Introduction
Peripheral vascular disease (
PVD) is due to
atherosclerosis of arteries in the limbs.
The level of arterial occlusion present is proportional to the symptoms. The pathogenesis and risk factors are the same as for coronary artery disease (CAD), and include:
- Hypertension
- Dyslipidaemia
- High LDL and low LDL levels
- Diabetes
- Obesity
- FH of arterial disease
- Smoking
- Age
- Male gender
Epidemiology
- Affects about 10% of the population
- Usually CAD (coronary artery disease) is also present. About 75% of patients will have symptomatic CAD. In the other group of patients it is believed the CAD is masked by PVD, as the PVD prevents patients from exerting themselves to a degree which would initiate symptoms of CAD.
Classification
Claudication – this is limb pain (inc aching, cramping and tired feeling of the legs) upon exertion. It most commonly occurs in the calves, but may also be present in the thighs, buttocks and even arms. The distance a patient can walk before they experience symptoms is known as the claudication distance.
- Claudication could be thought of ‘angina’ of the limbs
- Pain is usually relieved by rest
- As claudication progresses, the distance that a patient can walk reduces.
Can cause claudication / buttock pain at rest
Burning pain at night, due to elevation (which reduces limb perfusion), and is relieved by hanging the legs over the side of the bed (very bad sign!)
Patients may have:
- ‘Punched out’ ischaemic ulcers – usually on the toes and heels, rarely higher up the limb. These tend to occur after a localised traumatic event. They are often painful, but diabetic and alcoholic patients may not notice.
- Gangrene – often black necrotic gangrenous tissue surrounds the punched out ulcer lesions. Infection of this areas can occur (wet gangrene).
- Reduced / absent peripheral pulses – start distally, and work your way up until you find the pulse
- Skin atrophy – in chronic disease
- Hair loss - in chronic disease
- Cyanosis
- Excessive sweating – due to overactivity of the sympathetic nerves
- Erectile Dysfunction – Leriche syndrome – the result of distal aortic disease. Other features of the syndrome are buttock pain, and pale, cold legs. Surgery may be useful to reduce symptoms in these patients
- Amputation –may be necessary in patients with very severe disease. Usually only performed in patients with severe unremitting leg pain + gangrene, to prevent sepsis. Amputation should be performed as distally as possible, hopefully below the knee, as this provides the greatest flexibility with prosthetic replacement limbs, but must be high enough to provide sufficient perfusion to allow healing of the stump. Thus above the knee amputation is likely to heal better.
- Phantom limb pain is common, and usually treated with gabapentin. This is often used prophylactically, as this improves efficacy.
Investigations
Examination
- Elevating the leg may cause it to go pale and cold, as well as causing pain.
- Increased vascular filling time - Upon lowering, the leg may become hot and red as reperfusion occurs. Perfusion time tends to be reduced (>15s)
- Beuger’s angle <20’ – the leg will go pale and cold upon raising it 20’ off the couch.
- Oedema is not usually present
ABPI
Ankle-Brachial pressure index - This is usually diagnostic
- Measure the blood pressure in both arms and take the highest value
- Measure the blood pressure in both ankles and take the highest value
- Instead of the stethoscope, use a Doppler ultrasound probe to measure the pressure over the posterior tibial artery – record the pressure when your hear the first ‘whoosh’
- Using only systolic values, divide the ankle pressure by the brachial pressure
- A normal value is >1
- A value of <0.9 is pathological for limb ischaemia (PVD). The lower the number, the greater the degree of PVD
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