Atheroma tends to develop in the abdominal aorta and at the origins of major branches. Intermittent claudication Ischaemia of the lower limbs is usually accompanied by effort- related cramp in the calves, thighs and buttocks, which disappears with rest. The site of claudication indicates the probable site of stenosis or occlusion - the higher the claudication the higher the atheroma is likely to be found. The walking distance on the flat is usually remarkably repeatable. Claudication is often accompanied by profound weakness as well as cramp in the affected muscles which have become acidotic from anaerobic exercise.
More severe ischaemia produces a continuous pain at rest, particularly in bed.
The pain is most frequently in the toes or foot, with some paraesthesia. The foot is often hung over the edge of the bed and may be subject to ulceration and gangrene. It affects the small arteries of the hands and feet, with an intense inflammatory response, and often involves the veins as well. Cessation of smoking or chewing tobacco is imperative. Diagnosis and investigation Peripheral vascular disease is assessed by a careful history and clinical examination for signs of ischaemia, absent pulses, audible bruits over the proximal arteries, poor skin nutrition, low skin temperature and loss of hair, and then by blood pressure measurement.