Peripheral Vascular Disease

Question 1

What is peripheral vascular disease?

Answer 1

Stenosis of peripheral arteries due to atherosclerosis causes reduced blood supply to the distal limb

Question 2

What will you ask about/find on a history taking of peripheral vascular disease?

Answer 2

Symptoms:
Claudication - S (Calf/Thigh/Buttock), Q (Cramp like), T (brought about by exercise, constant in late stages), A (Exercise, specifically up hill), R (Rest)
Late Stage - Ulceration, Gangrene, Foot burning (typically at night hang foot over edge of bed to relieve pain)

Risk Factors:
Cardiovascular risk factors – Specifically Smoking
Previous stroke, coronary artery disease
Large association with renal artery stenosis – If one has atheroma formation, suspect it in the other

Specific questions to ask in a history taking:
Assess distance before any symptoms, and how long is needed to rest before symptoms go. Compare to past to ascertain effect on life and progression
Better or worse on walking up hill – Worse = PVD, Better = Neurogenic claudication
Rule out red flags of back pain e.g. Cauda Equina

Differentials:
Sciatica - Pain will follow path of sciatic nerve and commonly bilateral
Venous Claudication -Normally post DVT, similar pain on but affects the whole leg
Spinal Stenosis - Will have neurogenic claudication, worse on downhill not up, relieved by leaning forward. Affects buttocks more than calves
Bakers Cyst -Pain in the calf and behind the knee. The area is usually swollen, sore, and tender. The pain is present at rest and worse with exercise.
Mechanical injury - History of injury

Question 3

What will you look for/find on an examination of peripheral vascular disease?

Answer 3

Hands:
Weak peripheral pulses - Radial, Brachial
Abdomen:
Feel for a AAA
Listen for a renal bruit
Legs:
May have femoral bruit
Absent/Weak peripheral pulses - Femoral, Popliteal, Posterior Tibial, Dorsalis Pedis
Cold, Pale, Hairless Legs
Ulcer/Gangrene in severe disease
Assess Buerger’s Angle - Angle off the bed that the leg goes pale (<20 degrees in severe PVD)
Perform sciatic leg stretch test – To rule out sciatica

Question 4

What is the classification system used for peripheral vascular disease?

Answer 4

Fontaine Classification 
1 - Asymptomatic
2 - Intermittent claudication
3 - Claudication at rest
4 - Ulceration/Gangrene (Critical limb ischaemia)

Question 5

What investigations will you use in Peripheral Vascular Disease ?

Answer 5

Bedside:
ECG – Looking for evidence of pre-existing coronary artery disease
Ankle Brachial Pressure Index (ABPI) - The ratio of the blood pressure at the ankle to the blood pressure in the upper arm. Normal (1-1.2), PAD (0.5-0.9), Severe Ischaemia (<0.5). Diabetics can have normal results due to calcification in veins so consider this.
Glucose – Assessing other cardiovascular risk factors

Bloods:
FBC - To exclude any precipitating anaemia
ESR/CRP – Can be raised in severe disease, but will help to exclude arteritis
U&E - Check renal function as associated with renovascular disease
Lipids - Assessing other cardiovascular risk factors
Patients <50 years - Thrombophilia screen and homocysteine levels to rule out abnormal causes of clots

Imaging:
Doppler Ultrasound - Assesses location and severity of PVD

Question 6

What is the treatment of peripheral vascular disease?

Answer 6

Education about chronic nature of disease and possible complications e.g. loss of leg
Stop Smoking - Very important
Lose Weight
Exercise - Encourage exercising to point of maximal pain, improves collateral circulation
Reduce Cardiovascular Risk factor

Medical:
Antiplatelet therapy - Aspirin lifelong
Reduced Cardiovascular Risk Factors e.g. BP, diabetes, lipids
Naftidrofuryl Oxalate if not controlled with the above treatment and not suitable for surgery

Surgical: Should only be used after failed medical/lifestyle treatment
Percutaneous Transluminal Angioplasty - If limited to a single artery. Balloon inflated in artery narrowest point
Bypass Graft Surgery - If many arteries affected but distal arteries are good e.g. femoral-popliteal bypass.
Amputation - Used when all arteries not working. To relieve pain and risk of sepsis/death. The decision is the patients after failed therapy, but should involve 2 consultants. The knee is preserved where possible (improves mobility)