Snapshot A 65-year-old man presents to the ED with acute onset of pain, paresthesias, pallor, and an absent dorsalis pedis pulse in his right leg. The skin on his leg is cool and pallor is intensified by leg-raising. Introduction Arterial insufficiency is the result of arteriosclerosis or other artery-specific inflammatory process in most instances the popliteal artery is the most susceptible vessel for occlusion it is commonly a site of atherosclerosis it has a small caliber Presentation Symptoms claudication may or may not be relieved by rest acute onset or rest pain of the affected limb numbness distally Physical exam cyanosis atrophic changes of the leg and foot including thickened nails loss of hair shiny skin atrophied muscles decreased temperature on palpation diminished or absent distal pulses Aortoiliac occlusion can present with triad of bilateral lower limb claudication, impotence, and lower extremity muscular atrophy Evaluation Doppler ultrasound (best initial test) diagnostic gold standard identifies stenosis and occlusion of aortoiliac vessels Arteriography and digital subtraction angiography (most accurate test) necessary for surgical evaluation Differential Severe atherosclerosis, embolus, thrombus, compartment syndrome Treatment Nonoperative lifestyle modifications including smoking cessation exercise (best initial therapy) healthy diet control of cholesterol, hypertension, and DMII medical management beta-blockers may theoretically worsen claudication via B2-receptor blockade but often indicated due to coexisting coronary disease aspirin cilostazol pentoxifylline (mildly effective) blood pressure control with ACE inhibitors Operative angioplasty and stenting indicated in patients with rest pain in the forefoot or severely lifestyle-inhibited success is highly dependent on area of occlusion arterial bypass surgery indicated only when conservative treatment fails and angioplasty not an option amputation indicated as salvage procedure often occurs in uncontrolled diabetic patients Prognosis, Prevention, and Complications Prognosis clinical outcomes can range broadly depending on extent and rapidity of obstruction presence of collateral blood flow Risk of a future cardiovascular event is extremely high in patients with PAD risk of MI is greater than that of critical limb ischemia (defined as chronic ischemic rest pain, ulcers, or gangrene) Prevention healthy lifestyle, smoking cessation, diet, and exercise are the key factors early detection and intervention can reduce severity of symptoms and progression Complications include clot formation (i.e. thrombus) can lead to compartment syndrome following reperfusion development of acute ischemia distal limb amputation in cases of severe systemic disease