A 70-year-old man was referred to vascular surgery for a several-year history of bilateral lower extremity calf claudication at one block. His claudication symptoms were described as significantly lifestyle limiting with the right leg worse than the left. The patient had previous bilateral iliac artery stenting 2 years prior to presentation (Figure 4-1). His peripheral vascular risk factors include hypertension (HTN), hyperlipidemia, and tobacco abuse (30 pack-years). The patient denied symptoms of rest pain and did not have any evidence of tissue loss. His pedal pulses were palpable bilaterally. After discussing options, the patient agreed to a 3-month trial of a supervised exercise program with an oral phosphodiesterase inhibitor (cilostazol) and tobacco cessation.

At the return office visit, the patient reported minimal

improvement. The patient was unable to quit smoking. Ankle-brachial index (ABI) and segmental lower extremity pressures revealed

diminished blood flow bilaterally with a significant drop postexercise. The patient subsequently underwent an angiogram with bilateral lower extremity runoff.

Angiogram findings indicated a 70% stenosis of the right above-knee popliteal artery (Figure 4-2) and 80% stenosis of the popliteal-tibial artery junction (Figure 4-3).

The patient subsequently underwent percutaneous transluminal angioplasty (PTA) of both lesions with a cryoplasty balloon. This achieved a good angiographic result (Figure 4-4). He was maintained on daily antiplatelet therapy (clopidogrel).

Peripheral Arterial Disease

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  Progressive narrowing of the arteries due to atherosclerosis.¹

  
  
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  Mostly silent in early stages until luminal narrowing exceeds 50% vessel diameter.²

  
  
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  Prevalence of peripheral arterial disease (PAD) in adults over

  
  
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  40 years in the United States is approximately 4%.²

  
  
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  Prevalence of PAD in adults over 70 years in the United States is approximately 15%.²

  
  
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  20% to 25% of patients will require revascularization.²

  
  
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  Approximately 5% of patients will progress to critical limb ischemia.²

  
  
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  Patients with limb loss have 30% to 40% mortality in the first 24 months.⁴

Peripheral Arterial Disease

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  Global arterial tree inflammation accounts for atherogenesis and participates in local, myocardial, and systemic complications of atherosclero-sis.³

  
  
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  Vascular risk factors including diabetes, HTN, hyperlipidemia, and tobacco abuse augment cell adhesion molecules, which promote leukocyte binding to the arterial cell wall. This process perpetuates, causing remodeling of the arterial wall and lipid deposition within the tunica media. This process continues and begins to narrow the vessel lumen, eventually causing calcification of the arterial wall.³