Talk:Peripheral artery disease

Wiki Education Foundation-supported course assignment

This article was the subject of a Wiki Education Foundation-supported course assignment, between 16 August 2021 and 14 December 2021. Further details are available on the course page. Student editor(s): Emilywheeler56. Peer reviewers: Photogdahl.

Above undated message substituted from Template:Dashboard.wikiedu.org assignment by PrimeBOT (talk) 02:15, 18 January 2022 (UTC)

Wiki Education Foundation-supported course assignment

This article was the subject of a Wiki Education Foundation-supported course assignment, between 19 November 2018 and 14 December 2018. Further details are available on the course page. Student editor(s): Brittanylauren120. Peer reviewers: Cwa200.

Above undated message substituted from Template:Dashboard.wikiedu.org assignment by PrimeBOT (talk) 06:24, 17 January 2022 (UTC)

Shouldn't

Shouldn't ABI be Ankle Brachial Index? — Preceding unsigned comment added by 147.10.111.201 (talk) 00:26, 8 January 2005 (UTC)

Yes, it should. I have corrected it. Axl 22:40, 3 Jun 2005 (UTC)

Isn't this also known as PVOD? —Preceding unsigned comment added by Mkayatta (talk • contribs) 15:27, 18 February 2008 (UTC)

That seems like a less common name. I would prefer to rename the whole article PAD for Peripheral Arterial Diease. — Preceding unsigned comment added by Bakerstmd (talk • contribs) 21:41, 6 March 2014 (UTC)

Systematic review

The medical management of PAOD was recently reviewed: PMID 16449620. JFW | T@lk 21:04, 4 July 2006 (UTC)

Fontaine Stages

The 5-stage Fontaine staging mentioned in the article is not one I've ever seen before. As far as I know the common Fontaine stages (at least here in Europe) are:

Fontaine I: asymptomatic
Fontaine II: intermittent claudication (sometimes subdivided in IIa: intermittent claudication without impairment or max walking distance >200m and IIb: with impairment or max.walk.dist <200m)
Fontaine III: nightly or rest pain
Fontaine IV: tissue loss (necrosis or non-healing ulcers).
--- Arthurs 11:15, 30 December 2006 (UTC)

An even more recent paper includes infection and wound scores in predicting limb loss. See PMID 24126108. There are lots of classification schema.Bakerstmd (talk) 21:49, 6 March 2014 (UTC)

The classification of Fontaine has changed. The distance criteria has been abonded. — Preceding unsigned comment added by 131.174.230.39 (talk) 11:14, 19 September 2014 (UTC)

Problems with Mechanical Drilling

of the lower extremity arteries does not seem to be covered in the PAD articles including this one.

What are the results of such surgeries? (infections; residue from shaving plaque; clogging; scar clogging; time span of the improvement of such action; especially where the waist down clogging is extensive, is there really potential for substantial improvement; like several years for example? apparently not--improvement is minimal at best or such things would be discussed!)

The results of usage of the Foxhollow System referred to in a footnote to this article is not covered or is any of the other "drilling methods". Why is this not covered in this article? Why are the dark secrets not discussed? Pugetkid 09:32, 4 June 2007 (UTC)Pugetkid 6-3-07

Notes from a professional

I do these various tests and diagnosis for a living. And I just wanted to tell people some various things. 1) If you do not have REPEATABLE pain with walking you do not have claudication. Claudication is not a on again off again symptom. It will happen every time. 2) Numbness is not a symptom. Numbness is a nerve problem. If you circulation is so bad that you have numbness in your extremities, that indicates that the circulation is so bad that the nerves have died. In which case you will have accompaning tissue loss. 3) The chances of being able to do angioplasty to repair this is low. Also the length or time for repair with angioplasty is also low. 4) CT as a diagnostic tool is hardly ever used. The only time I know of is when someone is alleragic to the dye used during angioplasty. And with recient advances is ultrsaound we're moving away from even using it for that. 5) The fox method is also hardely ever used (in my area at least), There is a very specific visualiztion that will alow this procedure to be used. Chances are you will need a bypass. —Preceding unsigned comment added by Bloodsage (talk • contribs) 09:38, 29 July 2007

Thank you! Can you please help me change the article to reflect these key aspects? Bakerstmd (talk) 21:51, 6 March 2014 (UTC)

CT angiography

http://jama.ama-assn.org/cgi/content/abstract/301/4/415 - studies don't say for certain which imaging modality is best. JFW | T@lk 20:41, 28 January 2009 (UTC)

Proposed correction for the daignosis section - CT angiography typically requires 100-150mls of iodine based contrast, just like conventional angiography. —Preceding unsigned comment added by 194.66.84.39 (talk) 10:45, 23 March 2009 (UTC)

Therapy

"Prevention of foot failure: ketchup on the bottom of your feet."

