Infrainguinal Occlusive Disease

What is Infrainguinal Occlusive Disease?

Infrainguinal occlusive diseases, also known as arterial occlusive disease or chronic limb ischemia, are some of the most widespread illnesses affecting people around the world. These are conditions where the arteries in the lower part of the body are blocked or narrowed, typically caused by other health problems or atherosclerosis, the hardening of the arteries due to fatty deposits. As a consequence, they can lead to an increased risk of losing a limb or experiencing complications with the brain and heart blood vessels.

Some less common diseases can also cause symptoms of lower limb arterial insufficiency, such as poor blood flow to the legs. These include atheroembolism, a condition where cholesterol crystals break loose from plaque in the arteries and block blood flow, and Buerger’s disease, a rare disease of the arteries and veins in the arms and legs.

The symptoms of arterial occlusive diseases can vary depending on where the artery narrowing or blockage is located. In the lower limbs, the most common symptoms include intermittent claudication, a condition that causes pain while walking; rest pain, which is a constant, burning pain that worsens at night; and gangrene, which is the death of body tissue due to a lack of blood flow.

Doctors use different established classifications to determine the severity of these diseases. They include the Fontaine, Rutherford, Wagner, UT, PEDIS, and SVS WIfI systems. These classifications help them to assess the disease accurately and determine the best course of treatment.

The main arteries affected in infrainguinal occlusive diseases are those located below the groin area—in medical terms, inferior to the inguinal ligament. These include branches of the femoral artery which is an extension of the external iliac artery, the popliteal artery located behind the knee, and the arteries below the knee including the posterior tibial and dorsalis pedis artery.

What Causes Infrainguinal Occlusive Disease?

The arterial occlusive diseases, where the arteries get blocked, happen mostly because of a condition called atherosclerosis. Atherosclerosis is common in older adults, smokers, people with diabetes, high cholesterol, or high blood pressure.

There are also other elements that can contribute, such as high levels of C-reactive protein, homocysteine, blood clotting disorders, inflammation and injuries.

If a person has more than one of these risk factors, it increases the chances of artery blockage and can make it more severe.

Risk Factors and Frequency for Infrainguinal Occlusive Disease

An estimated one in five adults over 55 years old have this disease. Furthermore, it impacts close to 5 million people living in the United States. It’s particularly prevalent among African Americans and people of Hispanic descent. Lastly, smoking significantly raises your risk, making you four times more likely to develop the disease.

Signs and Symptoms of Infrainguinal Occlusive Disease

This disease typically affects men over the age of 50. If someone younger is showing symptoms, the doctor might consider other possible conditions such as Buerger disease or autoimmune disorders like vasculitis.

The main complaint from patients is usually increasing difficulty in walking and experiencing a kind of leg pain called intermittent claudication. This is a calf pain that happens when walking and eases once they rest. There can also be a type of pain that gets worse at night, and is even more uncomfortable when lying flat or raising the foot. It’s often relieved by dangling the foot off the bed or sitting in a chair.

Sores or ulcers commonly appear on fingers and toes, sometimes with a condition called gangrene.

To determine the severity of the disease, the doctor needs to establish the location of the pain related to the blood vessel blockage. They typically ask about pain in the buttocks, knees, calves, and fingers. Other symptoms like impotence and abdominal pain after eating could indicate other related conditions, such as mesenteric ischemia. It’s also vital to know if the patient has a history of stroke or transient ischemic attack.

Doctors will also want to know about any risk factors, such as previous conditions like diabetes, high blood pressure, high cholesterol, and also about current medication dosage and adherence.

During a physical examination, the doctor will observe the patient’s overall appearance and body build, looking out for signs of weight loss and muscle wasting. They will examine the eyes for signs of anemia or jaundice. All pulse points including those in the femoral, popliteal, posterior tibial, and dorsalis pedis artery will be checked by touching. The abdomen is examined for potential abdominal aortic aneurysm and listened to for unusual sounds (bruits).

