Popliteal Artery Occlusive Disease Workup

  • Author: Cynthia K Shortell, MD; Chief Editor: Vincent Lopez Rowe, MD   more...
 
Updated: Aug 12, 2011
 

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 etiology causing thrombosis, a hypercoagulability profile should be ordered as well. In addition, chest radiographs should be ordered and ECG should be obtained. Lab studies are used to assess intraoperative and postoperative morbidity and mortality risk.

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Imaging Studies

  • Conventional angiography
    • This 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 (US) examination
    • A duplex US examination of the popliteal region is helpful to establish the diagnosis of PAA, popliteal artery entrapment syndrome, and cystic degeneration of popliteal artery.
    • Compared with angiography, the benefit of duplex ultrasonography is the noninvasive nature of the study.
    • However, duplex ultrasonography shows less anatomic detail compared with angiography.
  • Magnetic resonance angiography (MRA)
    • MRA is an imaging 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. MRA in combination with arterial duplex scanning has the potential to replace contrast arteriography in the assessment of the patients with distal arterial occlusive disease.
    • Can be reformatted into three-dimensional angiographic images.
    • Lower spatial resolution than with CTA.
  • CT angiography (CTA)
    • CTA has become increasingly used and has evolved into a very effective imaging modality for patients with PAD. Besides being used for treatment decision and planning of the procedure, it is very useful for identifying graft failure and related complications.
    • It is similar to MRA in ease of use and clinical outcomes for initial imaging of PAD.
    • Ionizing radiation and contrast material is used.
    • It can be reformatted into three-dimensional angiographic images.
    • Total diagnostic cost is lower than MRA.
    • It uses the largest volume of contrast agent of all modalities and is relatively contraindicated in patients with renal insufficiency.
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Other Tests

Ankle-brachial index 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).

A normal ABI value does not absolutely rule out the possibility of occlusion. 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.

Table 2. Clinical Category and ABI (Open Table in a new window)

Clinical Category ABI
Normal>0.97 (usually 1.10)
Claudication0.40-0.80
Rest pain0.20-0.40
Tissue loss0.10-0.40
Acute ischemia< 0.10
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Staging

These criteria were established in an effort to classify the extent of PAD based on presenting clinical symptoms for standardization of treatment outcomes reporting. The Rutherford classification with categories (0 to 6) and corresponding Fontaine classification with stages (I to IV) are shown in Table 3 below.

Table 3. Rutherfod and Fontaine Classifications (Open Table in a new window)

RutherfordFontaine
GradeCategoryClinicalStageClinical
00AsymptomaticIAsymptomatic
I1Mild claudicationIIaMild claudication
I2Moderate claudicationIIbModerate to severe claudication
I3Severe claudicationIschemic rest pain
II4Ischemic rest painIIIIschemic rest pain
III5Minor tissue lossIVUlceration or gangrene
III6Major 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: Medical Simulation Corporation Grant/research funds Principal Investigator

Coauthor(s)

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

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

Disclosure: Medscape Salary Employment

Vincent Lopez Rowe, MD  Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center

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

Disclosure: Nothing to disclose.

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

Vincent Lopez Rowe, MD  Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center

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

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference 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]
StagePresentationDiagnostic and Therapeutic Indications
0No signs or symptomsNever justified
IIntermittent claudication (1 block) without physical changesUsually unjustified
IISevere claudication (less than half blocked), dependent rubor, decreased temperatureSometimes justified, not always necessary, may remain stable
IIIRest pain, atrophy, dependent cyanosis, decreased temperatureUsually indicated but patient may do well for long periods of time without revascularization
IVNonhealing ischemic ulcer or gangreneIndicated
Table 2. Clinical Category and ABI
Clinical Category ABI
Normal>0.97 (usually 1.10)
Claudication0.40-0.80
Rest pain0.20-0.40
Tissue loss0.10-0.40
Acute ischemia< 0.10
Table 3. Rutherfod and Fontaine Classifications
RutherfordFontaine
GradeCategoryClinicalStageClinical
00AsymptomaticIAsymptomatic
I1Mild claudicationIIaMild claudication
I2Moderate claudicationIIbModerate to severe claudication
I3Severe claudicationIschemic rest pain
II4Ischemic rest painIIIIschemic rest pain
III5Minor tissue lossIVUlceration or gangrene
III6Major tissue loss
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