Peripheral Vascular Disease
- Obstruction of ≥1 of the peripheral arteries secondary to embolism or thrombus
- Caused by atherosclerosis or embolus
- Patients with PAD may also have coronary artery and cerebrovascular disease.
- Risks factors (selected):
- Associated with morbidity and mortality from other forms of atherosclerosis (coronary artery disease, stroke)
- Limb loss
- Risks factors (selected):
- Chronic arterial insufficiency (CAI):
- Progressive obstructing atherosclerotic disease causing subacute ischemia and pain (claudication)
- 10% develop critical leg ischemia.
- Acute arterial insufficiency (AAI):
- Caused by arterial thrombosis (50%) or embolism
- Causes acute limb ischemia with signs and symptoms of the 6 Ps (below)
- Caused by rupture or partial disruption of an atherosclerotic plaque (aorta, femoral, iliac)
- Gives rise to cholesterol emboli that shower and obstruct arteriolar networks
- May be precipitated by invasive arterial procedures such as cardiac catheterization
- Obstruction by atherosclerotic plaques (CAI)
- Arterial thrombosis
- Arterial emboli:
- Cardiac emboli from dysrhythmias, valvular heart disease, or cardiomyopathy (80%)
- Vasculitis or foreign body
- Thrombosis of plaques from pre-existing CAI
Signs and SymptomsHistory
- Aching pain in the calves (femoropopliteal occlusion) or buttocks and thighs (aortoiliac region)
- Occurs with activity and slowly relieved by rest or dependent positioning
- Classic claudication presents in about 1/2 of patients with PVD.
- Severe disease presents with limb pain at rest:
- Usually starting in the foot
- Rapidly progressive claudication or ulceration
- Extremity pain:
- Sudden onset
- Gradual increase in severity
- Starts distally and moves proximally over time
- Decrease in intensity once ischemic sensory loss occurs
- Extremity pain:
- Complaint of cold and painful fingers or toes
- Small atherosclerotic emboli may affect both extremities.
- Usually related to recent arteriography, vascular or cardiac surgery
- Multiorgan involvement is common (renal, mesentery, skin, others)
Sudden onset of pain and pallor in extremity is limb and life threatening.
- Absent or decreased peripheral pulses
- Delayed capillary refill with cool skin
- Increased venous filling time
- Pallor and dependent rubor of the leg
- Muscle and skin atrophy
- Thickened nails and loss of dorsal hair
- Ulcerations (especially toes or heels) or gangrene with severe disease
- 6 Ps:
- Pain (1st, sometimes only symptom)
- Paresthesias (late finding)
- Paralysis (late finding)
- Identification of a source of a possible embolic process is crucial (atrial fibrillation, cardiomegaly).
- 6 Ps:
- Ischemic and painful digits
- “Blue toe syndrome”
- Livedo reticularis
- Ankle–brachial index (ankle systolic BP divided by higher arm systolic BP)
- Bedside test to determine whether CAI is present (see NEJM video reference)
- Ratio of <0.9 is abnormal and <0.4–5 indicates severe disease.
- Calcific arteries (diabetes) can have false negative ABI or elevated ABI (>1.3).
- Physical diagnosis using the 6 Ps
- Those with acute-on-chronic arterial insufficiency tolerate limb ischemia better than those without CAI, due to well-developed collateral circulation.
- Clinical diagnosis: Affected areas painful, tender, and may be either dusky or necrotic
- Workup may investigate source of emboli with duplex US, CT angiogram, EKG.
Diagnostic Tests and InterpretationLab
- CBC and platelets
- Electrolytes, BUN, creatinine, glucose
- Coagulation studies
- Creatine phosphokinase to evaluate for ischemia.
- Special tests for suspected etiologies:
- Hold blood for hypercoagulable studies
- Sedimentation rate, CRP for vasculitis
- Blood cultures for endocarditis
- Doppler US:
- Visualizes both venous and arterial systems
- Identifies level of arterial occlusion, as well as thrombosis and aneurysm
- Sensitivity and specificity >80–90% for occlusion of vessels proximal to the popliteal vessels
- Plethysmography/segmental pressure measurements:
- Uses measurements of the volume and character of blood flow to detect areas of CAI
- Less widely available than US, therefore requires an experienced technician
- Approximates US in sensitivity and specificity
- Determines details about the anatomy, including the level of occlusion, stenosis, and collateral flow
- Useful where the diagnosis of AAI is uncertain or before emergent bypass grafting
- Advantage is intervention (atherectomy, angioplasty, or intraluminal thrombolytics) can be done at the time of diagnosis.
- CT angiogram:
- CT is useful for diagnosis of occlusive aortic disease or dissection.
- Rapidly available and reliable
- Many centers have moved to CT angiogram as the 1st-line diagnostic tool. The decision for operative or angiographic intervention is based on the CT angiogram.
- Requires contrast, therefore may not be 1st line for patients with renal insufficiency
- Sensitive for evaluation of CAI and dissection
- Disadvantages are that MRI is time consuming and expensive.
- Acute thrombosis or emboli
- Arterial dissection
- Deep venous thrombosis
- Venous insufficiency
- Compartment syndrome
- Buerger disease
- Spinal stenosis
- Reflex sympathetic dystrophy
- Maintain hemodynamic stability with fluids.
