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ATHEROSCLEROSIS, ARTERIAL INSUFFICIENCY, AND ATHEROEMBOLIZATION ICD-10: I70

  • Atherosclerosis obliterans (ASO) is associated with spectrum of cutaneous findings of slowly progressive ischemic changes, especially when occurring on the lower extremities.

  • Symptoms range from acute ischemia to intermittent claudication with exertional muscle pain and fatigue to limb ischemia with rest pain and tissue damage.

  • Cutaneous findings range from dry skin, hair loss, onychodystrophy, gangrene, and ulceration.

  • Atheroembolism is the phenomenon of dislodgment of atheromatous debris from a proximal affected artery or aneurysm with centrifugal microembolization and resultant acute ischemic and infarctive cutaneous lesions.

  • More common with advanced age and invasive procedures.

  • Manifestations are blue or discolored toes (“blue toe”), livedo reticularis, and gangrene.

EPIDEMIOLOGY

AGE OF ONSET Middle aged to elderly. Males > females.

INCIDENCE Atherosclerosis is the cause of 90% of arterial disease in developed countries.

RISK FACTORS FOR ATHEROSCLEROSIS Cigarette smoking, hyperlipidemia, low high-density lipoprotein, high low-density lipoprotein (LDL), high cholesterol, hypertension, diabetes mellitus, hyperinsulinemia, abdominal obesity, family history of premature ischemic heart disease, and personal history of cerebrovascular disease or occlusive peripheral vascular disease.

PATHOGENESIS

Atherosclerosis is the most common cause of arterial Insufficiency and may be generalized or localized to the coronary arteries, aortic arch vessels to the head and neck, or those supplying the lower extremities, i.e., femoral, popliteal, anterior, and posterior tibial arteries. In addition to large-vessel arterial obstruction, individuals with diabetes mellitus often have microvasculopathy (see Section 15).

ATHEROEMBOLISM Multiple small deposits of fibrin, platelet, and cholesterol debris embolize from proximal atherosclerotic lesions or aneurysmal sites. Occurs spontaneously or after intravascular surgery or procedures such as arteriography, fibrinolysis, or anticoagulation.

CLINICAL MANIFESTATION

Atherosclerosis/Arterial Insufficiency of Lower Extremity Arteries

SYMPTOMS Pain on exercise, i.e., intermittent claudication. With progressive arterial insufficiency, pain and/or paresthesias at rest occur in the leg and/or foot, especially at night. Pallor, cyanosis, livedoid vascular pattern (Fig. 17-1), and loss of hair on affected limb. Earliest infarctive changes include well-demarcated map-like areas of epidermal necrosis. Later, dry black gangrene may occur over the infarcted skin (purple cyanosis → white pallor → black gangrene) (Fig. 17-2). Shedding of slough leads to well-demarcated ulcers in which underlying structures such as tendons can be seen.

FIGURE 17-1

Atherosclerosis obliterans, early The lower extremity shows pallor and there is mottled, livedoid erythema. (Used with permission of Dr. Kenneth Greer.)

FIGURE 17-2

Atherosclerosis obliterans There is pallor of the forefoot and mottled erythema distally with incipient gangrene on the great toe and the second digit. This is a female diabetic with partial occlusion of the femoral artery. The patient was a smoker. (Used with permission from Virginia Capasso, PhD, APRN.)

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