Peripheral artery disease

See acute arterial ischemia for acute limb ischemia


  • Peripheral artery disease = ABI <0.9 (normal ≥1.0)[1]
  • >70% of patients are either former or current smokers[2]
  • 33% of deaths are from reperfusion injury
    • Myoglobinemia, ARF, increased CK
  • Thrombosis accounts for >80% of lower limb ischemia
  • PAD indicates systemic atherosclerosis[3]

Clinical Features

Svere peripheral arterial disease with chronic dorsal foot ulceration.
Two ischemic ulcers: second toe (large) and first toe (small).
Peripheral arterial disease resulting in necrosis of multiple toes
  • Shiny, hyperpigmented skin, hair loss
  • Ulceration
    • Tend to be on foot/toes, more painful than venous ulcers
  • Cap refill >3sec

Differential Diagnosis

Foot diagnoses





  • Measuring
    1. Position patient supine
    2. Measure SBP from both brachial arteries using cuff and handheld Doppler over the AC fossa
    3. Measure SBP from both DP and PT arteries using cuff placed just proximal to the malleoli with Doppler over artery (5-8% of normal patients have absent DP pulse)
    4. Calculate ABI on each leg by taking the highest ankle SBP divided by the highest brachial SBP and record to 2 decimal places
  • Using calculation
    • 0.91–1.30: normal
    • 0.70–0.90: mild occlusion
    • 0.40–0.69: moderate occlusion
    • <0.40: severe occlusion
    • >1.30: poorly compressible/calcified vessels


  • Xray
    • Little use or benefit
  • Ultrasound
    • Accurate for detecting obstruction in femoral/popliteal/bypass grafts
      • Sn declines at/below the calf
    • Quality of signal (triphasic, biphasic, monophasic) is important to note
  • CTA
    • Sensitivity similar to that of conventional angiography
  • MRI
    • Limited utility in the ED setting
    • Detailed images of vasculature can be taken and plaques identified


  • Chronic PAD can recieve outpatient management (by vascular)


  • Chronic PAD can be managed as an outpatient

See Also

External Links


  1. Heald CL, et al. Ankle Brachial Index C. Risk of mortality and cardiovascular disease associated with the ankle-brachial index: systematic review. Atherosclerosis. 2006;189:61–69.
  2. Ng EL, et al. Prevalence of and risk factors for peripheral arterial disease in older adults in an Australian emergency department. Vascular. 2014; 22(1):1-12.
  3. Levy PJ. Epidemiology and pathophysiology of peripheral arterial disease. Clin Cornerstone. 2002;4:1–15.