- Apply cardiac monitor.
- Place the ischemic limb at rest and in a dependent position.
- Provide oxygen if low oxygen saturation or pulmonary symptoms.
- IV fluid bolus for hypotension
- EKG, monitor, pulse oximetry
- Supplemental oxygen
- Pain control
- Avoid temperature extremes
- Antiplatelet therapy with 75 or 325 mg of aspirin or clopidogrel (75 mg/day) may be used as 1st-line treatment. Dual therapy has not been shown to improve outcomes, although may be indicated in other forms of atherosclerosis.
- Other approved drugs include: Cilostazol 100 mg BID, dipyridamole 200 mg BID, pentoxifylline 400 mg TID
- Revascularization depending on the severity and location of obstruction:
- Balloon angioplasty
- Bypass grafting
- Risk-factor modification:
- Tobacco cessation
- Aggressive management of hyperlipidemia, HTN, diabetes
- Exercise therapy
- Limit further clot propagation with IV heparin.
- Do not anticoagulate patients suspected of having an aortic dissection or symptomatic aneurysm.
- Emergent consultation with vascular surgery or interventional radiology:
- To determine which diagnostic study is best to make the diagnosis
- To begin arrangements for possible operative therapy or other intervention
- Options for operative therapy include thrombectomy, embolectomy, angioplasty, regional arterial thrombolysis, bypass grafting.
- Blood flow to the affected limb must be re-established within 4–6 hr after onset of ischemic symptoms.
- Complications of AAI include:
- Compartment syndrome
- Irreversible ischemia requiring amputation
- Rhabdomyolysis, renal failure
- Electrolyte disturbances
- Treat conservatively if a limited amount of tissue is involved and renal function is not significantly compromised.
- No clear therapy for the ischemic digits besides supportive wound care and analgesia
- Some studies have tried corticosteroids to decrease inflammation, statins to stabilize plaque, aspirin, or dipyridamole
- Amputation for irreversibly necrotic toes
- Vascular surgeon referral within 12–24 hr of ED visit
- Prevent further embolic events by a thorough investigation and correction of the source of atheroemboli.
- Aspirin: 81–325 mg/d
- Cilostazol: 100 mg BID
- Clopidogrel: 75 mg/d
- Heparin: 80 U/kg bolus IV followed by 18 U/h IV
- Pentoxifylline: 400 mg TID
- All patients with AAI are admitted for evaluation and revascularization.
- CAI: Consider admission for rapidly progressive claudication or ischemic pain at rest:
- To undergo heparinization and angiography to rule out an acute thrombosis
- Atheroembolism admission indicated with large areas involved, significant pain, infection, or renal compromise
- If they have small lesions, adequate pain control, no evidence of renal compromise or superinfection, and follow-up within 24 hr
- No evidence of rapid progression, critical leg ischemia, gangrene, or infection
Issues for Referral
- CAI will need urgent referral to vascular surgery.
- Atheroembolism, depending on the origin of the emboli, may need referral to vascular surgery or to cardiology.
CAI without acute ischemia and atheroembolism with minimal involvement should have close follow-up to evaluate the extent of their disease.
- Alonso-Coello P, Bellmunt S, McGorrian C, et al. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e669S–e690S. [PMID:22315275]
- Creager MA, Kaufman JA, Conte MS. Clinical practice. Acute limb ischemia. N Engl J Med. 2012;366:2198–2206. [PMID:22670905]
- Grenon SM, Gagnon J, Hsiang Y. Video in clinical medicine. Ankle–brachial index for assessment peripheral arterial disease. N Engl J Med. 2009;361:e40. [PMID:19890121]
- Norgren L, Hiatt WR, Dormandy JA, et al. Intersociety consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007;45:SA5–S67.
- Rooke TW, Hirsch AT, Misra S, et al. 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;58:2020–2045. [PMID:21963765]
- White C. Clinical practice. Intermittent claudication. N Engl J Med. 2007;356:1241–1250. [PMID:17377162]
- Arterial Occlusion
- Venous Insufficiency
- 440.20 Atherosclerosis of native arteries of the extremities, unspecified
- 443.9 Peripheral vascular disease, unspecified
- 444.22 Arterial embolism and thrombosis of lower extremity
- 440.21 Atherosclerosis of native arteries of the extremities with intermittent claudication
- Unsp athscl native arteries of extremities, unsp extremity
- Peripheral vascular disease, unspecified
- Embolism and thrombosis of arteries of extremities, unspecified
- Athscl native arteries of extrm w intrmt claud, unsp extrm
- Embolism and thrombosis of arteries of the lower extremities
- 400047006 peripheral vascular disease (disorder)
- 286959000 Peripheral arterial embolism (disorder)
- 51274000 Atherosclerosis of arteries of the extremities
- 275520000 Claudication (finding)
- 153911000119104 Peripheral arterial insufficiency (disorder)
- 233958001 Peripheral ischemia (disorder)
- 33591000 Thrombosis of arteries of the extremities (disorder)
Sally A. Santen
Samantha R. Hauff
© Wolters Kluwer Health Lippincott Williams & Wilkins
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