upright=1.2 Diagnosing or identifying<unk>  requires history of symptoms and a physical exam followed by confirmatory testing. These tests could include CT scans (Computed Tomagraphic Angiography), MRA scans (Magnetic Resonance Angiography), or ultrasounds for imaging.In the setting of symptoms consistent with<unk>  a physician will then examine an individual for specific exam findings. Abnormal physical exam findings can lead a health care provider to consider a specific diagnosis. However, in order to confirm a diagnosis, confirmatory testing is required. These findings are associated with<unk> : * Decreased or absent pulses * Muscle atrophy or wasting * Noticeable blueness of the affected limb * Decreased temperature (coolness) in affected limb when compared to the other * Thickened nails * Smooth or shiny skin and hair loss * Buerger's test can check for pallor when the affected limb is in an elevated position. The limb is then moved from elevated to sitting position and is checked for redness, which is called reactive hyperemia. Buerger's test is an assessment of<unk> al sufficiency, which is the ability of the<unk>  to supply oxygenated blood to the tissue that it goes to. *Nonhealing lower extremity wound If<unk>  is suspected, the initial study is the ankle–brachial index (ABI). The ABI is a simple, non-invasive test, which measures the ratio of systolic blood pressure in the ankle to the systolic blood pressure in the upper arm. This is based on the idea that if blood pressure readings in the ankle are lower than those in the arm, a blockage in the<unk> es that provide blood from the heart to the ankle is suspected.An ABI range of 0.90 to 1.40 is considered normal. A person is considered to have<unk>  when the ABI is ≤ 0.90. However,<unk>  can be further graded as mild to moderate if the ABI is between 0.41 and 0.90, and severe if an ABI is less than 0.40. These categories can provide insight into the<unk>  course. Furthermore, ABI values of 0.91 to 0.99 are considered borderline and values >1.40 indicate noncompressible<unk> es. If an ABI >1.40 is calculated, this could indicate vessel wall stiffness caused by calcification, which can occur in people with uncontrolled diabetes. Abnormally high ABIs (>1.40) are usually considered false negatives and thus, such results merit further investigation and higher-level studies. Individuals with noncompressible<unk> es have an increased risk of cardiovascular mortality within a two-year period. In individuals with suspected<unk>  with normal ABIs can undergo exercise testing of ABI. A baseline ABI is obtained prior to exercise. The patient is then asked to exercise (usually patients are made to walk on a treadmill at a constant speed) until claudication pain occurs (for a maximum of 5 minutes), after which the ankle pressure is again measured. A decrease in ABI of 15%–20% would be diagnostic of<unk> . If ABIs are abnormal, the next step is generally a lower limb Doppler ultrasound to look at the site of obstruction and extent of atherosclerosis. Other imaging can be performed by angiography, where a catheter is inserted into the common femoral<unk>  and selectively guided to the<unk>  in question. While injecting a radio-dense contrast agent, an X-ray is taken. Any blood flow-limiting blockage found in the X-ray can be identified and treated by procedures including atherectomy, angioplasty, or stenting. Contrast angiography is the most readily available and widely used imaging technique. Modern computerized tomography (CT) scanners provide direct imaging of the<unk> al system as an alternative to angiography. Magnetic resonance angiography (MRA) is a noninvasive diagnostic procedure that uses a combination of a large magnet, radio frequencies, and a computer to produce detailed images of blood vessels inside the body. The advantages of MRA include its safety and ability to provide high-resolution, three-dimensional imaging of the entire abdomen, pelvis and lower extremities in one sitting. Classification Gangrene of three toes resulting from<unk>  The two most commonly used methods to classify<unk>  are the Fontaine and the Rutherford systems of classification. The Fontaine stages, were introduced by René Fontaine in 1954 to define severity of chronic limb ischemia: * Stage I: asymptomatic * Stage IIa: intermittent claudication after walking a distance of more than 200 meters * Stage IIb: intermittent claudication after walking a distance of less than 200 meters * Stage III: rest pain * Stage IV: ulcers or gangrene of the limb The Rutherford classification was created by the Society for Vascular Surgery and International Society of Cardiovascular Surgery, introduced in 1986 and revised in 1997 (and known as the Rutherford classification after the lead author, Robert B. Rutherford). This classification system consists of four grades and seven categories (categories 0–6): * Grade 0, Category 0: asymptomatic * Grade I, Category 1: mild claudication * Grade I, Category 2: moderate claudication * Grade I, Category 3: severe claudication * Grade II, Category 4: rest pain * Grade III, Category 5: minor tissue loss; ischemic ulceration not exceeding ulcer of the digits of the foot * Grade IV, Category 6: major tissue loss; severe ischemic ulcers or frank gangrene Moderate to severe<unk>  classified by Fontaine's stages III to IV or Rutherford's categories 4 to 5, presents limb threat (risk of limb loss) in the form of critical limb ischemia. Recently, the Society for Vascular Surgery came out with a classification system based on "wound, ischemia and foot Infection" (WIfI). This classification system, published in 2013 was created to account for the demographic changes that have occurred over the past forty years including increased incidence of high blood sugar and evolving techniques and ability for revascularization. This system was created on the basis of ischemia and angiographic<unk>  patterns not being the sole determinants of amputation risk. The WIfI classification system is broken up into two parts: wounds and ischemia. Wounds are graded 0 through 3 on the presence of ulceration and/or gangrene and ischemia. * Grade 0: no ulcer, no gangrene * Grade 1: small, shallow ulcer; no gangrene * Grade 2: deep ulcer with exposed tendon or bone, gangrene limited to toes * Grade 3: extensive, full-thickness ulcer; gangrene extending to forefoot or midfoot Ischemia is graded 0 through 3 based on ABI, ankle systolic pressure, and toe pressure. * Grade 0: ABI 0.8 or higher, ankle * Grade 1:<unk> al brachial index 0.6 to 0.79, ankle pressure 70 to 100 mm Hg, toe pressure 40 to 59 mm Hg * Grade 2: ABI 0.4–0.59, ankle pressure 50 to 70 mm Hg, toe pressure 30 to 39 mm Hg The TASC (and TASC II) classification suggested<unk>  treatment is based on the severity of<unk>  seen on angiogram. Screening It is not clear if screening for<unk>  in the general population is useful as it has not been properly studied. This includes screening with the ankle-brachial index. Testing for coronary<unk><unk>  or carotid<unk><unk>  is of unclear benefit. While<unk>  is a risk factor for abdominal aortic aneurysms (AAA), there is no data on screening individuals with asymptomatic<unk>  for abdominal aortic aneurysms. In people with symptomatic<unk>  screening by ultrasound for AAA is not unreasonable.
Peripheral artery disease
Lumbar spinal stenosis
Chronic venous insufficiency
Varicose veins
Diabetic foot
Spinal stenosis
Diabetic foot ulcer
Raynaud syndrome