Keys To Diagnosing Peripheral Arterial Disease

Kazu Suzuki, DPM, CWS, and Osami Kawarada, MD, FSCAI

Peripheral arterial disease (PAD) can result in a range of serious complications and death. Accurate and timely diagnosis is important for wound healing and proper preoperative workup in foot and ankle surgery. Offering insights from the latest PAD guidelines and research, these authors offer a closer look at non-invasive diagnostic methods and a brief review of medical, endovascular and surgical treatment of PAD.

Peripheral arterial disease (PAD) affects approximately 8 million Americans who experience significant and costly morbidity such as leg amputation and death.1 There is a 20 percent incidence of PAD in patients 75 years of age and older. Despite the prevalence of the disease and associated cardiovascular risk, only 25 percent of these patients undergo treatment.2

   Early diagnosis and treatment of PAD not only improves quality of life, it saves lives. According to the REACH Registry, approximately 16 percent of patients with PAD have other atherosclerotic changes, such as cerebrovascular disease and/or coronary artery disease.2 Consequently, patients with PAD have a mortality risk that is two to three times greater than patients who do not have PAD and patients with PAD reportedly die 10 years earlier on average than those without PAD.3 Remember that PAD is not just a “leg cramping problem” but an ominous sign of declining health that requires our close attention.

   Diabetes is an independent and significant risk factor for developing PAD. Currently, there are approximately 25.8 million people with diabetes or approximately 8.3 percent of the population in the United States.4 The American Diabetes Association consensus statement presents clinical data that one in three patients with diabetes mellitus are known to have PAD.4 The statement urged clinicians to participate actively in the diagnosis and treatment of this disease.

Recognizing The Challenges Of Diagnosing PAD

Although we often associate PAD with intermittent claudication (calf pain caused by walking), this classic symptom is present in only 10 percent of patients with PAD. Surprisingly, 50 percent of people with PAD have no symptoms while 40 to 50 percent may present with atypical, non-specific leg complaints.5

   Diagnosing PAD can be challenging visually and clinically. A recent systematic review of clinical studies on PAD found that a physical examination of the lower extremities (e.g., palpation of pulses and “classic findings” such as atrophic skin changes or lack of hair growth) alone is unreliable and “not independently sufficient to include or exclude the diagnosis of PAD.”6 The authors of the review strongly recommended the use of non-invasive vascular diagnostics to diagnose PAD.6

What You Should Know About Diagnosing Lower Extremity PAD

When it comes to diagnosing PAD, we follow a three-step checklist.

   1. Obtain a full history and perform a physical exam to determine the pre-test probability of PAD.

   2. For high-risk individuals, perform a non-invasive perfusion test.

   3. After confirming a PAD diagnosis with non-invasive perfusion testing, notify the patient’s primary care physician or cardiologist. For evaluation and treatment of symptomatic PAD, the patient should get a referral to a vascular specialist (i.e. vascular surgeon, interventional cardiologist or interventional radiologist). This referral is more urgent for patients with severe ischemia.

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