PERIPHERAL VASCULAR
DISEASE
Pathophysiology
• Form of atherosclerosis • Progressive disease
– Usually has a slow onset and patients present with symptoms that gradually get worse OR…
• PVD is a generic term that encompasses vascular insufficiencies such as
arteriosclerosis, arterial stenosis, Raynaud’s phenomenon.
• Peripheral arteriosclerosis is common in the elderly and is often associated with
hypertension and hyperlipidemia.
Two types of PVD
• Functional
Doesn’t have an organic cause.
Doesn’t involve defects in blood vessels’ structure, usually short-term effects and come and go.
Types of PVD continued
• Organic
Caused by structural changes in the blood vessels, such as inflammation.
How Common is PVD?
• Affects about 1 in 20 people over the age of 50, or 8 million people in the US.
• Approximately 1 million people in SA are affected.
• PVD is only diagnosed in 50% of the population. • Symptomatic PVD carries at least a 30% risk of
death within 5 years and almost 50% within 10
Symptoms of PVD (
NB
)
• Leg or hip pain during walking (intermittent claudication).
• The pain stops when you rest.
• Numbness, tingling or weakness in the legs. • Burning or aching pain in feet or toes when
resting.
• Sore on leg or foot that won’t heal. • Cold legs or feet.
Clarification of Terminology
• Claudication – when at rest / during low
energy tasks the patient experiences no
pain, as the blood flow is sufficient,
HOWEVER, as soon as the patient walks
fast / runs / does any activities that causes
fatigue, the blood flow to the limb is not
The 5 P’s (
NB
)
• Peripheral signs of PVD are the classic 5 P’s
Pulselessness
Paralysis
Paraesthesia
Pain
• Paralysis and paraesthesia suggest limb-threatening ischemia and mandate prompt evaluation and consultation.
• Advanced PVD may manifest as mottling in a “fishnet pattern”, pulselessness, numbness, or cyanosis. Paralysis may follow, and the
extremity may become cold; gangrene
eventaully may be seen. Poorly healing injuries or ulcers in the extremities help provide
Who is at risk for PVD?
• Over the age of 50 • Smokers
• Diabetics
• Overweight (especially with syndrome X or hyperinsulinism)
• Male gender
• Sedentary people
Pain Scale
• A subjective grading scale for PVD pain is as follows:
Grade 1: Definite discomfort or pain, but only of initial or modest levels (established, but minimal).
Grade 2: Moderate discomfort or pain from which the patient’s attention can be diverted, for example by
conversation.
Grade 3: Intense pain (short of Grade 4) from which the patient’s attention cannot be diverted.
How is PVD Diagnosed?
• Ankle-Brachial Index Test (ABI)
The blood pressure in your arms and ankles is checked using a regular blood pressure cuff and a special ultrasound stethoscope called a Doppler.
The pressure in your ankle is compared to the pressure in your arm to determine how well
your blood is flowing.
ABI
• Measurements are usually taken at rest and
after standardized treadmill exercise (i.e.. For 5 min. at 2mph, 12%).
• A normal resting ABI is 1 or 1.1.
• An index of 0.9 or less indicates the presence of obstructive disease.
• 0.5 or less suggests multiple-level arterial disease.
Duplex Ultrasonography and
Doppler Color-Flow Imaging
• Technical advances in ultrasonography have allowed reproducible measurements of blood vessels and blood flow as well as
standardization of criteria for assessment of PVD.
• Doppler color-flow imaging are useful in
Magnetic Resonance Imaging
and Angiography
• Useful in evaluating arterial dissection and characterizing vessel-wall morphology
(including hematoma or thrombus).
Treatment for PVD (
NB
)
• Severe lower extremity PVD is treated initially with cardiovascular disease risk factor modification:
Exercise training
Medication
Diet
Stop Smoking
Interventional Radiology
Surgery
Exercise
• Research has shown that regular exercise is the most consistently effective treatment for PVD. • Patients who have taken part in a regular
exercise program for at least 3 months have
seen substantial increases in the distances they are able to walk without experiencing painful
Exercise Prescription
• Training Intensity
Initial
• Set by result of peak treadmill.
• Starting exercise work load brings on claudication pain.
