Peripheral vascular disease (PVD)

Question 1

Definition

Answer 1

The narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas

Usually refers to the lower limbs resulting in claudication

Intermittent claudication:
– symptom of ischaemia during exertion and relieved by rest
– usually a crampy, achy pain in the calf, thigh or muscle area

Ischaemia- inadequate oxygen supply to tissues, due to a lack of blood supply

PVD can lead to critical limb ischaemia

– end stage of PVD:
—- where there is inadequate blood flow to the limb
—- signs- pain at rest, non-healing ulcers, and gangrene

Acute limb ischaemia:
– rapid onset of ischaemia into a limb
– usually from a thrombus, blocking the arterial supply of a distal limb

necrosis- death of tissue

Gangrene- death of tissue specifically due to an inadequate supply of a distal limb

Question 2

Aetiology

Answer 2

Atherosclerosis is a big cause- which is caused by chronic inflammation and activation of the immune system in the artery wall

The plaques cause:
– stiffening of the arterial wall leading to hypertension and strain on the heart
– stenosis leading to a reduction in blood flow
– plaque rupture, leading to a thrombus and then acute limb ischaemia
—- arterial thrombosis that is secondary to progressive atherosclerotic disease and thrombosis represents 40% of acute limb ischaemia cases

Rarer causes:
– blood vessel inflammation
– injury to the arms or legs
– changes in the muscles or ligaments
– radiation exposure

Question 3

Epidemiology

Answer 3

Men are more common than women

50-75% of patients with PAD also have coronary artery disease or carotid artery disease
– carotid artery disease increases the risk of brain stroke

Question 4

Risk factors

Answer 4

Non modifiable risk factors:
– older age
– family history
– male

Modifiable risk factors:
– smoking
– alcohol consumption
– obesity
– sedentary lifestyle
– poor diet
– poor sleep
– stress

Medical co-morbidities:
– diabetes
– hypertension
– chronic kidney disease
– inflammatory conditions such as RA

Question 5

Pathophysiology

Answer 5

Mainly driven by the progression of atherosclerotic disease leading to macro and microvascular dysfunction

Question 6

Clinical presentation

Answer 6

Intermittent claudication- crampy pain on exertion but releives with rest

Critical limb ischamia:
– pain
– pallor
– pulseless
– paralysis
– paraesthesia
– perishingly cold

Leriche syndrome:
– occlusion within the distal aorta or common iliac artery:
—- presents as:
——- thigh/buttocks claudication
—— absent femoral pulses
——- male impotence

– muscle wasting
– skin pallor
– hair loss
– ulcers that are non healing
– cyanosis
– gangrene
– reduced skin temperature
– leg numbness or weakness
– shiny skin on legs
– ED
– no pulse or weak pulse in legs and feet

Question 7

Investigations

Answer 7

May see previous signs of CVD:
– previous amputation
– previous coronary artery bypass graft (scar down middle of chest)
– previous stroke (facial weakness)

Peripheral pulses may be weak:
– carotid, brachial, abdominal aorta, radial, femoral, popliteal, posterior tibial, dorsalis pedis

Burgers test:
- used to test for PAD in the leg

Ankle-brachial pressure index test (API test):
– an API of lower than 0.9 indicates that there is PAD

Blood tests

Duplex ultrasound (assesses the speed and volume of the blood flow)

Question 8

Treatment

Answer 8

Prevention:
– dont smoke
– exercise
– loose weight

Medications:
– cholesterol drugs- statins (help lower cholesterol)

– blood pressure drugs

– antiplatelets to prevent blood clots

Surgeries:
– bypass
– thrombolytic therapy