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Popliteal Artery Occlusive Disease Workup

  • Author: Cynthia K Shortell, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
 
Updated: Apr 15, 2015
 

Laboratory Studies

In addition to clinical evaluation of patients with suspected popliteal artery occlusive disease, laboratory tests should be performed, including complete blood count and blood chemistries. If a hypercoagulable state is suspected to be the underlying cause of thrombosis, a hypercoagulability profile should be ordered as well. In addition, chest radiographs should be ordered and electrocardiography (ECG) performed. Laboratory studies are used to assess intraoperative and postoperative morbidity and mortality risk.

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Imaging Studies

Conventional angiography

Conventional angiography is the criterion standard evaluation for identifying popliteal occlusion. It also allows visualization of possible targets for distal bypass. It is invasive and uses ionizing radiation and contrast material. It is two-dimensional.

Duplex ultrasonography

Duplex ultrasound examination of the popliteal region is helpful for establishing the diagnosis of popliteal artery aneurysm (PAA), popliteal artery entrapment syndrome, and cystic degeneration of popliteal artery. In comparison with angiography, the main benefit of duplex ultrasonography is the noninvasive nature of the study. However, duplex ultrasonography shows less anatomic detail than angiography does.

Magnetic resonance angiography

Magnetic resonance angiography (MRA) is a modality that does not require conventional contrast agents and often yields good arterial images. It is more sensitive than angiography in imagining distal runoff vessels. Combined with arterial duplex scanning, MRA has the potential to replace contrast arteriography in the assessment of patients with distal arterial occlusive disease. MRA images can be reformatted into three-dimensional angiographic images; however, MRA has lower spatial resolution than computed tomography angiography (CTA) does.

Computed tomography angiography

CTA has become increasingly used and has evolved into a very effective imaging modality for patients with peripheral artery disease (PAD). Besides being used for treatment decision and planning of the procedure, it is very useful for identifying graft failure and related complications. CTA is similar to MRA with respect to ease of use and clinical outcomes for initial imaging of PAD.

CTA makes use of ionizing radiation and contrast material is used. The images it yields can be reformatted into three-dimensional angiographic images. Total diagnostic cost is lower than that of MRA. CTA uses the largest volume of contrast agent of all modalities and is relatively contraindicated in patients with renal insufficiency.

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Ankle-Brachial Index

The ankle-brachial index (ABI) is used to assess the amount of blood going to the distal leg relative to that in the brachial vessels.

It is capable of identifying the presence and severity of occlusive disease. Normally, the ABI is greater than 1.0 because ankle pressures are slightly higher than arm pressures. A correlation is found between the severity of signs and symptoms of arterial insufficiency and the ABI. Generally, the ABI is decreased to 0.4-0.8 in patients with claudication. An ABI lower than 0.4 is seen in patients with critical ischemia (rest pain or tissue necrosis). (See Table 2 below.)

Table 2. Clinical Category and Ankle-Brachial Index (Open Table in a new window)

Clinical Category ABI
Normal >0.97 (usually 1.10)
Claudication 0.40-0.80
Rest pain 0.20-0.40
Tissue loss 0.10-0.40
Acute ischemia < 0.10

 

A normal ABI does not absolutely rule out the possibility of occlusion. A falsely elevated ABI can be recorded in diabetic patients and patients with renal failure because of incompressible calcified lower leg arteries. In these patients, inspection of flow velocity waveform recording from the pedal arteries in conjunction with toe pressure measurement can be used to determine the degree of ischemia. In addition, patients with mild PAD may have normal ABIs at rest and may require provocative testing with exercise to diagnose their PAD.

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Staging

The Rutherford and Fontaine classifications were developed in an effort to categorize the extent of PAD on the basis of presenting clinical symptoms and thus to facilitate standardization of treatment outcomes reporting. (See Table 3 below.)

Table 3. Rutherford and Fontaine Classifications for Evaluating Extent of Peripheral Artery Disease (Open Table in a new window)

Rutherford Fontaine
Grade Category Clinical Stage Clinical
0 0 Asymptomatic I Asymptomatic
I 1 Mild claudication IIa Mild claudication
I 2 Moderate claudication IIb Moderate to severe claudication
I 3 Severe claudication   Ischemic rest pain
II 4 Ischemic rest pain III Ischemic rest pain
III 5 Minor tissue loss IV Ulceration or gangrene
III 6 Major tissue loss    
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Contributor Information and Disclosures
Author

Cynthia K Shortell, MD Professor of Surgery, Associate Professor of Radiology, Chief of Vascular Surgery, Program Director, Vascular Surgery Residency Program, Duke University Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Jovan N Markovic, MD General Surgery Resident, Department of Surgery, Duke University Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous authors Deron J Tessier, MD, and Russell A Williams, MBBS, to the development and writing of this article.

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Table 1. Indications for Diagnostic and Therapeutic Interventions [3]
Stage Presentation Diagnostic and Therapeutic Indications
0 No signs or symptoms Never justified
I Intermittent claudication (1 block) without physical changes Usually unjustified
II Severe claudication (less than half blocked), dependent rubor, decreased temperature Sometimes justified, not always necessary, may remain stable
III Rest pain, atrophy, dependent cyanosis, decreased temperature Usually indicated but patient may do well for long periods of time without revascularization
IV Nonhealing ischemic ulcer or gangrene Indicated
Table 2. Clinical Category and Ankle-Brachial Index
Clinical Category ABI
Normal >0.97 (usually 1.10)
Claudication 0.40-0.80
Rest pain 0.20-0.40
Tissue loss 0.10-0.40
Acute ischemia < 0.10
Table 3. Rutherford and Fontaine Classifications for Evaluating Extent of Peripheral Artery Disease
Rutherford Fontaine
Grade Category Clinical Stage Clinical
0 0 Asymptomatic I Asymptomatic
I 1 Mild claudication IIa Mild claudication
I 2 Moderate claudication IIb Moderate to severe claudication
I 3 Severe claudication   Ischemic rest pain
II 4 Ischemic rest pain III Ischemic rest pain
III 5 Minor tissue loss IV Ulceration or gangrene
III 6 Major tissue loss    
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