cardiovascular disorders
Peripheral Arterial Disease
Symptoms and Signs of Peripheral Arterial Disease
Intermittent claudicationis the typical manifestation of peripheral arterial disease. Intermittent claudication is a painful, aching, cramping, uncomfortable, or tired feeling in the legs that occurs during walking and is relieved by rest. Claudication usually occurs in the calves but can occur in the feet, thighs, hips, buttocks, or, rarely, arms. Claudication is a manifestation of exercise-induced reversible ischemia, similar to angina pectoris. As PAD progresses, the distance that can be walked without symptoms may decrease, and patients with severe PAD may experience pain during rest, reflecting irreversible ischemia. Rest pain is usually worse distally, is aggravated by leg elevation (often causing pain at night), and lessens when the leg is below heart level. The pain may be burning, tightening, or aching, although this finding is nonspecific. About 20% of patients with peripheral arterial disease are asymptomatic, sometimes because they are not active enough to trigger leg ischemia. Some patients have atypical symptoms (eg, nonspecific exercise intolerance, hip or other joint pain). Mild PAD often causes no signs. Moderate to severe PAD commonly causes diminished or absent peripheral (popliteal, tibialis posterior, dorsalis pedis) pulses. When below heart level, the foot may appear dusky red (called dependent rubor). In some patients, elevating the foot causes loss of color and worsens ischemic pain; when the foot is lowered, venous filling is prolonged (>15 seconds). Edema is usually not present unless the patient has kept the leg immobile and in a dependent position to relieve pain. Patients with chronic PAD may have thin, pale (atrophic) skin with hair thinning or loss. Distal legs and feet may feel cool. The affected leg may sweat excessively and become cyanotic, probably because of sympathetic nerve overactivity. As ischemia worsens, ulcers may appear (typically on the toes or heel, occasionally on the leg or foot), especially after local trauma. The ulcers tend to be surrounded by black, necrotic tissue (dry gangrene). They are usually painful, but people with peripheral neuropathy (eg, due to diabetes or alcohol use disorder) may not feel them. Infection of ischemic ulcers (wet gangrene) occurs readily, causing rapidly progressive cellulitis. The level of arterial occlusion influences location of symptoms. Aortoiliac PAD may cause buttock, thigh, or calf claudication; hip pain; and, in men, erectile dysfunction (Leriche syndrome). In femoropopliteal PAD, claudication typically occurs in the calf; pulses below the femoral artery are weak or absent. In PAD of more distal arteries, femoropopliteal pulses may be present, but foot pulses are absent. Arterial occlusive disease occasionally affects the arms, epecially the left proximal subclavian artery, causing arm fatigue with exercise and occasionally embolization to the hands. 