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.

• M/C affected artery: Femoral artery

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Aetiology

Risk factors

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

Cause

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

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Pathophysiology

• 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

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Classification

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 III: Rest pain, mostly in the feet
• Stage IV: Necrosis 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

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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

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Diagnosis

Ankle-brachial index (ABI): Best initial test

Ratio of the ankle systolic pressure to the arm systolic pressure

• ABPI_Leg: < 0.9

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

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Management

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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Summary