Peripheral arterial disease (PAD) is the obstruction or deterioration of arteries other than those supplying the heart and brain. PAD prevalence increases with age and is more common in Black individuals compared to Whites. A study in Ghana found higher PAD prevalence in Ghanaians living in Ghana compared to migrant Ghanaians in Europe. Risk factors for PAD include smoking, hypertension, diabetes, hyperlipidemia, and renal insufficiency. Treatment involves lifestyle modifications, medications, and revascularization procedures like angioplasty, stenting, or bypass surgery depending on the severity and location of arterial blockages. Amputations may be required for gangrenous or critically ischemic limbs.

1. Peripheral Arterial Disease
Dr. F. Brakatu

2. DEFINITION
PAD is the obstruction or deterioration of arteries other than those supplying the
heart and brain with impairment of circulation and resultant ischemia to the end
organ involved.

3. EPIDEMIOLOGY
Incidence of symptomatic PAD increases with age by 0.3%/yr for men 40-55yrs
and 1%/yr for men older than 75yrs
Non-hispanic Blacks:Whites - 2:1

4. PAD in GHANA
n=5516
Europe - (1487 Amsterdam, 546 Berlin,
1047 London) and Ghana [1419 urban
and 1017 rural] aged 25–70 yrs
Conc: Ghanaians living in Ghana have
higher prevalence of PAD than their
migrant compatriots
Case-control n=623 Anthropometric indices assessed
PAD (ABI ≤ 0.9, n = 261) and non-PAD (ABI > 0.9, n = 362) groups
PAD participants had higher BMI and waist
circumference than non-PAD participants
PAD participants had higher BMI and waist
circumferences than non-PAD participants
BMI ≥ 30 kg/m2 was associated with twofold increase in the odds of PAD.

5. HIGH RISK GROUPS
❖ Smokers
❖ Hypertension
❖ Dyslipidemia
❖ Hypercoagulable state
❖ Renal insufficiency
❖ DM ie 33% of DM pts older than
50yrs

6. PATHOLOGY
Atherosclerosis - commonest cause - tends to occur in bifurcations and bends
Non-atheromatous arteriopathies - Raynaud’s syndrome, Buerger’s disease
Vasculitis - Large (GCA & Takayasu), Medium (Polyarteritis nodosa, Kawasaki,
Bechet, Cogan), Small -vessel (Wegner, Churg-Strauss, microscopic polyangitis)
Heritable Arteriopathies - cystic medial necrosis, pseudoxanthoma elasticum,
arteria magna syndrome
Congenital - Persistent sciatic artery, popliteal entrapment syndrome, adventitial
cystic disease
Peripheral Arterial Aneurysms - Femoral & popliteal artery aneurysms

7. RISK FACTORS
Age>40
Smoking (10x RR for PAD)
Hypertension
DM - (2 to 4x RR for PAD)
Male sex
Black race
Atherosclerosis at other sites
Family History of CV disease
CKD
Metabolic Syndrome
Hyperlipidaemia
HIV Infection
Heavy Metal Exposure
Homocysteinemia

8. CAUSES OF ACUTE ARTERIAL ISCHEMIA
Arterial embolism
Thrombosis of an atheromatous plaque
Thrombosis of an aneurysm(usually popliteal)
Arterial Dissection (usually aortic)
Traumatic disruption
External compression eg. cervical rib or popliteal entrapment

9. FEATURES OF CHRONIC ARTERIAL INSUFFICIENCY
Lower extremity pain
● Intermittent Claudication - buttock & hip, thigh, calf, foot -claudication
distance?
● Atypical extremity pain
● Ischemic rest pain
● Severe diffuse pain
Non-healing wound/ulcer
Pregangrene/gangrene

10. CLINICAL HISTORY
Characterize the pain - SOCRATES
● Typically occurs with activity and relieved by rest
● Usually calf pain (SFA)
● May have Thigh or buttock pain (Aortoiliac involvement)
Comorbidities - CAD, Carotid artery stenosis, prior stroke
Past Surgical History and Interventions
Drug Hx - Antiplatelets, beta blockers, ACEi, statins
Allergies to contrast

11. CLINICAL FEATURES OF ACUTE ARTERIAL INSUFFICIENCY
6Ps - Pain , Paraesthesia, Pulselessness, Pallor, Perishingly cold, Paralysis
NB: Look out for mottled skin - partial occlusion

12. PHYSICAL EXAMINATION

13. INSPECTION
Memory :SNUGGS
Skin
● Hands - tar staining, wasting of small muscles (thoracic outlet
syndrome)
● Face - xanthalesma, corneal arcus
● Abdomen - obvious pulsatile mass
● Legs - shiny skin, discoloration (haemosiderin deposit)
Nails - tar staining, onycholysis, thick &brittle nails
Ulcers - malleoli, between toes, pressure areas
Guttering & Gangrene - venous guttering, gangrene, tissue loss
Scars - amputations, prev. surgery

