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ICD-9 : 440 ° ICD-10 : I70   Image not available. Image not available. Image not available. 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 age to elderly.

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Sex

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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 (HDL), high low-density lipoprotein (LDL), high cholesterol, hypertension, diabetes mellitus, hyperinsulinemia, abdominal obesity, family history of premature ischemic heart disease, personal history of cerebrovascular disease or occlusive peripheral vascular disease.

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Diabetes Mellitus and Lower Leg Ischemia

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Gangrene of lower extremities is estimated to be up to 150 times more frequent in diabetic than in nondiabetic individuals, most often occurring in those who smoke.

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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 narrowing of arteries supplying the upper extremities is much less common. Atheromatous deposits and thromboses occur commonly in the femoral artery in Hunter canal and in the popliteal artery just above the knee joint. The posterior tibial artery is most often occluded where it rounds the internal malleolus, the anterior tibial artery where it is superficial and becomes the dorsalis pedis artery. 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). Detection of atherosclerosis is often delayed until an ischemic event occurs, related to critical decrease in blood flow.

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In addition to large-vessel arterial obstruction, individuals with diabetes mellitus often have microvasculopathy associated with endothelial cell proliferation and basement membrane thickening of arterioles, venules, and capillaries (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 ...

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