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By late middle age 5% of men and women have developed peripheral arterial disease, and within 5 years one quarter of these will develop pain at rest, ulceration, and gangrene (critical limb ischemia).1 Physicians practicing in the specialty of pain medicine need to be familiar with the causes and management of pain due to peripheral vascular disease because it has a high prevalence and appropriate management can significantly improve the quality of life for these patients. The pain physician may also be able to significantly improve life expectancy because one half of the patients with symptomatic peripheral vascular disease also have coronary and/or carotid artery disease, and many will not be receiving recommended secondary and tertiary preventive therapy. This chapter outlines the disease conditions and treatments for pain associated with peripheral vascular disease.2

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Pain similar to that experienced with peripheral vascular disease can be experimentally produced using a sustained tourniquet inflation on an extremity. In experimental studies, as time passes, tissue oxygenation levels fall, metabolic byproducts accumulate, reactive cellular agents are released, nociceptive signals entering the central nervous system increase, and patients report increasing pain intensity. The affective descriptors for this pain may differ and be more difficult to tolerate than pain produced by other experimental modalities. Patients with peripheral vascular disease experience this type of pain but without the ability to restore blood flow by releasing the tourniquet. Effective management of this pain can make a significant difference in quality of life for these patients.

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Arterial insufficiency is most commonly the result of occlusive diseases with atheroma formation (arteriosclerosis obliterans), but less commonly it occurs in thromboangiitis obliterans (Buerger disease), Raynaud syndrome, diabetic arteritis, and arteritis associated with collagen disease. Other diseases with vascular-related causes such as migraine and cluster headache are discussed elsewhere (Chapter 20).

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Atheroma and Its Consequences: Arteriosclerosis

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The role of lipids was suggested with the early appearance of fatty streaks in young soldiers during emergency surgery and at autopsy in the 1970s. The role of lipids distinguishes arteriosclerosis from other arterial disease. Primary and secondary prevention strategies are available to reduce the incidence and/or aggressively treat the known risk factors of hypercholesterolemia, hypertension, cigarette smoking, and poor control of diabetes. As the disease progresses, plaque formation tends to occur at bifurcations in large- and medium-sized arteries, where turbulence, alteration of laminar flow, and shear stress may provoke an endothelial and/or vascular smooth muscle response. Arteriosclerosis is a dynamic process that involves vascular and inflammatory tissue responses with decreased release of nitric oxide and other protective secretions, increased release of cytokines by inflammatory cells responding to exposed matrix, and release of growth factors from the endothelium, as well as platelet activation. Arteries may initially respond to this process with an increase in size, but this arterial remodeling may not be sustained in the face of ongoing plaque accumulation. Although a full discussion of the process ...

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