The doctor will check how the patient walks, and other tests to determine the severity of the disease will be performed. These include looking for skin reddening, ulcers, changes in skin texture, hair loss, skin color alterations, or amputated digits. The doctor will also evaluate sensation and lack of feeling (numbness).

Crucially, a test called the ankle-brachial pressure index (ABPI) will be conducted. Normal ABPI values range from 1.0 to 1.3: a score below 0.9 indicates intermittent claudication, under 0.5 points to pain at rest, and under 0.3 suggests critical limb ischemia. It’s a highly sensitive test and is critical for diagnosis and assessing the severity of the disease.

However, in diabetes patients, the ABPI may show a value higher than 1.3 because of vessel calcification. In these cases, segmental waveform analysis or the toe-brachial index is used as an alternative.

Testing for Infrainguinal Occlusive Disease

When investigating potential health issues, doctors often order a variety of laboratory tests that include a complete blood count, fasting blood sugar levels, a check of your cholesterol (also known as a lipid profile), and tests to check the function of your kidneys (serum creatinine) and electrolyte levels. An electrocardiogram (EKG) is also usually done to monitor the electrical activity of your heart.

The first line of investigation using imaging is usually an ultrasound combined with a doppler test. This is often referred to as a duplex scan. This test is designed to show how well blood is flowing through your veins and arteries and if there is any clot present. It also helps calculate something called the ankle-brachial pressure index, which simply compares the blood pressure in your ankle with the blood pressure in your arm.

Additionally, doctors may use an imaging technique called angiography. This involves taking images of your blood vessels using either a computed tomography scan (also known as a CT scan) or a magnetic resonance angiography (similar to an MRI but specifically for blood vessels). Both of these methods can give doctors a clear picture of the state of your blood vessels.

Treatment Options for Infrainguinal Occlusive Disease

The management of your condition can be divided into different categories including:

1. Lifestyle changes: The most effective treatment starts with changes in your daily habits. This includes losing weight if necessary, getting regular exercise, eating a healthier diet, and taking good care of your feet.

2. Medication: Low-dose aspirin and statins (a type of drug that helps control cholesterol levels) can help, as can a drug called cilostazol that helps expand your blood vessels for better blood flow in your legs. It’s also important to manage any other health conditions you might have, like high blood pressure or diabetes, with prescription medications as directed by your doctor. Note: there’s a type of blood pressure medication called beta-blockers that could potentially make claudication, a medical term for leg pain, worse.

3. Endovascular treatments: These are treatments applied directly inside the blood vessels and include procedures such as inflating a tiny balloon inside the vessel (angioplasty) or inserting a small metal tube (stent) to keep the vessel open. Some vascular surgeons are combining both of these to improve patient outcomes and decrease mortality.

4. Surgical treatments: More serious cases may require surgery, such as creating a new route for blood to flow around a blockage (bypass) or cleaning out the inside of a blood vessel (endarterectomy). In cases where the tissue can’t be saved, amputation could be necessary.

Specifically, for a bypass:

* If the blockage is in the superficial femoral artery, a bypass route can be created from the femoral to the popliteal arteries, above the knee. This bypass route has a 50-75% five-year success rate. Bypass is more effective when performed in main arteries close to the body’s center as compared to those located farther away.

* If needed below the knee, the bypass from the femoral to the distal arteries has a 50-60% five-year success rate.

When possible, the greater saphenous vein, a large vein located in the leg, is used for the graft as it increases the success rate and reduces the risk of infection. If using this vein isn’t possible, synthetic materials such as ePTFE are used for the graft.

In some diseases like Buerger disease, which is inflammation and clotting in the small and medium-sized blood vessels, stopping smoking is the very first step in treatment.

