk with PAD. Fig. 3 outlines one clinical approach in
plaques. Being in early developmental phase, the patients with suspected PAD. Clinically, the first
infrastructure, duration of procedure, and costs step involves a thorough history taking and phys-
are present limitations of molecular imaging. ical examination, including obtaining an ABI or
Nevertheless, this technique may prove potentially TBI in patients with noncompressible vessels.
useful and cost effective in select patients.40,69 Patients with an abnormal ABI can be further eval-
uated with PVRs and segmental pressure measure-
SUMMARY ments to determine the location of disease within
the lower extremities. In addition, patients with
Most patients with PAD are symptomatic. normal ABIs and high suspicion of PAD should be
Symptomatic patients may present with typical or evaluated with exercise testing to unmask hemo-
atypical symptoms. Both symptomatic and asymp- dynamically significant disease.
tomatic patients are at an increased risk of MI, Once a diagnosis of PAD is established, appro-
stroke, and cardiovascular and all-cause mortal- priate treatment can be instituted, which includes
ities. Furthermore, progression of PAD results in aggressive risk factor modification, medical
a decreased quality of life for the affected indi- therapy, and, if indicated, invasive intervention.
vidual. Patients with known risk factors for PAD CTA or MRA studies are usually sought as prepro-
should be actively screened with appropriate phys- cedural planning for either surgical or percuta-
ical examination and diagnostic testing. Timely neous intervention. DSA, however, may allow for

Patients who are older than 50 years or with traditional cardiovascular risk factors:
Routine carotid, aortic, renal auscultation and peripheral pulse examination

Appropriate cardiovascular risk factor modification: antiplatelet agents,

lipid management, hypertension management, diabetes control

Perform baseline ABI No Clinically symptomatic Critical limb ischemia with nonhealing
wounds, rest pain or gangrene

Yes
Baseline ABI with PVR

Intermittent claudication symptoms

Consider alternative or non-specific leg symptoms
diagnosis
CTA , MRA or DSA define the
Baseline ABI with PVR arterial anatomy and assist with
endovascular or surgical planning

Normal Exercise ABI ABI ≥ 0.91–1.3 ABI ≤ 0.9 ABI ≥1.3*

Vascular rehabilitation/walking program Ongoing lifestyle

Abnormal
with or without pharmacologic therapy limiting symptoms

Satisfactory improvement – continue

vascular rehabilitation/walking program
Fig. 3. The evaluation of a patient with suspect lower extremity atherosclerotic PAD. * If ABI is greater than 1.3,
use TBI and PVR waveforms to determine the presence of vascular disease and follow the appropriate algorithm
for ABI of 0.9 or less or of 0.91 to 1.3 or more.
 PAD Diagnosis 327

imaging and intervention in a single setting. Once functioning in men and women with peripheral arte-
surgical or percutaneous intervention is per- rial disease. J Gen Intern Med 2003;18(6):461–7.
formed, patients should be placed in surveillance 9. Regensteiner JG, Hiatt WR, Coll JR, et al. The
programs, typically using duplex ultrasonography, impact of peripheral arterial disease on health-
to identify potential problems and help manage related quality of life in the Peripheral Arterial
restenosis or impending occlusion. Adoption of Disease Awareness, Risk, and Treatment: New
recently developed performance measures and Resources for Survival (PARTNERS) Program. Vasc
national guidelines for the diagnosis and treatment Med 2008;13(1):15–24.
of PAD in clinical practice should improve both the 10. Resnick HE, Lindsay RS, McDermott MM, et al. Rela-
overall care provided to patients with this systemic tionship of high and low ankle brachial index to all-
disease process and outcomes. cause and cardiovascular disease mortality: the
Strong Heart Study. Circulation 2004;109(6):733–9.
11. Criqui MH, Langer RD, Fronek A, et al. Mortality over
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