Clinical Features

Up to 20–50% of patients with PAD are asymptomatic.

• Seen in approx. 10–35% of patients

• Pain, cramps, or paresthesia distal to arterial occlusion

  • Femoropopliteal disease (most common): typically causes calf claudication

  • Aortoiliac disease (Leriche syndrome)

    • Level of the aortic bifurcation or bilateral occlusion of the iliac arteries

    • Triad of bilateral buttock, hip, or thigh claudication, erectile dysfunction, and absent/diminished femoral pulses

  • Tibiofibular disease: typically causes foot claudication

• Worsens upon exertion ,

• Completely relieved by rest or lowering affected limbs

• Reproducible on asking the patient to walk the same distance at which symptoms typically occur

Rest pain occurs as disease progresses and indicates severe ischemia.

• Typically occurs first in the toes and forefoot

• Worsens with reclining (e.g., while sleeping)

• Improves on hanging feet off the bed or on standing

• Indicative of limb-threatening arterial occlusion

• Characterized by the presence of any one of the following:

  • Rest pain lasting ≥ 2 weeks

  • Nonhealing ulcers

  • Tissue loss (gangrene)

• Trophic changes

  • ↓ Skin temperature, ↓ perspiration

  • ↓ Hair on legs, ↓ nail growth, brittle nails

  • Atrophied muscles

  • Dry atrophic, shiny skin and/or bluish skin discoloration

  • Livedo reticularis (advanced disease)

  • Gangrene, ulcers, necrosis (end-stage disease): See also “Arterial ulcer.”

• Absent or diminished pulses: examine distal pulses bilaterally, including

  • Upper extremity: brachial artery, radial artery

  • Lower extremity: femoral artery , popliteal artery , posterior tibial artery , and dorsalis pedis artery

• Buerger sign [4][5]

  • With the patient in the supine position, elevate the lower limbs to a 45° angle at the hip.

  • Evaluate for pallor of the feet.

  • Ask the patient to sit up with their legs off of the examination table in the dependent position.

  • Evaluate the time taken for the color to return to the feet and for the veins to become distended.

  • Positive Buerger sign

    • Skin pallor on limb elevation

    • Reactive hyperemia on limb dependency

    • A venous filling time of > 20 seconds may indicate advanced ischemia.

• Bruit: over the affected artery may be heard in > 60–70% of cases with PAD