Case study: Peripheral Vascular Disease

A.T. is a 65-year-old black female with claudication secondary to peripheral arterial disease (PAD). She has a history of coronary artery disease, myocardial infarction, heart failure, endarterectomy, hypertension, hyperlipidemia, type 1 diabetes mellitus, and asthma.

She was referred to the Division of Vascular Surgery at Henry Ford Hospital complaining of fatigue and heaviness in her lower thighs and calves during walking. Resting ankle-brachial index (ABI) was 0.50 and 0.70 at the right and left dorsalis pedis, respectively. She was prescribed cilostazol and encouraged to “…walk through the pain as much as possible.”

Due to worsening claudication, A.T. underwent an abdominal aortogram with arteriogram of the lower extremities. Results showed aortoiliac disease with multiple stenoses of varying degrees. Areas of calcification were noted from the lower aorta and iliac artery to the anterior tibial artery affecting both the left and right limbs. Case study: Peripheral Vascular Disease

Results from a stress echocardiogram showed cardiac wall motion abnormalities consistent with exercise-induced ischemia. She exercised for 5.8 minutes on the Bruce protocol, limited by general fatigue. The electrocardiogram displayed left bundle branch block, resting ejection fraction was 40%, peak blood pressure was 160/80 mmHg, and peak heart rate was 120 b·min⁻¹. No symptoms were reported. Her medications are cilostazol, carvedilol, amlodipine, isosorbide dinitrate, clopidogrel, simvastatin, potassium, triamcinolone, ipratropium, and pirbuterol.

She began supervised exercise training in cardiac rehabilitation following a hospitalization for angina. At rest her blood pressure was 120/50 mmHg, heart rate was 79 b·min⁻¹, blood glucose was 6.89 mmol·L⁻¹ (266 mg·dL⁻¹) and her HbA1c was 8.0%. Her initial exercise sessions were limited by bilateral claudication of her thighs and calves. Moderate pain occurred after 9 minutes of walking on day 1. A pain-rest walking program was initiated and followed for 12 weeks. She then joined the Henry Ford PREVENT program, which provides patients with a low-cost, long-term supervised exercise environment. Case study: Peripheral Vascular Disease

She now exercises at least 3 d·wk⁻¹ for 60 minutes each session. She splits her exercise time between a seated stepper and a treadmill. On most days she is now able to walk 30 continuous minutes without limiting claudication pain.

The natural history of arteriosclerosis involves an intimal plaque that progressively develops until it eventually causes a significant flow limiting occlusion of the vessel and reduction of blood supply relative to demand. Arteriosclerosis is a systemic disorder affecting the major circulations, with the intimal plaque occurring segmentally in multiple locations. When the plaque occurs in the distal aorta or in the arteries of the lower extremities, it is referred to as PAD. Case study: Peripheral Vascular Disease

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More than 8 million individuals in the United States above the age of 40 are estimated to have PAD . The prevalence of PAD per ABI is 4.3% in persons older than 40 years and up and 29% in those 70 years and older. Thus PAD afflicts more than 4 million Americans and more than 200 million people worldwide. The age-adjusted prevalence of PAD increases to approximately 12% when more sensitive vascular imaging studies are used. Unlike coronary artery disease, the incidence of PAD is similar in men and women. Coronary artery disease occurs in 60% to 90% of patients with PAD. The incidence of cerebral vascular disease is increased in patients with PAD as well. Case study: Peripheral Vascular Disease

Peripheral arterial disease is part of the spectrum of atherosclerosis. It is associated with coronary and carotid artery disease. PAD increases mortality by 6-fold, due mostly to myocardial infarction and stroke. The 5-year mortality rate in patients with PAD is ≈ 30%, with a major lower extremity amputation rate near 1% to 2%. If the patient continues to smoke, the mortality rate doubles and the risk for amputation increases 10-fold. Aortoiliac disease has a higher mortality than femoral artery disease due to a greater prevalence of coronary artery disease in patients with the former. Case study: Peripheral Vascular Disease

Ten percent of patients with intermittent claudication will go on to have ischemic pain at rest (aka, critical limb ischemia), often leading to ulceration or amputation. The presence of diabetes mellitus also affects morbidity and mortality in patients with PAD. Sixty percent of leg amputations are the result of diabetic peripheral vascular disease. In fact, among patients with diabetes for 25 years or more, the risk of below the knee amputation is increased 12-fold.

The risk factors for coronary artery disease are also risk factors for the development of PAD (i.e., age greater than 65 years, cigarette smoking, and diabetes mellitus). Patients with type 2 diabetes mellitus have a 4-fold increased risk for PAD, while their risk for myocardial infarction or stroke is increased only 2-fold. The severity of PAD is not related to glycemic control but rather to the number of coexisting risk factors. Therefore, hypertension, hyperlipidemia and hyperhomocysteinemia are also important risk factors for PAD. For each 0.03 mmol·L⁻¹ (1 mg·dL⁻¹) increase in total cholesterol, there is a 1% increased incidence of PAD. A reduced high-density lipoprotein cholesterol and increased triglyceride are also closely associated with PAD. In the presence of these risk factors and given the systemic nature of atherosclerosis and its poor prognosis, patients with PAD should be thought of as already having coronary and carotid artery disease. Case study: Peripheral Vascular Disease

Unless there is acute occlusion by thrombosis, the symptoms of PAD occur gradually and progressively. Intermittent claudication is the major symptom of PAD. Claudication is derived from the Latin word claudicato, meaning to limp, which describes the gait of a patient with intermittent claudication. Intermittent claudication is most often described as an aching, cramping, or tightness in the muscles of the leg (usually the calf) that occurs with exercise and is relieved with rest. The pain usually disappears within several minutes after stopping exercise. The discomfort reoccurs at a constant distance. The distance is shorter if the patient is walking uphill or climbing stairs, and this pain does not occur at rest.

Despite claudication being the hallmark symptom of PAD, it is estimated that approximately 60% to 70% of individuals with disease do not have this symptom. The reason for this disparity is not entirely clear, but often patients with PAD may have diabetic neuropathy, which could mask symptoms, or they may simply not report discomfort because of the false assumption that it is simply pain associated with the aging process (e.g., arthritis). Another possibility could be because of avoidance of activities that may cause leg pain (e.g. exercise, yard work, walking long distances Case study: Peripheral Vascular Disease

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