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Atherosclerosis, Arterial Insufficiency, and Atheroembolization

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ICD-9: 440 ○ ICD-10: I70 Image not available.

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

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

  • 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

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Epidemiology

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Age of Onset
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Middle aged to elderly. Males > females.

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Incidence
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Atherosclerosis is the cause of 90% of arterial disease in developed countries, affecting 5% of men >50 years; 10% (20% of diabetics) of all men with atherosclerosis develop critical limb ischemia.

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Risk Factors for Atherosclerosis
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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.

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Pathogenesis

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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. Atheromatous material in the abdominal or iliac arteries can also diminish blood flow to the lower extremities as well as break off and embolize downstream to the lower extremities (atheroembolization). In addition to large-vessel arterial obstruction, individuals with diabetes mellitus often have microvasculopathy (see Section 15, Diabetic Dermopathy).

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Atheroembolism
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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.

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Clinical Manifestation

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Atherosclerosis/Arterial Insufficiency of Lower Extremity Arteries
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Symptoms
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Pain on exercise, i.e., intermittent claudication. With progressive arterial insufficiency, pain and/or paresthesias at rest occur in leg and/or foot, especially at night.

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Pallor, cyanosis, livedoid vascular pattern (Fig. 17-1), loss of hair on affected limb. Earliest infarctive changes include well-demarcated maplike 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.

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Figure 17-1.

Atherosclerosis obliterans, early The great toe shows pallor and there is mottled, livedoid erythema ...

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