Er, what??? —Preceding unsigned comment added by 65.161.188.11 (talk) 08:37, 5 February 2010 (UTC)

NEW AHA recommendation

AHA recommended that the name of the syndrome should be peripheral artery disease (PAD) just like the coronary artery disease (CAD). Don't you guys think that we need to acknowledge the recommendation accordingly and talk more about PAD? —Preceding unsigned comment added by Aceofhearts1968 (talk • contribs) 17:05, 8 June 2010 (UTC)

I rather agree. I work in the US (have worked in PVD/PAD surgery in CA, IL and MA) and PVD is indeed usually referred to as PAD. Bakerstmd (talk) 21:40, 6 March 2014 (UTC)

Title

Shouldn't be the title 'Peripheral arterial disease (PAD)' and 'Peripheral vascular disease' redirects to the first? I think the term 'vascular disease' could confuse arterial disease with varicose veins or even lymphedema. — Preceding unsigned comment added by 193.144.99.21 (talk) 14:15, 5 April 2014 (UTC)

I agree. Can we generate some consensus about moving this page to peripheral artery disease BakerStMD T|C 21:50, 21 November 2014 (UTC)

 Done (Thanks to a helpful admin) BakerStMD T|C 16:48, 13 January 2015 (UTC)

Image

What do you think about to find a more 'typical' ischemic ulcer, like that: http://www.globalskinatlas.com/imagedetail.cfm?TopLevelid=456&ImageID=1320&did=6 or http://www.globalskinatlas.com/imagedetail.cfm?TopLevelid=1220&ImageID=2886&did=458 The one in the page suggest another concomitant causes as venous insufficiency and arterial hypertension Is difficult to find one picture with an explicit consent of the patient. — Preceding unsigned comment added by 193.144.99.21 (talk) 14:22, 5 April 2014 (UTC)

I agree. That image looks like venous rather than arterial disease to me. Next time I see a patient with a good typical arterial ulcer I'll ask if I can take a picture and upload it :p BakerStMD T|C 16:49, 13 January 2015 (UTC)

Still needs a better picture. A toe ulcer would be ideal. The current image doesn't look typical: foot is too pink, plus the ulcer is bleeding. BakerStMD 13:34, 27 April 2018 (UTC)

Trials

doi:10.1161/CIRCULATIONAHA.114.011021

Circulation, basically a secondary source that says there aren't many good trials. JFW | T@lk 00:23, 12 November 2014 (UTC)

Merge rest pain with PAD

There really isn't anything at Rest pain. I propose that it be merged with PAD in the signs and symptoms section. BakerStMD T|C 21:49, 13 January 2015 (UTC)

Bakerstmd I'd just redirect that here, to be honest. JFW | T@lk 23:43, 14 January 2015 (UTC)

 Done. BakerStMD T|C 23:59, 14 January 2015 (UTC)

Citations to improve

From a request for peer reivew on the wp:med talk page: Thought about requesting a formal peer review for Peripheral artery disease, but thought I'd ask here first. From people not too involved, what needs work? I think this might be a B-class article. Would like to bring it to GA, as is High importance. BakerStMD 03:28, 7 April 2015 (UTC)

in terms of references, 12,21,22,23,25-29,30,32,34,35,37-40,42,43,47,48 are non-MEDRS compliant (they are well beyond five years for a review), you might want to look for newer reviews for those...references #20, #33, are both primary sources and should be replaced with reviews. thank you--Ozzie10aaaa (talk) 12:52, 7 April 2015 (UTC)

NEJM

doi:10.1056/NEJMcp1507631 JFW | T@lk 00:39, 4 March 2016 (UTC)

Antithrombotics after surgery

Evidence base is not great for choice of agents doi:10.1161/CIRCULATIONAHA.117.024469 JFW | T@lk 09:41, 21 June 2017 (UTC)

Chronic limb ischemia

doi:10.1056/NEJMcp1709326 JFW | T@lk 08:12, 12 July 2018 (UTC)

Work Plan

I would like to work on the format of this article to make it more visually appealing, change medical jargon to make the article more clear, and include more detail about this topic. This article has a lot of good information and I believe I can continue to expand on it to make it more informative. This topic is very "bread and butter" general medicine and important to have a good reference. I believe the sections that are included-- signs and symptoms, causes, risk factors, treatment, screening, etc.-- can continue to be expanded upon. I would also like to include a differential diagnosis section and expand the screening section.

