Peripheral neuropathy may initially present similarly
With CLI, pain worsens when leg elevated, relieved when leg dependent
Severe arterial obstruction or occlusion
Often multifocal disease
Typical ABI < 0.4
Acute limb ischemia (ALI)
Sudden interruption of arterial blood flow to extremity
Usually due to embolus or in situ thrombosis
Embolic source may be cardiac or aneurysm
Symptoms: 6 Ps of ALI
Pain, pulselessness, pallor, paresthesias, paralysis, and poikilothermia (i.e., cold)
Rutherford classification for ALI
I: Viable
No sensory loss; no motor loss
May have audible Doppler arterial pulse
IIa: Marginally threatened
Pain/sensory loss, no weakness
IIb: Immediately threatened
Pain/sensory loss and mild weakness
III: Irreversible (nonviable)
Anesthesia/paralysis, muscle rigor
Physical Examination in Peripheral Artery Disease
Diminished/absent pulses distal to stenosis
Infrainguinal lesion: Normal femoral, decreased or absent DP/PT pulses
Bruit over stenosis
Cool extremity, distal hair loss
Poor wound healing
Inspect area between toes as kissing toe ulcers from pressure between metatarsal heads often seen
Dependent rubor and elevation pallor
Often seen in CLI
Fontaine Stages of PAD
Stage 1: Asymptomatic but decreased pulses; ABI < 0.9
Up to 75% of patients with PAD are asymptomatic
Could be related to sedentary/limited lifestyle
Stage 2: IC
2a: Distance > 200 m
2b: Distance < 200 m
Stage 3: Ischemic rest pain
Stage 4: Ulceration, gangrene
Trans-Atlantic Inter-Society Consensus II (TASC II): Categorization of Atherosclerotic Lesions Based on Morphology
Type A
Single stenosis ≤ 10 cm in length
Single occlusion ≤ 5 cm in length
Endovascular therapy is treatment of choice
Type B
Multiple lesions ≤ 5 cm in length
Single stenosis or occlusion ≤ 15 cm in length
Heavily calcified lesion ≤ 5 cm in length
Typically, endovascular treatment preferred
Type C
Multiple lesions adding up to > 15 cm
Recurrent stenosis after 2 endovascular treatments
Multiple lesions > 3 cm but < 5 cm in length
Surgery preferred; consider endovascular therapy if high-risk patient for open revascularization
Type D
Chronic total occlusions (CTO) > 20 cm or involving popliteal artery/proximal trifurcation
Poor endovascular results, surgery is standard
Infrainguinal Vascular Anatomy
CFA
Continuation of external iliac artery below inguinal ligament
Overlies femoral head
Angiographic surrogate of inguinal ligament are inferior epigastric/deep circumflex iliac artery origins
Surgical endarterectomy treatment of choice for atherosclerotic disease of CFA
Bifurcates into superficial and deep femoral arteries
SFA
From CFA bifurcation to caudal end of adductor (Hunter) canal
Distal portion of SFA, within adductor canal, is prone to atherosclerotic disease
3/4 of femoropopliteal occlusions occur within adductor canal
Relatively absent of side branch vessels
Profunda femoris artery
a.k.a. deep femoral artery
Extends from femoral bifurcation into thigh musculature
Provides important collaterals in setting of SFA stenosis/occlusion
Perforating branches resistant to atherosclerosis
Popliteal artery
SFA becomes popliteal artery at adductor hiatus
Courses behind knee, between gastrocnemius heads
Bifurcates into anterior tibial, tibioperoneal trunk
Anterior tibial artery (ATA)
Passes anteriorly through intraosseous membrane
Becomes DP artery at ankle level
Tibioperoneal trunk
a.k.a. tibial fibular trunk
Variable but typically short segment
Divides into peroneal and PT arteries
Peroneal artery
a.k.a. fibular artery
Relatively resistant to atherosclerosis
Normally patent to just above ankle joint
Has communicating branches with ATA
PT artery
Supplies posterior compartment
