Peripheral artery disease resident survival guide
Synonyms and keywords: Peripheral artery disease approach, Approach to claudication, Approach to the peripheral arterial disease
For the complete wikidoc page on claudication click here.

# Overview
Claudication is the description of cramping muscle pain that occurs after a certain degree of exercise and is relieved by rest. Claudication is classically caused by peripheral arterial disease, in which an obstruction in the artery of the lower limbs can lead to an insufficient blood flow which is not enough to supply the demands from the muscles of that region, but there are other conditions that can mimic its symptoms such as nerve root compression, spinal stenosis, hip arthritis, symptomatic Baker's cyst, venous claudication and chronic compartment syndrome.

# Causes

## Life Threatening Causes
There are no life-threatening causes, which include conditions that may result in death or permanent disability within 24 hours if left untreated.

## Common Causes
- Peripheral arterial disease
- Venous claudication
- Arterial thromboembolism
- Cholesterol embolism
- Vasculitis
- Nerve root compression (radiculopathy, plexopathy)
- Peripheral neuropathy
- Lumbar canal stenosis (pseudoclaudication)
- Spinal stenosis
- Arthritis/Connective tissue disease
- Baker's cyst
- Muscle strain
- Ligament/tendon injury
- Chronic compartment syndrome 

# Diagnosis
Shown below is a flowchart for diagnostic testing for suspected peripheral arterial disease according to the 2016 AHA/ACC guidelines:
Shown below is a table summarizing the differential diagnosis of claudication according the age and clinical presentation:

# Treatment

# Do's
- Assess for peripheral arterial disease, as it is the most common cause for intermittent claudication, but do consider other causes depending on the age;
- Confirm the diagnosis by measuring the ankle-brachial pressure indices;
- Assess the risk factors for atherosclerosis and mitigate them. Encourage patients to cease smoking, to control their blood glucose, prescribe antiplatelet drugs, optimize antihypertensive medication doses, start statins and encourage exercise;
- If there is no improvement, symptoms are disabling or diagnosis is uncertain, refer to a specialist.
- The best treatment options for peripheral arterial disease are: open surgery, endovascular therapy, and exercise therapy. These were superior to medical management in achieving longer walking distance and managing claudication.
- Antiplatelet drugs with either aspirin or clopidogrel alone is recommended to reduce myocardial infarction, stroke, and vascular death in patients with symptomatic PAD.
- In patients with claudication, supervised exercise programs increases functional status and reduces leg symptoms.
- Patients with diabetes mellitus should be oriented to perform self-foot examination and healthy foot behaviors. Quick diagnosis and treatment of foot infections can prevent amputation.

# Don'ts
- Symptomatic treatment of the claudication and leg pain must not overshadow the reduction of cardiovascular risk, as these patients have a significantly increased risk of death.
- When treating peripheral arterial disease, always attempt reducing symptoms with less invasive treatment options such as exercising, do not immediately refer patients to more invasive treatment options;
- Don't forget to address other causes of claudication if the patient is presenting it at a younger age, or if the treatment doesn't improve the symptoms.
- Do not perform invasive or non-invasive anatomic assessments for asymptomatic patients.
- In patients who are not at increased risk of peripheral arterial disease, and without a history of physical examination findings suggestive of PAD, the ankle-brachial index is not recommended.
- Anticoagulation should not be used to reduce the risk of cardiovascular ischemic events in patients with PAD.
- Pentoxifylline is not effective for treatment of claudication.