Peripheral Vascular disease

Question 1

Define peripheral vascular disease and summarise its aetiology and epidemiology

Answer 1

Definition: Occurs due to atherosclerosis causing stenosis of arteries via a multifactorial process involving modifiable and non-modifiable risk factors

Aetiology:
- Occurs due to atherosclerosis in peripheral vascular disease
- Types of PVD include:
• Intermittent claudication- calf pain on exercise
• Critical limb ischaemia- pain at rest
Note: this is the MOST SEVERE manifestation of peripheral vascular
• Acute limb ischaemia- a sudden decrease in arterial perfusion in a limb, due to thrombotic or embolic causes
• Arterial ulcers
• Gangrene

Risk factors:

• Smoking
• Diabetes
• Hypertension
• Hyperlipidaemia
• Physical inactivity
• Obesity

Epidemiology:

• 55-70 yrs = 4-12% affected
• 70+ yrs = 15-20% affected
• More common in males
• Incidence increases with age

Question 2

Describe the history/presenting symptoms of peripheral vascular disease

Answer 2

• Intermittent claudication- cramping pain in calf, thigh or buttock after walking for a given distance (claudication distance) and relieved by rest
  • Calf claudication = femoral disease
  • Buttock claudication = iliac disease

- Features of critical limb ischaemia 
   • Ulcers
   • Gangrene 
   • Rest pain
   • Night pain (relieved by dangling leg over the edge of the bed)

• Leriche Syndrome
  • Buttock claudication
  • Impotence
  • Absent/weak distal pulses

- Fontaine classification of peripheral vascular disease
  • Asymptomatic 
  • Intermittent claudication
  • Rest pain
  • Ulceration/gangrene

Question 3

What are the signs of peripheral vascular disease upon physical examination?

Answer 3

- Acute limb ischaemia- 6Ps
   • Pain 
   • Pale
   • Pulseless
   • Paralysis
   • Paraesthesia 
   • Perishingly cold

- Other symptoms:
   • Atrophic skin
   • Hairless
   • Punched-out ulcers (often painful)
   • Colour change when raising leg (to Buerger's angle)

Question 4

What investigations are used to identify peripheral vascular disease?

Answer 4

• Full cardiovascular risk assessment
  • Blood pressure
  • FBC- anaemia will worsen ischaemia
  • Fasting blood glucose
  • Lipid levels
  • ECG- Check for pre-existing coronary artery disease
  • Thrombophilia screen- for patients elder than 50 yrs
• Colour Duplex Ultrasound
  • FIRST-line
  • Shows site and degree of stenosis
• MRI/CT
  • Assesses extent and location of stenoses
• ABPI (Ankle-Brachial Pressure Index)
  • Marker of cardiovascular disease
  • ABPI < 0.8 = do not apply pressure bandage because this will worsen ischaemia