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Infrainguinal Occlusive Disease: Workup

Author: Richard M Stillman, MD, FACS, Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center
Contributor Information and Disclosures

Updated: Jun 24, 2008

Workup

Laboratory Studies

  • Several screening laboratory studies are useful to evaluate the possibility of associated systemic risk factors and contributing problems.
    • Perform a complete blood cell count to screen for hematologic diseases such as thrombocytopenia, thrombocytosis, polycythemia, and leukemia.
    • Obtain a fasting blood glucose level to screen for diabetes.
    • Creatinine and blood urea nitrogen determinations help screen for renal insufficiency.
    • A fasting and lipid profile helps screen for hyperlipidemia.
    • Perform a urinalysis to screen for glycosuria or proteinuria.
    • Perform a coagulation workup to assess the prothrombin and activated partial thromboplastin times. In some cases (eg, patients with a personal or family history of thrombotic problems, particularly a history of failed vascular interventions), the workup should include a fibrinogen level, a euglobulin lysis time, a protein C assay, a protein S assay, antiphospholipid antibody titers, and an anticardiolipin antibody assay.
    • Consider obtaining a serum homocysteine level to screen for hyperhomocysteinemia in patients with an atypical history, early onset, or a family history. This problem, which is associated with both arterial and venous disease, can be treated by dietary supplementation with folate and vitamin B-12. However, note that no conclusive data indicate that such treatment lowers long-term vascular risks.
    • Consider determining the erythrocyte sedimentation rate. Although elevation of the erythrocyte sedimentation rate is a nonspecific finding, the test screens patients with vascular disease for 2 potential risk factors that are somewhat difficult to measure directly, hyperfibrinogenemia and hyperviscosity syndromes.
  • A noninvasive vascular laboratory evaluation of peripheral arterial occlusive disease includes the following:
    • Pulse-volume recording (PVR), or plethysmography, uses pneumatic cuffs encircling the thighs, calves, ankles, feet, and sometimes toes to sense segmental volume changes with each pulse beat. The resulting tracings provide useful information about the hemodynamic effects of the arterial disease at each level. In patients with severe disease, tracings at the transmetatarsal level may become nearly flat. In patients with mild disease, particularly involving the aortoiliac segment, PVR tracings may appear normal at rest and may become abnormal only after the patient walks until symptoms occur. PVR is noninvasive and rapid; therefore, it may be repeated frequently to help assess the overall hemodynamic response to medical or surgical treatment.
    • A handheld Doppler scanner may be used to assess arterial signals, to localize arteries to facilitate palpation of pulses, or to determine loss of the Doppler signal as a proximal blood pressure cuff is inflated. The latter pressure divided by the upper extremity systolic pressure is called the ankle-brachial index (ABI) and can help indicate the severity of arterial compromise.21  A normal ABI averages 1. An ABI less than 0.9 suggests atherosclerotic disease with a sensitivity of approximately 95% and a specificity of 99%.5 In general, an ABI below 0.3 suggests a poor chance for healing of distal ischemic ulcerations. Unfortunately, the ABI is often falsely elevated if the underlying arteries are heavily calcified, a finding common in patients with diabetes.
    • Skin perfusion pressure (SPP) is defined as the pressure at which skin perfusion returns as an inflated blood pressure cuff is slowly deflated. This point can be measured using washout of a radioisotope, the reappearance of pulsatile flux on photoplethysmography, or the motion of erythrocytes on laser Doppler. An SPP over 40 mm Hg correlates with the likelihood of the healing of ischemic wounds.22
    • Duplex scanning can provide images of arterial segments that help localize the extent of disease, and simultaneous Doppler measurement of flow velocity can help estimate the degree of stenosis. Duplex scanning is quite useful in visualizing aneurysms, particularly of the aorta or popliteal segments. Unfortunately, Doppler techniques are not accurate for assessing the hemodynamic consequences of atherosclerotic peripheral arterial disease involving the extremities.

