VASCULAR DISEASES

Arterial diseases include those acute and chronic disorders that result in partial or complete, functional or anatomic occlusion, or aneurysmal dilatation of the arteries. An example of functional occlusion is abnormal vascular reactivity of the arteries supplying a given tissue, such as vasospasm. Recognition of the broad differential diagnosis of lower extremity arterial disease is important to optimize management. Peripheral arterial disease (PAD) has increased in prevalence and put a severe burden on patients and the economy.43 PAD affects more than 8 million adults in the United States alone.69 PAD is a disease of aging with an increase in disease prevalence from 10% in individuals age 65 years to more than 30% in octogenarians.60 Patients with PAD commonly present with symptoms of intermittent claudication or critical limb ischemia. In general, symptoms occur distal to the level of stenosis. If the patient is active, intermittent claudication is the typical presenting complaint. If the patient is inactive, then rest pain, ulceration, dependent rubor, or gangrene may be the presenting finding (Fig. 25.1). Patients with intermittent claudication have a significantly higher mortality than age-matched controls, approximately 12% per year.53 Of these deaths, 66% are caused by heart disease and 10% by strokes. Only one in four patients with intermittent claudication will develop critical limb ischemia. Longitudinal studies have shown that the amputation rate in this group of patients is only 1% to 7% at 5 to 10 years.18