There are several health conditions that can cause symptoms similar to vascular disease. Let’s take a look at some of them:

Leriche syndrome: This is a problem with your aortoiliac artery, causing symptoms like pain in the buttocks, problems with sexual function, and loss of muscle mass in the lower limbs.
Buerger disease: This disease usually affects young male smokers and may cause symptoms like dead tissue in the fingers or toes, pain, and difficulty feeling a pulse.
Vasculitis: This refers to inflammation of the blood vessels, which can cause various symptoms.
Deep venous thrombosis: This condition can cause pain and swelling in the calf. There may also be risk factors present, such as a history of blood clots or long periods of inactivity.
Osteoarthritis: This is a type of joint disease that can cause pain and stiffness.
Popliteal compartment syndrome: This is a painful condition that occurs when pressure within the muscles builds to dangerous levels.
Neurogenic claudication: This can be caused by issues like narrowness of the spine (lumbar stenosis) or a ruptured disc. The symptoms may not always be present or caused by physical activity. You may also observe certain signs during a physical exam, such as cool skin, slow return of color to your feet when pressed, and a lack of observable pulse.

What to expect with Infrainguinal Occlusive Disease

Infrainguinal occlusive diseases might cause severe blood supply problems to the legs in 5 to 10% of patients. This condition can be mostly managed successfully with medication.

However, the success rate of an endovascular approach, a treatment using a tube to clear the disease from inside the blood vessel, is not as high compared to surgical treatment.

The survival rate for patients with this disease is generally 50% over ten years. However, this drops significantly for patients who need surgical treatment, reaching roughly halfway of the ten-year rate within five years.

Possible Complications When Diagnosed with Infrainguinal Occlusive Disease

The most frequent severe complication is critical limb ischemia and high-risk stenosis, which often results in amputation and higher chances of death.

The surgical approach can cause complications after the operation. These can include infections, bleeding, heart or kidney issues, formation of a pseudoaneurysm, graft rejection, and complications related to blood clots.

There’s also a higher chance of needing to be readmitted to the hospital within 30 days and having complications or dying while in the hospital.

Later complications often include restenosis, which is when an artery that has been opened narrows again.

Common Complications:

Critical limb ischemia and high-risk stenosis
Amputation
Increased death rates
Infections after surgery
Bleeding
Heart or kidney issues
Formation of pseudoaneurysm
Graft rejection
Complications related to blood clots
Higher chance of hospital readmission within 30 days
Complications or death while in hospital
Restenosis (artery narrowing again)

Preventing Infrainguinal Occlusive Disease

Making changes to your lifestyle is a crucial part of the treatment process. Losing weight, quitting smoking, and altering your diet can lead to better health outcomes. These proactive steps can boost your overall wellness and help control the disease’s progression.

Medication, such as aspirin and statins, and managing any other health conditions you have, can also help to stop the disease from getting worse. However, beta-blockers should be avoided. Statins are particularly beneficial showing that, in a span of 5 years, patients who have had a bypass surgery to improve blood flow (revascularization) tend to survive longer.

If you are dealing with foot problems, you should be seen by a foot specialist, known as a podiatrist. Managing any open sores (ulcers) you may have on your feet is also important.

Regular check-ups are vital in monitoring your health and managing your disease effectively. If your pain becomes worse or if you’re finding it more difficult to walk (reduced claudication distance), you should seek medical help right away.

Frequently asked questions

Infrainguinal occlusive disease, also known as arterial occlusive disease or chronic limb ischemia, is a condition where the arteries in the lower part of the body are blocked or narrowed, typically caused by other health problems or atherosclerosis. This can lead to an increased risk of losing a limb or experiencing complications with the brain and heart blood vessels.

An estimated one in five adults over 55 years old have this disease.