Distally forms plantar arch of foot
PREPROCEDURE
Indications
Contraindications
Preprocedure Imaging
Getting Started
PROCEDURE
Patient Position/Location
Procedure Steps
Alternative Procedures/Therapies
POST PROCEDURE
Things to Do
OUTCOMES
Complications
Expected Outcomes
Selected References
Solimeno G et al: Technical perspectives in the management of complex infrainguinal arterial chronic total occlusions. J Vasc Surg. 75(2):732-9, 2022
Anand GM et al: Single versus multiple vessel endovascular tibial artery revascularization for critical limb ischemia: a review of the literature. Int J Angiol. 29(3):175-9, 2020
Bevan GH et al: Evidence-based medical management of peripheral artery disease. Arterioscler Thromb Vasc Biol. 40(3):541-53, 2020
Kim SM et al: Device selection in femoral-popliteal arterial interventions. Interv Cardiol Clin. 9(2):197-206, 2020
Kim TI et al: New innovations and devices in the management of chronic limb-threatening ischemia. J Endovasc Ther. 27(4):524-39, 2020
Levin SR et al: Lower extremity critical limb ischemia: a review of clinical features and management. Trends Cardiovasc Med. 30(3):125-30, 2020
Ansel GM: Drug-coated balloons versus drug-eluting stents in the femoropopliteal artery: comparing apples to oranges? J Cardiovasc Surg (Torino). 60(4):456-9, 2019
Naghi J et al: New developments in the clinical use of drug-coated balloon catheters in peripheral arterial disease. Med Devices (Auckl). 9:161-74, 2016
Pernès JM et al: Infrapopliteal arterial recanalization: a true advance for limb salvage in diabetics. Diagn Interv Imaging. 96(5):423-34, 2015
Thukkani AK et al: Endovascular intervention for peripheral artery disease. Circ Res. 116(9):1599-613, 2015
Hardman RL et al: Overview of classification systems in peripheral artery disease. Semin Intervent Radiol. 31(4):378-88, 2014
Sarode K et al: Drug delivering technology for endovascular management of infrainguinal peripheral artery disease. JACC Cardiovasc Interv. 7(8):827-39, 2014
Creager MA et al: Clinical practice. Acute limb ischemia. N Engl J Med. 366(23):2198-206, 2012
Hynes BG et al: Endovascular management of acute limb ischemia. Ann Vasc Surg. 26(1):110-24, 2012
Van Den Berg J et al: Lesion characteristics of patients with chronic critical limb ischemia that determine choice of treatment modality. J Cardiovasc Surg (Torino). 53(1):45-52, 2012
Karnabatidis D et al: Quality improvement guidelines for percutaneous catheter-directed intra-arterial thrombolysis and mechanical thrombectomy for acute lower-limb ischemia. Cardiovasc Intervent Radiol. 34(6):1123-36, 2011
Lawrence PF et al: When should open surgery be the initial option for critical limb ischaemia? Eur J Vasc Endovasc Surg. 39 Suppl 1:S32-7, 2010
Norgren L et al: Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 45 Suppl S:S5-67, 2007
Related Anatomy
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Related Differential Diagnoses
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References
Tables
Tables
KEY FACTS
Terminology
Preprocedure
Procedure
Outcomes
TERMINOLOGY
Definitions
Peripheral artery disease (PAD)
Occlusion or stenosis of noncoronary, noncerebral arteries
Symptoms range from asymptomatic to rest pain/tissue loss
PAD risk factors
Age > 50 years, obesity, male sex, hypertension, hyperlipidemia
Diabetes
Have more aggressive PAD
5x higher amputation rate
Typically affects distal, small-caliber vessels
Severity of symptoms depends on degree of stenosis, collateral circulation, intensity of exertion
Ankle-brachial index (ABI)
Noninvasive evaluation of peripheral circulation
Performed with blood pressure (BP) cuff and continuous Doppler