Imaging Studies

  • Conventional Angiography: If surgical treatment is contemplated, angiography is needed to delineate the extent and significance of atherosclerotic disease. Major risks associated with conventional contrast-injection angiography are related to the puncture and to the use of contrast agents. 
    • Technique: Typically, a catheter is inserted retrograde via a femoral puncture, and contrast is power-injected into the infrarenal aorta. Films are taken as the contrast is followed down to both feet. In certain cases, as with aortic occlusion, a femoral approach to the aorta may not be possible. In this case, the radiologist may use an alternate entry such as via an axillary artery or even directly into the infrarenal aorta via a translumbar approach.
    • Puncture-related complications: The arterial catheter is usually passed through a 5-F sheath that is 1.6 mm in diameter. This is a sizable hole in the femoral artery, which may be only 6-10 mm in diameter. After the catheter is removed, gentle pressure must be applied to the puncture site for approximately 30 minutes, and the radiologist must balance the need for hemostasis against the possibility of arterial occlusion. Risks include hemorrhage, pseudoaneurysm formation, and clotting or dislodgement of an intimal flap, which may acutely occlude the artery at or near the entry site. Currently, newer methods of percutaneous closure of the puncture sites have significantly reduced the site complication rates.
    • Contrast-related risks: Angiographic contrast material is nephrotoxic. The risk of precipitating acute renal failure is highest in patients with underlying renal insufficiency and those patients with diabetes. Patients with both of these risk factors have a 30% rate of acute renal failure following contrast angiography. Hence, an acceptable serum creatinine level must be confirmed prior to elective angiography. Avoid contrast angiography (if possible) for patients with any significant degree of renal impairment. If contrast angiography is absolutely required despite renal impairment, use a minimal volume of contrast material. In addition, providing adequate hydration prior to, during, and after the procedure is essential. Oral administration of the antioxidant acetylcysteine (Mucomyst) the night prior to and then just before angiography may be protective of renal function for patients at risk of contrast-induced nephropathy.23
    • Metformin warning: To prevent the possibility of fatal lactic acidosis, patients with diabetes who are taking metformin (Glucophage) must not take this medication immediately following contrast angiography. Patients may resume taking the medication when normal renal function is confirmed 1-2 days after contrast exposure.
  • Alternatives to conventional angiography 
    • Magnetic resonance angiography: Magnetic resonance angiography (MRA) is an alternative both for patients for patients who are allergic to iodinated contrast material. MRA is not innocuous. Gadolinium chelates, the contrast agents used in MRA, have been linked recently to three potentially serious side-effects in patients with renal insufficiency: acute renal injury, pseudohypocalcemia, and nephrogenic systemic fibrosis.24 MRA is contraindicated in patients with implanted hardware such as a hip prostheses or pacemakers. The resolution may be inadequate for the vascular surgeon in planning reconstructive procedures, particularly in the smaller infrapopliteal arteries, although MRA technology and contrast agents continue to improve.25
    • Multidetector computed tomographic angiography (MDCT): MDCT avoids arterial puncture. By using precisely timed intravenous contrast injection, multidetector (16 or 64 channel) CT scanners can generate angiographic images of excellent resolution and at a relatively high acquisition speed. MDCT carries the contrast-related risks described above.26
    • Carbon dioxide angiography: Carbon dioxide angiography is an alternative for patients with renal insufficiency; however, it is not widely available and requires some iodinated contrast material in addition to the carbon dioxide gas in order to provide useful images.
    • Plain radiography: Plain radiographs are not routinely obtained in the workup of peripheral arterial occlusive disease. This is because arterial calcification seen on plain radiographs is not a specific indicator of severe atherosclerotic disease. Calcification of the arterial media is not diagnostic of atherosclerosis, and even calcification of the arterial intima, which is diagnostic of atherosclerotic disease, does not necessarily imply hemodynamically significant stenosis.

Histologic Findings

Atherosclerotic vessels demonstrate proliferation of smooth muscle cells in the intima and invasion of the damaged intima by atherosclerotic plaque consisting of necrotic cells, lipids, cholesterol crystals, and connective tissue. These lesions typically occur in an eccentric location with respect to the arterial lumen. Soft thrombus may deposit on ulcerated atherosclerotic plaques.

More on Infrainguinal Occlusive Disease

Overview: Infrainguinal Occlusive Disease
Workup: Infrainguinal Occlusive Disease
Treatment: Infrainguinal Occlusive Disease
Follow-up: Infrainguinal Occlusive Disease
Multimedia: Infrainguinal Occlusive Disease
References
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Further Reading

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Keywords

infrainguinal occlusive disease, peripheral atherosclerotic disease, peripheral vascular disease, chronic arterial insufficiency, femoropopliteal occlusive disease, aortoiliac occlusive disease, stent, stenting, ischemic lower extremity disease, arteriosclerosis obliterans, complex regional pain syndromes, CRPS, posttraumatic pain syndromes, causalgia, mimocausalgia, Sudeck atrophy, reflex sympathetic dystrophy, intermittent claudication, gangrene, amputation

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Contributor Information and Disclosures

Author

Richard M Stillman, MD, FACS, Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center
Richard M Stillman, MD, FACS is a member of the following medical societies: American College of Angiology, American College of Surgeons, Association for Academic Surgery, and Society of University Surgeons
Disclosure: Nothing to disclose.

Medical Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Travis J Phifer, MD, Chief, Division of Vascular Surgery, Professor, Department of Surgery and Radiology, Louisiana State University Health Sciences Center in Shreveport
Travis J Phifer, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Society for Academic Emergency Medicine, Society for Vascular Surgery, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
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