Treatment of Peripheral Arterial Disease in the Elderly Person

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Author(s):

Wilbert S. Aronow, MD, CMD

Peripheral arterial disease (PAD) is a chronic arterial, occlusive disease of the lower extremities caused by atherosclerosis. PAD may cause intermittent claudication, which is pain or weakness with walking that is relieved with rest.

Only one-half of elderly persons with documented PAD are symptomatic. Persons with PAD may not walk far enough or fast enough to induce muscle ischemic symptoms because of comorbidities such as pulmonary disease or arthritis, they may have atypical symptoms unrecognized as intermittent claudication, they may fail to mention their symptoms to their physicians, or they may have sufficient collateral arterial channels to tolerate their arterial obstruction.

If the arterial flow to the lower extremities cannot meet the needs of resting tissue metabolism, critical lower-extremity ischemia occurs with pain at rest or tissue loss. Critical ischemia causes pain at rest in the toes or foot with progression to ulceration or gangrene.

NONINVASIVE DIAGNOSIS
Persons with PAD of the lower extremities may have decreased or absent arterial pulses. Noninvasive tests used to assess lower-extremity arterial blood flow include measurement of ankle and brachial artery systolic blood pressures, characterization of velocity wave form, and duplex ultrasonography. Measurement of ankle and brachial artery systolic blood pressures, using a Doppler stethoscope and blood pressure cuffs, allows calculation of the ankle-brachial index (ABI), which is normally 0.9-1.2. An ABI of less than 0.90 is 95% sensitive and 99% specific for the diagnosis of PAD. The lower the ABI, the more severe the restriction of arterial blood flow, and the more serious the ischemia. Patients with calcified arteries from diabetes mellitus or renal failure occasionally have relatively noncompressible arteries leading to falsely elevated ABI values in the normal range.

Duplex ultrasonography combines Doppler frequency measurements with two-dimensional images of blood vessels. The severity of flow restriction caused by an arterial stenosis can be accurately assessed by this comprehensive, noninvasive method.

PREVALENCE
The prevalence of PAD increases with age.

References:

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