The signs and symptoms of Infrainguinal Occlusive Disease include: - Increasing difficulty in walking - Intermittent claudication, which is a calf pain that occurs while walking and eases with rest - Nighttime pain that worsens when lying flat or raising the foot - Sores or ulcers on fingers and toes, sometimes with gangrene - Pain in the buttocks, knees, calves, and fingers - Impotence and abdominal pain after eating - History of stroke or transient ischemic attack - Risk factors such as diabetes, high blood pressure, and high cholesterol - Medication dosage and adherence - Weight loss and muscle wasting - Signs of anemia or jaundice in the eyes - Checking pulse points in various arteries - Examination of the abdomen for potential abdominal aortic aneurysm and unusual sounds - Evaluation of walking pattern - Skin reddening, ulcers, changes in skin texture, hair loss, skin color alterations, or amputated digits - Sensation and lack of feeling (numbness) - Ankle-brachial pressure index (ABPI) test, with values below 0.9 indicating intermittent claudication, below 0.5 indicating pain at rest, and below 0.3 suggesting critical limb ischemia - Alternative tests like segmental waveform analysis or toe-brachial index for diabetes patients with vessel calcification.

The doctor needs to rule out the following conditions when diagnosing Infrainguinal Occlusive Disease: 1. Leriche syndrome: This is a problem with the aortoiliac artery, causing symptoms like pain in the buttocks, problems with sexual function, and loss of muscle mass in the lower limbs. 2. Buerger disease: This disease usually affects young male smokers and may cause symptoms like dead tissue in the fingers or toes, pain, and difficulty feeling a pulse. 3. Vasculitis: This refers to inflammation of the blood vessels, which can cause various symptoms. 4. Deep venous thrombosis: This condition can cause pain and swelling in the calf. There may also be risk factors present, such as a history of blood clots or long periods of inactivity. 5. Osteoarthritis: This is a type of joint disease that can cause pain and stiffness. 6. Popliteal compartment syndrome: This is a painful condition that occurs when pressure within the muscles builds to dangerous levels. 7. Neurogenic claudication: This can be caused by issues like narrowness of the spine (lumbar stenosis) or a ruptured disc. The symptoms may not always be present or caused by physical activity. You may also observe certain signs during a physical exam, such as cool skin, slow return of color to your feet when pressed, and a lack of observable pulse.

To properly diagnose Infrainguinal Occlusive Disease, a doctor may order the following tests: 1. Complete blood count (CBC) 2. Fasting blood sugar levels 3. Lipid profile (cholesterol test) 4. Serum creatinine test (to check kidney function) 5. Electrolyte levels test 6. Electrocardiogram (EKG) to monitor heart activity 7. Ultrasound combined with a doppler test (duplex scan) to assess blood flow and detect clots 8. Angiography using computed tomography scan (CT scan) or magnetic resonance angiography (MRA) to visualize blood vessels. These tests help evaluate the overall health of the patient, assess blood flow, and identify any blockages or abnormalities in the blood vessels.

Infrainguinal Occlusive Disease can be treated through a combination of lifestyle changes, medication, endovascular treatments, and surgical treatments. Lifestyle changes include losing weight, regular exercise, eating a healthier diet, and taking good care of the feet. Medication options include low-dose aspirin, statins, and cilostazol. Endovascular treatments involve procedures like angioplasty and stent insertion. Surgical treatments may be necessary in more serious cases, such as bypass surgery or endarterectomy. The success rates of bypass surgery vary depending on the location of the blockage. The greater saphenous vein is preferred for grafting, but synthetic materials can be used if necessary. In some cases, stopping smoking is the first step in treatment.

When treating Infrainguinal Occlusive Disease, there can be several side effects and complications. These include: - Critical limb ischemia and high-risk stenosis - Amputation - Increased death rates - Infections after surgery - Bleeding - Heart or kidney issues - Formation of pseudoaneurysm - Graft rejection - Complications related to blood clots - Higher chance of hospital readmission within 30 days - Complications or death while in hospital - Restenosis (artery narrowing again)

The prognosis for Infrainguinal Occlusive Disease is generally a 50% survival rate over ten years. However, the prognosis is worse for patients who require surgical treatment, with a significantly lower survival rate within five years.

A vascular surgeon.

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