Ankle:brachial systolic pressure ratio
Use higher ankle pressure [dorsalis pedis (DP) or posterior tibial (PT)]
Divide by higher of 2 brachial artery pressures
Interpretation
≥ 1.3: Calcified vessels
Medial calcification can be seen in end-stage renal disease or diabetes
Unreliable examination as calcification prevents vessel compression
Use toe-brachial index instead
0.9-1.3: Normal
< 0.9: Abnormal; indicates presence of PAD
0.4-0.9: Mild to moderate PAD; intermittent claudication likely
< 0.4: Severe PAD; critical limb ischemia likely
Toe-brachial index (TBI)
> 0.7: Normal
0.5-0.7: Mild
0.35-0.5: Moderate
< 0.35
Moderate to severe if toe pressure > 30 mm Hg
Severe if toe pressure < 30 mm Hg
Intermittent claudication (IC)
Reproducible crampy muscular leg pain with exercise, relieved with rest
Peripheral neuropathy may initially present similarly
With CLI, pain worsens when leg elevated, relieved when leg dependent
Severe arterial obstruction or occlusion
Often multifocal disease
Typical ABI < 0.4
Acute limb ischemia (ALI)
Sudden interruption of arterial blood flow to extremity
Usually due to embolus or in situ thrombosis
Embolic source may be cardiac or aneurysm
Symptoms: 6 Ps of ALI
Pain, pulselessness, pallor, paresthesias, paralysis, and poikilothermia (i.e., cold)
Rutherford classification for ALI
I: Viable
No sensory loss; no motor loss
May have audible Doppler arterial pulse
IIa: Marginally threatened
Pain/sensory loss, no weakness
IIb: Immediately threatened
Pain/sensory loss and mild weakness
III: Irreversible (nonviable)
Anesthesia/paralysis, muscle rigor
Physical Examination in Peripheral Artery Disease
Diminished/absent pulses distal to stenosis
Infrainguinal lesion: Normal femoral, decreased or absent DP/PT pulses
Bruit over stenosis
Cool extremity, distal hair loss
Poor wound healing
Inspect area between toes as kissing toe ulcers from pressure between metatarsal heads often seen
Dependent rubor and elevation pallor
Often seen in CLI
Fontaine Stages of PAD
Stage 1: Asymptomatic but decreased pulses; ABI < 0.9
Up to 75% of patients with PAD are asymptomatic
Could be related to sedentary/limited lifestyle
Stage 2: IC
2a: Distance > 200 m
2b: Distance < 200 m
Stage 3: Ischemic rest pain
Stage 4: Ulceration, gangrene
Trans-Atlantic Inter-Society Consensus II (TASC II): Categorization of Atherosclerotic Lesions Based on Morphology
Type A
Single stenosis ≤ 10 cm in length
Single occlusion ≤ 5 cm in length
Endovascular therapy is treatment of choice
Type B
Multiple lesions ≤ 5 cm in length
Single stenosis or occlusion ≤ 15 cm in length
Heavily calcified lesion ≤ 5 cm in length
Typically, endovascular treatment preferred
Type C
Multiple lesions adding up to > 15 cm
Recurrent stenosis after 2 endovascular treatments
Multiple lesions > 3 cm but < 5 cm in length
Surgery preferred; consider endovascular therapy if high-risk patient for open revascularization
Type D
Chronic total occlusions (CTO) > 20 cm or involving popliteal artery/proximal trifurcation
Poor endovascular results, surgery is standard
Infrainguinal Vascular Anatomy
CFA
Continuation of external iliac artery below inguinal ligament
Overlies femoral head
Angiographic surrogate of inguinal ligament are inferior epigastric/deep circumflex iliac artery origins
Surgical endarterectomy treatment of choice for atherosclerotic disease of CFA
Bifurcates into superficial and deep femoral arteries
SFA
From CFA bifurcation to caudal end of adductor (Hunter) canal
Distal portion of SFA, within adductor canal, is prone to atherosclerotic disease
3/4 of femoropopliteal occlusions occur within adductor canal
Relatively absent of side branch vessels
Profunda femoris artery
