Internal Medicine

Peripheral Vascular Disease (PVD)

Peripheral artery disease (PAD) or Peripheral vascular disease (PVD) is a narrowing of the arteries other than those that supply the heart or the brain.

Peripheral artery disease (PAD) or Peripheral vascular disease (PVD) is a narrowing of the arteries other than those that supply the heart or the brain.

  • M/C affected artery: Femoral artery


Risk factors

  • Smoking (M/imp risk factor)
  • Diabetes mellitus
  • Hypertension
  • Heart disease
  • Hyperlipidemia
  • Non-modifiable:
    • Family history of circulation problems
    • Old age
    • Male sex


  • Organic PVD:
    • Atherosclerosis (M/C)
    • Thromboembolus
  • Functional PVD:
    • Vasospasms (short-term)


  • Pain in foot:
    • Block of lower tibial and plantar vessels
  • Pain in calf:
    • Block in femoropopliteal segment
  • Pain in thigh:
    • Block in superficial femoral artery
  • Pain in hips/buttock:
    • Block in common iliac or aortoiliac segment
    • Usually associated with impotence: Leriche’s syndrome


Fontaine classification

  • Stage I: Asymptomatic, incomplete blood vessel obstruction
  • Stage II: Mild claudication pain in limb
    • Stage IIA: Claudication when walking > 200 meters
    • Stage IIB: Claudication when walking < 200 meters
  • Stage IIIRest pain, mostly in the feet
  • Stage IVNecrosis and/or gangrene of the limb

Rutherford classification

  • Grade 0, Category 0: Asymptomatic
  • Grade I, Category 1: Mild claudication
  • Grade I, Category 2: Moderate claudication
  • Grade I, Category 3: Severe claudication
  • Grade II, Category 4: Rest pain
  • Grade III, Category 5: Minor tissue loss; Ischemic ulceration not exceeding ulcer of the digits of the foot
  • Grade IV, Category 6: Major tissue loss; Severe ischemic ulcers or frank gangrene

Clinical features

Intermittent claudication:

Muscle pain on mild exertion (ache, cramp, numbness or sense of fatigue), classically in the calf muscle, which occurs during exercise, such as walking, and is relieved by a short period of rest.
  • All the “P”s
    • Pallor increase
    • Pulses decreased
    • Perishing cold
    • Pain
    • Paraesthesia
    • Paralysis

II. Ischemic rest pain

Continuous burning pain in the lower leg or feet.
  • Continuous pain on elevation
    • Relieved on lowering (hanging feet or walking)
  • Colour changes: Elevation pallor, dependent rubor

Critical limb ischemia (CLI):

Also referred to as limb threat, is an advanced stage of peripheral artery disease (PAD).
  • TRIAD:
    1. Ischemic rest pain
    2. Arterial insufficiency ulcers
    3. Gangrene


Ankle-brachial index (ABI): Best initial test

Ratio of the ankle systolic pressure to the arm systolic pressure
  • ABPILeg: < 0.9
Calculate and interpret ankle-brachial index (ABI)
Degrees of arterial perfusion and associated ankle-brachial index (ABI) ranges, signs and symptoms, and waveforms. Lower arterial perfusion is associated with more severe peripheral arterial disease. | How to calculate and interpret ankle-brachial index (ABI) numbers. (2021, February 9). Medmastery.

Buerger’s test

  • Elevation pallor
    • Vascular angle or Buerger’s angle is the angle to which the leg has to be raised before it becomes pale, whilst in supine decubitus
      • Normal limb may not show pallor even at 90°
      • Vascular angle < 20°: Severe ischemia
  • Sunset foot
    • When patient shifts to sitting position, the leg will revert to the pink colour more slowly than normal and also pass through the normal pinkness to a red-orange colouring (rubor – redness)
  • Rubor of dependency
    • Foot will return to its normal colour if descended

Claudication test:

Differential diagnosis:

  • Neurogenic claudication
  • Diabetic neuropathy
  • Statin myopathy
  • Small vessel disease


Modify risk factors:

  • Smoking cessation
  • Lipid management (Statins)
  • BP control (ACEi, Beta blockers)
  • Exercise program

Medical management:

  • Lipid lowering therapy (statins)
  • Antihypertensives: ACE inhibitors, ARBs & β-blockers
  • Antiplatelet therapy (aspirin, clopidogrel)
  • Cilostazol
  • Pentoxyfylline

Revascularization procedures:

  • Percutaneous transluminal angioplasty (PTA)
  • Atherectomy
  • Arterial bypass surgery
  • Arterial thrombosis or embolism:
    • Thrombolysis and thrombectomy
  • Gangrene:
    • Amputation


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