n CME : Your SA Journal of CPD - Claudication of the lower limb : an approach to investigation and management




Peripheral arterial disease (PAD) is a chronic atherothrombotic occlusive disorder of the peripheral circulation that predominantly affects the large, medium-sized and small arteries of the lower limbs. The prevalence of PAD ranges from 3% to 10% overall, increasing to 15 - 20% in patients over 70 years. Classic risk factors for PAD include age over 55 years, smoking, diabetes mellitus, hypercholesterolaemia, hypertension, obesity and sedentary lifestyle. Patients with PAD may be asymptomatic or can present with intermittent claudication (IC) and/or critical limb ischaemia (CLI). Patients with CLI have ankle pressures below 50 mmHg and/or toe pressures below 30 mmHg, ischaemic rest pain and/or tissue necrosis (skin ulcer or gangrene). PAD may be classified into 3 segmental types depending on the distribution of the occlusive disease (Table I). Patients with CLI have multi-segment disease as a rule. PAD is not a benign disease; the risk of mortality in patients with established PAD secondary to cardiovascular and cerebrovascular events far outweighs the 4% risk of a major amputation over 10 years. Asymptomatic patients with PAD have an approximately 10-year shorter life expectancy than patients without PAD. Patients with IC have a 10-year mortality rate approaching 50%. Patients with CLI have 1- and 5-year mortality rates approaching 25% and 50% respectively. The modern evidence-based approach to treatment of PAD therefore emphasises lifestyle modification, control of risk factors, antiplatelet therapy, lipid-lowering agents and foot care. Patients with CLI will, in addition, need some form of surgical therapy: amputation, percutaneous transluminal angioplasty (PTA), peripheral stent or bypass procedure.


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