Infrainguinal Occlusive Disease Clinical Presentation

Updated: Nov 13, 2023
  • Author: Christian Ochoa, MD; Chief Editor: Vincent Lopez Rowe, MD, FACS  more...
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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 correctable 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 infrainguina Pressure ulcer of heel exacerbated by infrainguinal arterial occlusive disease.

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. [24]


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 (PAD).

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