Which sections will I prioritize? -I plan to focus on the mechanism of action (pathophysiology) of PAD, include more signs and symptoms, (as mentioned above) include a differential diagnosis section, and work on creating a clear and concise treatment section. -Mechanism of action- while PAD is more focused on the peripheral vasculature the pathophysiology is similar to that of CAD (as mentioned)- but the mechanism is not discussed in detail. I'd like to include this. I would like to delve into dyslipidemia to allow for an apparent tie between the disease risk factors and the disease pathophysiology. -I plan to work on decreasing the medical jargon within the signs and symptoms to achieve a better understanding for people searching this disease process. This can be achieved by using resources such as the plain language medical dictionary by the University of Michigan and the every day words for public health and communication. These sources will allow me to make sure that I am translating medical jargon and defining these terms to allow understanding for public access. -I plan to discuss current AHA guidelines for revascularization as treatment for PAD. I would like to restructure the guidelines section, because it is under treatment but not very clear that the guidelines are applicable to the treatment topic as a whole (e.g. when and when not to treat).

What resources do I intend to utilize? -Access medicine, Clinical key.. Including Harrison's Principles of Internal Medicine (20th ed)

How will I decide what things (signs, symptoms, side-effects, etc.) to explicitly include/exclude? -I will edit to include topics based on what the public wants to know about a disease process (e.g. what I would want to know about a disease process if my family member were affected by it). Also, what current established research is available.

Will I also embed additional links to other Wiki pages? -There are a good deal of appropriate and helpful links already included in this article (e.g. dyslipidemia, hypertension, diabetes, etc.) and I will plan to add additional links as I begin editing.

Brittanylauren120 (talk) 20:32, 19 November 2018 (UTC)

The version of Harrison's you appear to be using is the 18th? Doc James (talk · contribs · email) 00:05, 4 December 2018 (UTC)

Hi Doc James, I'm using Harrison 20th Edition — Preceding unsigned comment added by Brittanylauren120 (talk • contribs) 18:25, 6 December 2018 (UTC)

Testing someone who has symptoms is not screening but a diagnostic work up. This does not make sense "Therefore, patients with symptomatic PAD should be screened and treated to reduce risk."

Some of your edits also broke the references so restored a bunch of it.

Also did you read the ref that supported this "is an abnormal narrowing of arteries other than those that supply the heart or brain."?

The change you made to the text made it less supported.

Please read WP:MEDMOS. Provides lots of key information on language use and formating. Doc James (talk · contribs · email) 19:47, 9 December 2018 (UTC)

@Doc James: Thank you for pointing this out. I changed the subheading from “Screening” to “Screening and Diagnostic Testing.” I did this to allow for inclusion of the additional information I wanted to include… There have been studies done that demonstrate that there is no benefit or decreased mortality in screening asymptomatic PAD… However, it has been shown that it decreases mortality when patients w/ symptomatic PAD are screened for coronary artery disease; as there is an increased risk of coronary and carotid artery disease in these patients.

Thank you for restoring my references.

Re: “is an abnormal narrowing of arteries other than those that supply the heart or brain”—I used an additional resource to change the format. However, used the initial wording. I will go back and update this. Thanks. Brittanylauren120 (talk) 21:04, 12 December 2018 (UTC)

Can you please read all of WP:MEDMOS? A few key points:

We have recommended sections discussed.

We also have recommended ordering of sections discussed.

Best Doc James (talk · contribs · email) 12:18, 13 December 2018 (UTC)

I have read all of WP:MEDMOS. I will make sure to not use words like "patient" and will make section changes according to guides. If there are any other specific things that you'd like me to revisit, let me know. Thanks Brittanylauren120 (talk) 13:07, 14 December 2018 (UTC)

Thanks User:Brittanylauren120 :-) Often we order the lead to follow the order of the body of the text. Thus restored the cause and mechanism section. Best Doc James (talk · contribs · email) 14:10, 14 December 2018 (UTC)

@Doc James: Why were the additional causes of PAD (thrombosis, fibromuscular dysplasia, etc) removed? Also, why could the formatting just not be changed... I.e. instead of deleting the discussion of atherosclerosis as a cause, why could it not just be moved lower so that it follows the format of the article? Brittanylauren120 (talk) 14:19, 14 December 2018 (UTC)

Still here with "Other mechanisms include artery spasm, thrombosis, and vasculitis."? Discussion of atherosclerosis as a cause was NOT deleted. We still say "The underlying mechanism is usually atherosclerosis."

