PERIPHERAL VASCULAR DISEASE

Question 1

What is peripheral vascular disease?

Answer 1

Obstruction or narrowing of arteries distal to the aorta and not within the coronary or brain circulation.

Question 2

What grading system is used?

Answer 2

Fountaine’s classification

Question 3

What is grade I?

Answer 3

Asymptomatic

Question 4

What is grade II? (IIa and IIb)

Answer 4

Intermittent claudication

a) pain with walking more than 200m
b) pain with walking less than 200m

Question 5

What is grade III?

Answer 5

Pain at rest or nocturnal pain

Question 6

What is grade IV?

Answer 6

Necrosis and gangrene

Question 7

What is epidemiology?

Answer 7

Affects 4-12% of people aged 55-70 and 15-20% of people aged >70. 7% of middle-aged men and 4.5% of middle-aged women. Strongly age-related

Question 8

What is the aetiology?

Answer 8

PVD can result from atherosclerosis, inflammatory processes leading to stenosis, an embolism, or thrombus formation

Question 9

What does it cause?

Answer 9

Either acute or chronic ischaemia

Question 10

What are the risk factors?

Answer 10

Same as those for atherosclerosis (smoking and DM being the most important).

Question 11

What are the symptoms?

Answer 11

• Cramping pain felt in calf, thigh or buttock after walking a given distance (claudication distance) – buttock pain suggests iliac disease; calf pain suggests femoral disease; buttock pain + male impotence suggests Leriche syndrome
• Pain resolves with rest
• Pain at night resolved by hanging leg out of bed
• Male impotence – suggests Leriche syndrome if with buttock pain
• Painful ulcer with well-defined edges and necrotic tissue
Gangrene

Question 12

What are the 6 x signs of acute limb ischaemia?

Answer 12

6 Ps of acute limb ischaemia:
• Pallor – redness returns on lowering leg
• Pulselessness – absent femoral, popliteal or foot pulses
• Pain
• Paralysis
• Parasthaesia
• Perishing with cold

Question 13

What are the other signs?

Answer 13

• Hair loss
• Delayed capillary refill (>15s)
• Small, painful, ‘punched-out’ ulcers over bony prominences
• Thickened, brittle toenails
• Smooth, shiny, dry skin
+ve Buerger’s test – angle to which the leg has to be raised for it to turn pale; normal = no pallor even at 90 degrees; <20 degrees is positive sign

Question 14

What are the differentials?

Answer 14

• Sciatica/spinal cord claudication - all pulses present; shooting pain
  
  • DVT/venous claudication – hot, swollen leg; no hair loss; painless ulcer with ragged edges; haemosiderin
  • Knee or hip osteoarthritis – joint pain and stiffness; worse in evening; pulses present; no pallor or hair loss
  • Peripheral neuropathy – numbness or tingling; pulses present; weakness; gait abnormalities; not cold or pale
  • Popliteal artery entrapment – young patients; congenital; myotomy of gastrocnemius; diminished pulses on forced plantar/dorsiflexion
  • Buerger’s disease – young to middle aged presentation; affects mainly males; two or more limbs affected; Raynaud’s phenomenon

Question 15

What are the investigations?

Answer 15

1. ABPI
2. Colour duplex USS
3. MR/CT angiography

Question 16

How do you do ABPI?

Answer 16

○ Measure 4 ankle and 2 arm pressures
○ Right ABPI = highest of right ankle pressures/highest arm pressure
○ Left ABPI = highest of left ankle pressures/highest arm pressure
○ <1 = circulatory problems
§ >0.9 = borderline – higher prognosis
§ 0.5-0.9 = PAD
§ <0.5 = critical limb ischaemia – low prognosis
○ If resting ABPI is normal then an exercise one can be done – measure before and after exercise, if there is a drop of 15-20% then this is diagnostic of PAD
○ >1.4 = incompressible arteries – seen in DM or renal disease, falsely high results

Question 17

What risk factor modifications are there?

Answer 17

○ Quit smoking
		○ Treat HTN and high cholesterol
		○ Weight reduction if overweight
		○ DM control
		○ Exercise to point of maximal pain
Supervised exercise programmes – reduce symptoms by improving collateral blood flow

Question 18

What medical treatment options?

Answer 18

○ Clopidogrel to reduce MI/stroke risk 1st line
○ Vasoactive drugs e.g. naftidrofuryl oxidate offer modest benefit and recommended only in those who do not wish to undergo revascularisation and if exercise fails to improve symptoms

Question 19

What surgical options?

Answer 19

a. Percutaneous transluminal angioplasty
§ For disease limited ot a single arterial segment
§ Balloon inflated in narrowed segment
b. Surgical reconstruction
§ If atheramotous disease is extensive but distal run-off is good
§ Arterial reconstruction with bypass graft
§ Femoral-popliteal bypass, femoral-femoral crossover, aorto-bifemoral bypass grafts
§ Autolgous vein grafts are superior to prosthetic grafts
c. Amputation
§ In severe ischaemia with unreconstructable arterial disease
§ <3% patients with intermittent claudication require major amputation within 5 years
Knee should be preserved wherever possible as it improves mobility and rehabilitation potential

Question 20

What is prognosis?

Answer 20

Outcome for patients presenting with intermittent claudication over five years:
• 50% will improve, 25% will stabilise and 25% will worsen. Of those who worsen, 20% (5% of total) will need intervention and 8% (2% of total) will need a major limb amputation.
• 5-10% will have a non-fatal cardiovascular event.
• 30% will die: cardiac 16%, cerebral 4%, other vascular 3%, non-vascular 7%.
• 55-60% will survive with no cardiovascular event.