A 70-year-old man was referred to vascular surgery for a several-year history of bilateral lower extremity calf claudication at one block. His claudication symptoms were described as significantly lifestyle limiting with the right leg worse than the left. The patient had previous bilateral iliac artery stenting 2 years prior to presentation (Figure 4-1). His peripheral vascular risk factors include hypertension (HTN), hyperlipidemia, and tobacco abuse (30 pack-years). The patient denied symptoms of rest pain and did not have any evidence of tissue loss. His pedal pulses were palpable bilaterally. After discussing options, the patient agreed to a 3-month trial of a supervised exercise program with an oral phosphodiesterase inhibitor (cilostazol) and tobacco cessation.
Abdominal aortogram showing previous iliac artery stents on both sides (arrows).
At the return office visit, the patient reported minimal
improvement. The patient was unable to quit smoking. Ankle-brachial index (ABI) and segmental lower extremity pressures revealed
diminished blood flow bilaterally with a significant drop postexercise. The patient subsequently underwent an angiogram with bilateral lower extremity runoff.
Angiogram findings indicated a 70% stenosis of the right above-knee popliteal artery (Figure 4-2) and 80% stenosis of the popliteal-tibial artery junction (Figure 4-3).
Angiogram findings of the right leg indicating 70% stenosis of the right above-knee popliteal artery (two arrows).
Angiogram of the right lower leg showing 80% stenosis of the popliteal-tibial artery junction (large arrow) and the three tibial arteries (small arrows).
The patient subsequently underwent percutaneous transluminal angioplasty (PTA) of both lesions with a cryoplasty balloon. This achieved a good angiographic result (Figure 4-4). He was maintained on daily antiplatelet therapy (clopidogrel).
Angiogram of the right leg showing a good angiographic result after percutaneous transluminal angioplasty (PTA) of both lesions with a cryoplasty balloon.
Peripheral Arterial Disease
Progressive narrowing of the arteries due to atherosclerosis.1
Mostly silent in early stages until luminal narrowing exceeds 50% vessel diameter.2
Prevalence of peripheral arterial disease (PAD) in adults over
40 years in the United States is approximately 4%.2
Prevalence of PAD in adults over 70 years in the United States is approximately 15%.2
20% to 25% of patients will require revascularization.2
Approximately 5% of patients will progress to critical limb ischemia.2
Patients with limb loss have 30% to 40% mortality in the first 24 months.4
ETIOLOGY AND PATHOPHYSIOLOGY