History

Most people harboring atherosclerotic disease of the lower extremities are asymptomatic; others develop ischemic symptoms. Some patients attribute ambulatory difficulties to old age, unaware of the existence of a potentially correctible problem.

Symptomatic patients may present with intermittent claudication, ischemic pain at rest, nonhealing ulceration of the foot (see the image below), or frank ischemia of the foot.

Pressure ulcer of heel exacerbated by infrainguinal arterial occlusive disease.

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Cramping or fatigue of major muscle groups in one or both lower extremities that is reproducible upon walking a specific distance suggests intermittent claudication. This symptom increases during ambulation until walking is no longer possible, and it is relieved by several minutes of rest. The onset of claudication may occur sooner with more rapid walking or when walking uphill or up stairs.

The claudication of infrainguinal occlusive disease typically involves the calf muscles, whereas symptoms that occur in the buttocks or thighs suggest aortoiliac occlusive disease.^[23]

Physical Examination

Physical examination discloses absent or diminished peripheral pulses below a certain level. Although diminished common femoral artery pulsation is characteristic of aortoiliac disease, infrainguinal disease alone is characterized by normal femoral pulses at the level of the inguinal ligament and diminished or absent pulses distally.

Specifically, loss of the femoral pulse just below the inguinal ligament occurs with a proximal superficial femoral artery occlusion. Loss of the popliteal artery pulse suggests superficial femoral artery occlusion, typically in the adductor canal. Loss of pedal pulses is characteristic of disease involving the distal popliteal artery or its trifurcation.

It is important, however, to be aware that absence of the dorsalis pedis pulse may be a normal anatomic variant, noted in approximately 10% of the population. On the other hand, the posterior tibial pulse is present in 99.8% of persons aged 0-19 years. Hence, absence of both pedal pulses is a more specific indicator of peripheral arterial disease.

Other findings suggestive of atherosclerotic disease include a bruit heard overlying the iliac or femoral arteries, skin atrophy, loss of pedal hair growth, cyanosis of the toes, ulceration or ischemic necrosis, and, after 1-2 minutes of elevation above heart level, pallor of the involved foot followed by dependent rubor (see the image below).

Cyanosis of first toe and dependent rubor of foot, characteristic of arterial insufficiency.

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Differential Diagnoses

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Media Gallery

Pressure ulcer of heel exacerbated by infrainguinal arterial occlusive disease.
Cyanosis of first toe and dependent rubor of foot, characteristic of arterial insufficiency.
Contrast angiogram showing severe atherosclerotic disease in distal superficial femoral artery.

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Table 1. Staging for Chronic Limb Ischemia

Rutherford Category	Fontaine Grade	Clinical Description	Objective Criteria
0	0	Asymptomatic – No hemodynamically significant disease	Normal treadmill or reactive hyperemia test
1		Mild claudication	Completes treadmill exercise (5 min at 2 mph on 12% incline) AP* after exercise >50 mm Hg but at least 20 mm Hg lower than resting value
2	I	Moderate claudication	Between Rutherford categories 1 and 3
3		Severe claudication	Cannot complete treadmill exercise and AP after exercise < 50 mm Hg
4	II	Ischemic rest pain	Resting AP < 40 mm Hg, flat or barely pulsatile ankle or metatarsal PVR**; TP † < 30 mm Hg
5	III	Minor tissue loss (nonhealing ulcer, focal gangrene with diffuse pedal ischemia)	Resting AP < 60 mm Hg, ankle or metatarsal PVR flat or barely pulsatile; TP < 40 mm Hg
6		Major tissue loss (extending above transmetatarsal level, functional foot no longer salvageable)	Same as Rutherford category 5
AP = Ankle pressure. *PVR = Pulse-volume recording. † TP = Toe pressure.

Table 2. TASC Classification for Femoral Popliteal Lesions

Type	Description
Type A lesions	Single lesions ≤10 cm in length Single occlusions ≤5 cm in length
Type B lesions	Multiple lesions (stenoses or occlusions), each ≤5 cm Single stenosis or occlusion ≤15 cm not involving the infrageniculate popliteal artery Single or multiple lesions in the absence of continuous tibial vessels to improve inflow for a distal bypass Heavily calcified occlusion ≤5 cm in length Single popliteal stenosis
Type C lesions	Multiple stenoses or occlusions totaling >15 cm with or without heavy calcification Recurrent stenoses or occlusions that need treatment after two endovascular interventions
Type D lesions	Chronic total occlusions of common femoral artery or superficial femoral artery (>20 cm, involving the popliteal artery) Chronic total occlusion of popliteal artery and proximal trifurcation vessels