Subsequent
• Speed or grade increased if patient walks > 10 minutes.
Exercise Prescription
• Duration
Initial
• 35 minutes (intermittent walking)
Subsequent
• Add 5 minutes every session until 50
Exercise Prescription
• Frequency
3-5 times per week.
• Specificity of Activity
Stop Smoking
• On average, smokers are diagnosed with PVD as much as 10 years earlier than non-smokers. • Stopping smoking now is the single most
important thing you can do to halt the
Medications
• Drugs that lower cholesterol or control high blood pressure.
• Decrease blood viscosity.
Trental, Persantine, or Coumadin
• Antiplatlet agents: their primary long-term benefit is reduction in cardiovascular events and mortality.
ASA doses of 75 to 325mg QD have shown protective benefits.
Ticlid and Plavix also have shown promise in
Interventional Radiology
Treatments
• Angioplasty • Stents
Gene-Based Therapy
• The field of molecular genetics has provided new understanding of vascular physiology and pathology and has opened exciting frontiers in the treatment of PVD.
• Direct gene transfer by intramuscular injection of DNA encoded with vascular growth factors has resulted in growth of new vessels and
Surgical Treatments for PVD
Aneurysms
• Most common lethal peripheral vascular abnormality.
An artery whose diameter is 1.5 times the normal. • Aortic aneurysms are caused by weakening of the
artery walls due to atherosclerosis. The weakened walls balloon out, forming an aneurysm.
Aortoiliac Occlusive Disease
• Typically involves the distal abdominal aorta as well as the common and external iliac
arteries.
• Aortobifemoral bypass with a prosthetic graft has been the traditional treatment of choice for aortoiliac occlusive disease since the
1960’s.
• The operative morbidity and mortality are in the 2% range, and long-term patency
Superficial Femoral Occlusive
Disease
• Presents with symptoms of claudication of the calf and sole of the foot.
Usually improves as collateral circulation develops.
Tibial Artery Disease
• Distal atherosclerotic disease involving the
tibioperoneal trunk and the tibial vessels is the most difficult to treat and leads to the greatest morbidity and tissue loss.
Upper Extremity Disease
• Atherosclerotic disease involving the arms is almost always limited to the larger proximal vessels and rarely involves the brachial,
radial, or ulnar arteries.
• Although these patients have no symptoms, they can have a large discrepancy in BP
between the left and right arms.
Thrombosis
• A thrombus, or blood clot, within a blood vessel.
• Normally, a blood clot forms to prevent
bleeding but a thrombus is an abnormal blood clot in the vessel when it is not even
punctured.
• The clotting process may be encouraged by the buildup of fatty acids on the vessel walls. • Thrombosis in the vein may cause pain and
Deep Venous Thrombosis
• A blood clot in a deep vein.
• May form on the valves within the vein, and may subsequently increase in size to totally occlude the vein.
• Sometimes parts of the clot may break off
and travel in the bloodstream to the lungs and cause serious health problems (pulmonary
embolism).
• DVT is perhaps the most dangerous problem. • Patients with DVT have a 30 to 40% risk of
Phlebitis
• Inflammation of the leg veins. • Two types:
Inflammation of the veins on the surface of the leg (more common).
Inflammation of the deep veins of the leg. • Phlebitis is caused by an infection or injury. • Can cause a blood clot to form and this clot
Pulmonary Embolism
• An embolus is a clot or any other piece of material that is carried around in the blood. • Pulmonary embolism is where the embolus
gets stuck in a vessel going to the lungs.
• The only way a clot can go to a vessel in the lungs is if it passes through the heart and is pumped out of the pulmonary artery.
Varicose Veins
• Caused because either the blood flow is too slow making the vein pile up with blood or the valve in the vein is not working well so the blood falls
down due to gravity and piles up in the veins of the legs.
• Sclerotherapy: Irritant chemical is injected into
the veins, causing them to scar and seal off. This “detours” the blood to nearby healthier veins.
• Stripping: Procedure used to remove larger
• Surgery continues to play an important role in the management of peripheral vascular
disease.
• Revascularization procedures provide
excellent outcomes for many patients at risk for loss of a limb or seriously impaired quality of life.
• Although endovascular techniques are now being used for managing many vascular