a.k.a. deep femoral artery
Extends from femoral bifurcation into thigh musculature
Provides important collaterals in setting of SFA stenosis/occlusion
Perforating branches resistant to atherosclerosis
Popliteal artery
SFA becomes popliteal artery at adductor hiatus
Courses behind knee, between gastrocnemius heads
Bifurcates into anterior tibial, tibioperoneal trunk
Anterior tibial artery (ATA)
Passes anteriorly through intraosseous membrane
Becomes DP artery at ankle level
Tibioperoneal trunk
a.k.a. tibial fibular trunk
Variable but typically short segment
Divides into peroneal and PT arteries
Peroneal artery
a.k.a. fibular artery
Relatively resistant to atherosclerosis
Normally patent to just above ankle joint
Has communicating branches with ATA
PT artery
Supplies posterior compartment
Distally forms plantar arch of foot
PREPROCEDURE
Indications
Contraindications
Preprocedure Imaging
Getting Started
PROCEDURE
Patient Position/Location
Procedure Steps
Alternative Procedures/Therapies
POST PROCEDURE
Things to Do
OUTCOMES
Complications
Expected Outcomes
Selected References
Solimeno G et al: Technical perspectives in the management of complex infrainguinal arterial chronic total occlusions. J Vasc Surg. 75(2):732-9, 2022
Anand GM et al: Single versus multiple vessel endovascular tibial artery revascularization for critical limb ischemia: a review of the literature. Int J Angiol. 29(3):175-9, 2020
Bevan GH et al: Evidence-based medical management of peripheral artery disease. Arterioscler Thromb Vasc Biol. 40(3):541-53, 2020
Kim SM et al: Device selection in femoral-popliteal arterial interventions. Interv Cardiol Clin. 9(2):197-206, 2020
Kim TI et al: New innovations and devices in the management of chronic limb-threatening ischemia. J Endovasc Ther. 27(4):524-39, 2020
Levin SR et al: Lower extremity critical limb ischemia: a review of clinical features and management. Trends Cardiovasc Med. 30(3):125-30, 2020
Ansel GM: Drug-coated balloons versus drug-eluting stents in the femoropopliteal artery: comparing apples to oranges? J Cardiovasc Surg (Torino). 60(4):456-9, 2019
Naghi J et al: New developments in the clinical use of drug-coated balloon catheters in peripheral arterial disease. Med Devices (Auckl). 9:161-74, 2016
Pernès JM et al: Infrapopliteal arterial recanalization: a true advance for limb salvage in diabetics. Diagn Interv Imaging. 96(5):423-34, 2015
Thukkani AK et al: Endovascular intervention for peripheral artery disease. Circ Res. 116(9):1599-613, 2015
Hardman RL et al: Overview of classification systems in peripheral artery disease. Semin Intervent Radiol. 31(4):378-88, 2014
Sarode K et al: Drug delivering technology for endovascular management of infrainguinal peripheral artery disease. JACC Cardiovasc Interv. 7(8):827-39, 2014
Creager MA et al: Clinical practice. Acute limb ischemia. N Engl J Med. 366(23):2198-206, 2012
Hynes BG et al: Endovascular management of acute limb ischemia. Ann Vasc Surg. 26(1):110-24, 2012
Van Den Berg J et al: Lesion characteristics of patients with chronic critical limb ischemia that determine choice of treatment modality. J Cardiovasc Surg (Torino). 53(1):45-52, 2012
Karnabatidis D et al: Quality improvement guidelines for percutaneous catheter-directed intra-arterial thrombolysis and mechanical thrombectomy for acute lower-limb ischemia. Cardiovasc Intervent Radiol. 34(6):1123-36, 2011
Lawrence PF et al: When should open surgery be the initial option for critical limb ischaemia? Eur J Vasc Endovasc Surg. 39 Suppl 1:S32-7, 2010
Norgren L et al: Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 45 Suppl S:S5-67, 2007
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