Peripheral Vascular Disease

Question 1

PVD is what?

Answer 1

Usually refers to peripheral arterial disease (=atherosclerosis)

Peripheral venous disease = chronic venous insufficiency (=valvular incompetence or obstruction of deep veins)

Question 2

Arterial and venous questions?

Answer 2

Arterial:

• How far can you walk? What causes relief? etc
• Do you ever get pain at rest?
• Physical changes - cool, pale, ulcers?
• CVD risk factors

Venous:

• Risk factors = pregnancy, past Hx of trauma/fractures/surgery, hormones, obesity, smoking
• Personal or family hx of thrombophilia, DVT/PE
• Varicose veins
• physical changes - swelling, eczema, pigmentation, ulcers

Question 3

Socrates for arterial versus venous?

Answer 3

Arterial: 
S = calves, thighs, buttocks 
O = while walking (claudication) or at rest (critical limb ischaemia) 
C = tight cramp/pain
R = ?angina
A = pallor, paraesthesia, paralysis, cold
T = predictable 
E = activity and relieved by rest 

Venous: 
S = calves, ankles 
O = gets worse as the day goes on 
C = aching or throbbing 
R = groin 
A = swelling of feet and ankles 
T = below
E = exacerbated by long periods on feet, relieved by elevation

Question 4

On Exam:

Answer 4

Arterial:

• pallor, mottling, gangrene
• scars, hair loss
• ulcers = punched out, deep, regular, painful, minimal exudate

Venous:

• varicose veins
• hemosiderosis (red/brown deposit)
• oedema, eczema
• lipodermatosclerosis (shiny and red above ankles)
• ulcers = irregular, shallow, painless, lots of exudate

PALPATION:

• temp and cap refil
• skin texture
• calf tenderness
• varicose veins, pitting oedema

PULSES:
- rate, rhythm, character, symmetry

AUSCULTATION:
- carotid, abdominal, renal and femoral

SPECIAL TESTS:
art - leg lift test 15-30 degrees till leg goes white then drop below bed for reactive hyperaemia

ven - cough impulse

Question 5

Differential Diagnosis

Answer 5

arterial:
- neurogenic claudication (spinal stenosis)
- Osteoarthritis of hip/knee
- Peripheral neuropathy

Venous:
- HF, liver cirrhosis, nephrotic syndrome, GI

Question 6

Ix

Answer 6

Basic bloods: FBC, Lipids, UEC, BGLs

Arterial:
Ankle-Brachial Pressure Index (ABPI) = 1-1.2 normal, < 0.9 is arterial disease, > 1.2 is calcified arteries
Duplex ultrasound
CT angio/MR angio if considering intervention

Venous:
Duplex USS
CT and MR venography reserved for complex abnormalities
ABPI to rule out concurrent arterial insufficiency

Question 7

Management:

Answer 7

Arterial:

• risk factor management (smoking cessation), regular exercise)
• Anti-platelet (clopi =1st line)
• Statin
• Surgical = revascularisation or amputation

Venous:

• weight loss, exercise
• Compression stocking
• education about prolonged standing and elevating when possible
• endovascular surgery