14. PALPATION
Memory: PC BOAT
Pulses - Radial, brachial, carotid, feel for AAA,
femoral, popliteal, DP, TP
Capillary Refill - both upper and lower limbs
Buerger’s Angle + Test & Pole test
Oedema - DVT, lymphedema, post-surgical
Allen’s Test
Temperature

16. Pearls
● Peripheral pulses should be graded as 0–2, with normal
pulsations being 2, diminished 1, and absent 0
● DP pulse is congenitally absent in approximately 10% of the
population and that the posterior tibialis pulse is congenitally
absent in < 1% of the population ( Ludbrook J, Clarke AM,
McKenzie JK: Significance of absent ankle pulses. Br Med J
1962;I:1724–1726)
● An abnormal posterior tibialis pulse is 71.2% sensitive and
91.3% specific for PAD, whereas an abnormal dorsalis pedis
pulse is only 50% sensitive and 73.1% specific (Criqui MH et
al)

17. AUSCULTATION
Memory : CALF
Listen for bruits at the
● Carotid
● Aorta
● iLiacs
● Femoral

18. COMPLETION
ABPI
Varicose vein Exam - can have mixed arterial & venous disease
Cardiac Exam - Full Cardio exam + ECG
Neurological Exam - DM neuropathy may be present
BP(both arms) & HR - HPT & AF common
Investigations - Duplex, MRA, CTA, IADSA

19. ABPI

20. INVESTIGATIONS
ABPI
Doppler USG and Duplex - Triphasic waveform is normal
Segmental limb systolic pressure measurements
Arterial plethysmography/pulse volume recordings
Angiography - DSA. Gold Standard. Diagnostic and therapeutic
CTA
MRA - highly sensitive & specific
Carbon dioxide angiography - in patients with severe renal
insufficiency; risk of CO2 embolism, gas trapping and mesenteric
ischaemia
Intravascular Ultrasound - for endovascular treatment of chronic total
occlusion & aortic dissections
Tissue Oxygenation

22. Aortogram showing occluded
aorta with left renal artery
occlusion
Endovascular Ultrasound showing a patent
common iliac stent (A) vs common iliac stent
thrombosis
(Courtesy Dr. Syed Gilani, University
of Texas Medical Branch at Galveston, Department of Cardiology.)

23. CLASSIFICATION OF PERIPHERAL ARTERY DISEASE

24. DIFFERENTIAL DIAGNOSES
Nerve root compression (neurogenic claudication)
Spinal stenosis
Arthritis
Symptomatic baker’s cyst
Venous claudication
● Entire leg but usually worse in thigh & groin
● Tight bursting pain
● Subsides slowly with relief speeded by elevation
● Hx of Iliofemoral DVT, signs of venous congestion & edema
Chronic compartment syndrome

25. MEDICAL TREATMENT
Smoking cessation
Regular exercise - increases initial claudication distance by 179% and
the maximal walking distance to 122% (TASC Working Group:
Management of peripheral arterial disease. J Vasc Surg 2000;31(1
suppl):S1–S296)
Dyslipidemia correction - diet, exercise, medications
Manage hypertension
Antiplatelets & Vasodilators (Nifedipine, Pentoxifylline & Cilostazole) -
may increase claudication distance

26. Mean maximal walking distance of
cilostazol-treated patients (n = 227) was
significantly greater at every postbaseline
visit compared with patients who received
pentoxifylline (n = 232) or placebo (n = 239)
The Pentoxyfilline group did not differ
significantly from the placebo group
Cilostazol (PDE-3 inhibitor) is
contraindicated in patients with a low left
ventricular ejection fraction or subjective
CCF

28. SURGICAL TREATMENT

29. REVASCULARIZATION

30. REVASCULARIZATION- INTERVENTIONAL
Angioplasty - good for short occlusions & better for proximal
disease
Stenting - indicated for failed angioplasties & correction of intimal
arterial defects
Lumbar sympathectomy - used if arterial reconstruction is not
feasible
● Blockade of the lumbar sympathetic chain improves blood
supply to skin, with some relief of symptoms

31. REVASCULARIZATION - SURGICAL
Anatomical Procedures - restore vascular continuity through
replacement of the diseased region eg. femoropopliteal bypass
and femorodistal bypass
Extra-anatomical Procedures - restore vascular continuity by
diverting blood from other unrelated areas to the diseased region
(and are also therefore useful as a salvage procedure if there is
infection present), eg axillo-bifemoral and femorofemoral
crossover grafts

32. AORTO-BIFEMORAL BYPASS
Indication: occlusive or stenotic aortoiliac disease not
amenable to angioplasty or stenting a bifurcated,
prosthetic graft is anastomosed proximally to the aorta,
and distally to the iliac or femoral vessels.
Graft patency rates are excellent. Operative
mortality rate is approximately 5%.