Can you please add page numbers or chapters to the books you are using. Do you think we need an exhaustive list in the lead (ie also trauma and fibromusclar dysplasia)? Or just a few of the other alternatives? Atherosclerosis of course is the most common mechanism. Doc James (talk · contribs · email) 14:25, 14 December 2018 (UTC)

Okay, not atherosclerosis as a cause, but I added an additional detail that was deleted- age under 40. I just re-added, but changed the location so that it matches the article lay out. Re: adding additional mechanisms.. I added multiple causes of peripheral artery disease as to include the most and current information. I think it provides a level of detail necessary for all types of people that are reading the article. E.g. Fibromuscular dysplasia leads to narrowing of arteries. I also have plans to discuss the mechanism of why arterial spasm and some of the other causes of PAD cause narrowing.

Yes, i can add page numbers. Brittanylauren120 (talk) 14:55, 14 December 2018 (UTC)

Am still waiting on page numbers...

Where did this come from "Testing for coronary artery disease and carotid artery disease is recommended"

Ref specifically says "Currently, there is no evidence to demonstrate that screening all patients with PAD for asymptomatic atherosclerosis in other arterial beds improves clinical outcome"

Which is the exact opposite of what you added? Doc James (talk · contribs · email) 02:03, 17 December 2018 (UTC)

Peer Review

@BrittanyLauren120:

First of all, I wanted to compliment the flow and organization of the article. It has all of the main sections that it needs to give the reader a good understanding of peripheral artery disease. The article is also very thorough and it looks like the edits you have made have made the article even more thorough and complete. You did a great job making the signs and symptoms section easy to read, especially for non-medical readers. The rest of the article doesn't get bogged down in medical jargon either. Although, the diagnostic tests section may be overwhelming for a non-medical reader. I wonder if a simple table or graphic to show the ABI values and their significance could help it be easier on the eyes.

The article appears neutral and balanced. And it looks like you're doing a great job of using secondary sources without creating any bias or making claims without citations. It looks like there's a few paragraphs (first 2 paragraphs of signs and symptoms, first paragraph of diagnosis) where the same source is being used for the entire paragraph but only cited once. I understand that the information is all coming from that one source, but it might be safer to cite several times throughout the paragraphs. The revascularization subheader of the treatment section might need a few more citations at the end of the paragraph as well. But it seems like you're using up-to-date sources that are not biased to cite the information.

Overall, this article looks like it's coming together. Last thing, I saw in your work plan that you were planning to add pathophysiology and mechanism to the causes section. I think that would be a great addition to the article and really bring it to the next level of thoroughness. Great work!! Cwa200 (talk) 15:04, 10 December 2018 (UTC)

Lead image

An arterial insufficiency ulcer in a person with severe peripheral artery disease

Peripheral arterial disease resulting in necrosis of multiple toes

User:Bakerstmd Have restored the prior image. The first image here has much better lighting than the second. Poor wound healing is a very common sign of PAD and this image has a source supporting it that discusses the case in question. Not all cases are as severe as the second image. Happy to use a different image just the second one is not very good. Doc James (talk · contribs · email) 03:45, 10 March 2019 (UTC)

User: Doc James I appreciate that the lighting isn't as good in the second image. However, the first wound is bleeding (which generally isn't associated with PAD wounds) and the dorsum of the foot is an atypical location for a PAD wound. Poor wound healing is associate with PAD, but that wound looks like it will heal and is likely not associated with PAD. While I agree, wounds are a late finding, but if we're going to have a PAD-associated wound as the lead image, it should be a typical, ischemic wound. Also bear in mind that that first image comes from an industry-sponsored paper (looking at a dermal matrix thing) so it was in their interest to pick wounds that were likely to heal. The toes in the second image come from a German governmental paper on PAD, and are much more typical appearing. I'd love to generate some consensus on the issue. BakerStMD 16:42, 11 March 2019 (UTC)

user:Bakerstmd you able to get an image with better lighting or able to improve the lighting of this one? Doc James (talk · contribs · email) 00:40, 12 March 2019 (UTC)

References

What do you think of this one?[1]

I can ask the author to drop the NC.[2] Doc James (talk · contribs · email) 01:01, 12 March 2019 (UTC)

User: Doc James I hate to be difficult, but that one isn't typical either. The location on the ankle is a more typical location for a venous insufficiency ulcer. I appreciate that the authors of the article attributed it to atherosclerosis, but as the title of the article implies, it is a rare case rather than a typical case of PAD. I'm not in a setting where I can upload images of any of my patients, but I will keep looking for a more typical one that is free use.BakerStMD 13:33, 13 March 2019 (UTC)

user:Bakerstmd Thanks. An ulcer IMO is better than gangrene. Would be good to have a case before it progresses to that degree. Doc James (talk · contribs · email) 15:54, 13 March 2019 (UTC)