5-Minute Emergency Consult

Peripheral Vascular Disease

Basics

Description

  • 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.
  • Epidemiology:
    • Risks factors (selected):
      • Age
      • Smoking
      • Diabetes
      • Hyperlipidemia
      • HTN
    • Associated with morbidity and mortality from other forms of atherosclerosis (coronary artery disease, stroke)
    • Complications:
      • Aneurysm
      • Thrombosis
      • Ulceration
      • Limb loss
  • 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)
  • Atheroembolism:
    • 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

Etiology

  • Obstruction by atherosclerotic plaques (CAI)
  • Arterial thrombosis
  • Arterial emboli:
    • Cardiac emboli from dysrhythmias, valvular heart disease, or cardiomyopathy (80%)
    • Aneurysms
    • Infection
    • Tumor
    • Vasculitis or foreign body
    • Thrombosis of plaques from pre-existing CAI
  • Atheroembolism

Diagnosis

Signs and Symptoms

History
  • CAI:
    • Claudication:
      • 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
  • AAI:
    • Extremity pain:
      • Sudden onset
      • Gradual increase in severity
      • Starts distally and moves proximally over time
      • Decrease in intensity once ischemic sensory loss occurs
  • Atheroembolism:
    • 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)

Physical Exam
ALERT
Sudden onset of pain and pallor in extremity is limb and life threatening.
  • CAI:
    • Absent or decreased peripheral pulses
    • Delayed capillary refill with cool skin
    • Increased venous filling time
    • Bruits
    • 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
  • AAI:
    • 6 Ps:
      • Pain (1st, sometimes only symptom)
      • Pallor
      • Pulselessness
      • Poikilothermic
      • Paresthesias (late finding)
      • Paralysis (late finding)
    • Identification of a source of a possible embolic process is crucial (atrial fibrillation, cardiomegaly).
  • Atheroembolism:
    • Ischemic and painful digits
    • “Blue toe syndrome”
    • Livedo reticularis

Essential Workup

  • CAI:
    • 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).
  • AAI:
    • 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.
  • Atheroembolism:
    • 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 Interpretation

Lab
  • 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

Imaging
  • 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
  • Angiography:
    • 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
  • MRI:
    • Sensitive for evaluation of CAI and dissection
    • Disadvantages are that MRI is time consuming and expensive.

Differential Diagnosis

  • Acute thrombosis or emboli
  • Arterial dissection
  • Deep venous thrombosis
  • Venous insufficiency
  • Compartment syndrome
  • Buerger disease
  • Spinal stenosis
  • Neuropathy
  • Bursitis
  • Arthritis
  • Reflex sympathetic dystrophy

Treatment

Pre Hospital

  • 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.

Initial Stabilization/Therapy

  • IV fluid bolus for hypotension
  • EKG, monitor, pulse oximetry
  • Supplemental oxygen
  • Pain control
  • Avoid temperature extremes

Ed Treatment/Procedures

  • CAI:
    • 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
      • Atherectomy
      • Bypass grafting
    • Risk-factor modification:
      • Tobacco cessation
      • Aggressive management of hyperlipidemia, HTN, diabetes
      • Exercise therapy
  • AAI:
    • 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
  • Atheroembolism:
    • 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.

Medication

  • 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

Ongoing Care

Disposition

Admission Criteria
  • 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

Discharge Criteria
  • Atheroembolism:
    • If they have small lesions, adequate pain control, no evidence of renal compromise or superinfection, and follow-up within 24 hr
  • CAI:
    • 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.

Follow-Up Recommendations

CAI without acute ischemia and atheroembolism with minimal involvement should have close follow-up to evaluate the extent of their disease.

Additional Reading

  • 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]

See Also

  • Arterial Occlusion
  • Venous Insufficiency

Codes

ICD-9

  • 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

ICD-10

  • 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

SNOMED

  • 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)

Authors

Sally A. Santen
Samantha R. Hauff


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