33. AXILLO-BIFEMORAL GRAFT
Indication: aortic or bilateral iliac occlusion or stenosis
not amenable to angioplasty or stenting, in the
presence of a hostile abdomen, or in a patient not fit
for major abdominal surgery
Procedure : A long graft is anastomosed proximally to
the axillary artery as it passes under pectoralis major,
and distally to the femoral arteries
Patency rates are less good than aortobifemoral
grafting for this procedure but it is useful in high-
risk cases with otherwise untreatable critical
ischaemia.

34. FEMOROFEMORAL CROSSOVER GRAFT
Indication: Unilateral iliac occlusive disease not
amenable to angioplasty or stenting
Procedure: a prosthetic vascular graft is
anastomosed from one femoral artery, tunnelled
subcutaneously and anastomosed to the other to
restore flow.
Mortality and patency rates are excellent.
The procedure does not require general
anaesthesia

35. FEMOROPOPLITEAL &
FEMORODISTAL BYPASS
Indications:
● Chronic lower limb ischaemia with incapacitating
claudication or critical ischaemia
● May also be performed for acutely ischaemic limb
(acute-on-chronic thrombosis, occluded popliteal
aneurysm, etc).

36. VASCULAR GRAFTS
Autologous - LSV can be harvested and used in the reverse direction (flow not
impeded by vein cusps) or used in situ after destruction of the vein cusps
Prosthetic - Dacron or PTFE.
● They may be woven or plasticised and may be supported by an external
scaffolding to prevent compression during movement
● They have a much lower patency rate than autologous grafts

37. PROSTHETIC GRAFTS

38. CAUSES OF GRAFT FAILURES
Early Causes (eg after 1 month): commonly technical failure (low flow state due to
poor inflow or insufficient run-off)
Mid-term causes (eg after 1 year): commonly neointimal hyperplasia causing
stenosis in the graft
Late causes (eg after 2–5 years): commonly atheromatous disease progression
(in inflow or run-off)

39. COMPLICATIONS
Early:
● Haemorrhage
● Graft Thrombosis
● Wound Infection
● Swollen Leg (Reperfusion of
DVT)
● Lymphatic fistula
Late:
● Graft Thrombosis
● False Aneurysm
● Graft Infection

40. AMPUTATIONS
Indications:
Dead - gangrene
Dying - Vascular disease
Dangerous - eg. Tumor or severe infection
Damned Nuisance - useless, painful limb after
trauma, neurological damage
The Ideal Stump:
● It should be of optimum length
● Vascularity of the flaps should be normal
● Good soft tissue cover -no projecting spur of bone
● End of stump is firm and conical in shape
● Stump should not be under tension
● Heals by primary intention
● Scar should not be in a tension area
● Scar should be transverse
● Does not transmit pressure through the scar
● Heals by primary intention
● Is freely mobile
● Opposing muscle groups are sutured together at
the end
● Has a mobile joint above the amputation level

41. Hemipelvectomy (Hind quarter amputation)
Used mainly when there’s associated malignancy

42. HIP DISARTICULATION

43. TRANSFEMORAL AMPUTATION (AKA)
Adductor myodesis (Gottschalk 2004; Tintle et al. 2010)
● Improves clinical outcomes
● Creates dynamic balance (otherwise unopposed abductors)
● Provides soft tissue envelope for prosthesis fit (5-10deg adduction ideal)

44. GRITTI STOKES (SUPRACONDYLAR) vs GUILLOTINE
(THROUGH KNEE) AMPUTATION
Amputation through femur near adductor
tubercle
Synovium excised to prevent post-op
effusion
Patella is arthrodesed to femur for
improved end bearing
Improved outcomes compared to AKA
For non-ambulatory patients and ambulatory patients who can’t have transtibial
amputation
LEAP Study Outcomes:
● Require more dependence than BKA
● Worse outcomes on Sickness Impact Profile (SIP) than AKA & BKA
● Physicians less satisfied with clinical, cosmetic and functional recovery

45. TRANSTIBIAL AMPUTATION (BKA)
Long posterior flap - 12-15cm ideal (longer
than this getss into Achilles which has a
suboptimal blood supply for cushion
Modified skewed flap is also an option
Modified Ertl - fibular strut graft
● Bone bridge enhance weightbearing
through fibula and increase surface
area for load transfer

46. SYME’S AMPUTATION (ANKLE DISARTICULATION)
The heel is disarticulated, and the malleoli excised and covered with a long posterior skin flap
30% require revision at a higher level

47. CHOPART vs LISFRANC vs TRANSMETATARSAL
AMPUTATIONS

48. RAY AMPUTATION

49. TAKE HOME MESSAGE
Look out for risk factors
Thorough Clinical Exam can go a long way
Assess candidacy for revascularization
Adhere to principles of amputation