Clinical features

Mild disease presents as intermittent claudication:

• pain is felt in one or both calf muscles on walking:
• the patient may be aware of their "claudication distance"
• rest relieves the pain

More severe disease presents as critical ischaemia, usually, without preceding claudication. Patients tend to be older and less active than typical claudicants. The precise clinical features depend on the site of the arterial stenosis, however symptoms usually develop insidiously over a period of weeks, being manifest initially in the skin of the foot.

The following factors make the diagnosis of vascular claudication more likely (1):

• pain that occurs in the calf muscles on walking rather than diffuse leg pain
• symptoms that come on more quickly when hurrying or walking up hill
• pain which resolves quickly with rest (usually <5min)
• the pain is not present at rest
• absence of numbness/weakness of the legs

Pain from a spinal or nerve root origin (spinal canal claudication for example) usually produces symptoms not localised to a muscle group, and symptoms are often of weakness or heaviness on walking

Patients with critical ischaemia usually complain of:

• rest pain
• failure of trivial injuries to heal
• ulcers
• pressure sores
• impotence

On examination:

• the leg may be cold, numb, pale and cyanosed
• there may be venous guttering
• peripheral pulses are weak or absent
• Buerger's test is positive
• there may be arterial bruits, for example over the carotid or femoral arteries
• trophic skin changes include:
  • thin, hairless, shiny skin
  • arterial ulcers
  • gangrene
• there may be signs of previous (auto)amputation

Untreated, the necrotic tissues may become infected, resulting in wet gangrene, and eventually, septicaemia and death.

Reference:

• 1. BHF Factfile (September 2009). Intermittent claudication and peripheral arterial disease