Peripheral vascular disease is a common disorder of both large and small vessels that affects millions of people. Atherosclerosis develops in the vessels resulting in narrowing and hence limiting blood flow. The disease can lead to a loss of limb or life.
Physical exam of a patient with PVD depends on whether the condition is acute or chronic. In a patient with an acutely cold leg the 5Ps include presence of:
Blood work required in the work up of a patient with PVD includes:
Transcutaneous oximetry is also used to assess degree of perfusion in PVD. The technique is being used in outpatient clinics to assess wound healing before and after surgery.
The treatment of PVD is multidisciplinary and divided into acute and chronic management .
When a patient presents with an acutely cold leg, the treatment is emergency revascularization. When a patient presents with a cold leg to the ED, attention should first be directed to the ABCs. Two large bore IVs should be inserted and routine blood work is necessary. Because some of the patients may be on blood thinners, a coagulation profile is necessary. If the patient has an acutely cold leg, heparin should be started immediately. The heparin must be administered intravenously and the PTT should be maintained at 1.5-2 times normal. This should be followed by an ultrasound duplex test if there are no pulses palpable. The vascular surgeon must be notified immediately for further care. Most patients require some type of pain medication.
Once an individual has been diagnosed with PVD, the treatment involves treating the risk factors and causes :
The prognosis of patients with PVD is guarded. Because the disease is progressive, eventually most patients develop symptoms. PVD is also associated with a high risk of myocardial ischemia and stroke because the same pathology is present in these disorders. For individuals with mild disease, there may be no symptoms but for those with severe disease, the individual may develop impotence, intermittent claudication, non healing ulcers, decreased exercise endurance, limitation in lifestyle and rest pain. Those with severe leg ischemia may end up with above or below knee amputations. Even with surgical therapy, complications are common and patency rates of grafts are not overly impressive. If the individual with PVD does not change his/her lifestyle, then the morbidity and mortality rates are high .
PVD is quite common not only in North America but across the globe. In the USA alone, it is estimated that there are nearly 10 million people with PVD. The disorder is often seen after the 5th decade of life and carries a high morbidity. With the aging population, it is estimated that a number of affected people with PVD are also going to significantly increase. PVD occurs with equal frequency in men and women but the outcomes in diabetic women tend to be worse. The primary reason for this are the small sized blood vessels in females which can be readily obstructed by atherosclerotic plaques.
Among races, PVD is slightly more common in African Americans compared to Caucasians and Hispanics. The ethnic susceptibility is likely related to higher prevalence of hypertension, diabetes and obesity in this population. Unlike many other disorders, PVD is often neglected and not recognized. In addition, there is gross misuse and abuse of unproven and unrecognized therapies. Several studies indicate that in primary practice, PVD is often not diagnosed or recognized despite presence of risk factors. This often leads to progression of disease, which ultimately results in extremity amputation. Even when the disorder is recognized, it is not thoroughly worked up and the treatment is often poorly managed.
PVD occurs primarily because of atherosclerosis. The process starts with deposition of cholesterol in the intimal layers of the vessel. Over time, this develops into a cholesterol plaque covered with a fibrous layer. As the size of the plaque grows it can obstruct blood flow distally. Sometimes, the atherosclerotic plaque can rupture and promote thrombosis or generate emboli which occlude blood vessels distally. Atherosclerosis can affects all types of vessels but is most common at points where blood vessels bifurcate. Along these areas there is turbulence and stasis, which promotes shear stress and injury. Atherosclerotic disease is usually segmental in distribution but does vary from patient to patient. When the progression of atherosclerosis is slow, the small and medium sized blood vessels get occluded and numerous collateral vessels develop.
The symptoms of PVD occur when the blood vessel is occluded by thrombus, emboli or acute trauma that compromises tissue perfusion. Overall, atherosclerosis affects the blood vessels in the lower extremities more frequently than those in the upper extremities. Risk factors that predispose patients to formation of thrombosis include
Sudden occlusion of a blood vessel is usually due to emboli, which in most cases are from the heart. Other sources of emboli include foreign bodies, tumor or atheromatous fragments from other blood vessels (eg abdominal aorta). The most common sites where atherosclerosis occurs and have a high tendency to promote thrombosis include:
The presentation of a patient with atherosclerosis depends on the nature of the occlusion, development of collateral circulation and presence of symptoms. In general, emboli tend to have high morbidity as the patient has not had time to develop collateral circulation. In either case, both emboli and thrombosis results in decreased tissue perfusion to the distal vessel.
Individuals who have moderate to severe PVD can be managed as outpatients but need close follow up and monitoring. All patients with PVD should be warned about the harmful effects of smoking and types of physical activities that lead to injury. The individual should be told to avoid cold environments but when going out and should dress warm. They should be educated that many cold and cough medications can act as vasoconstrictors and limit blood supply to the extremity.
Use of illicit drugs like cocaine should be avoided as it may lead to increased arterial tone. In addition, beta-blockers may exacerbate the symptoms of claudication.
After discharge the patient must be started on antiplatelet agents to prevent worsening of PVD and decrease risk of cardiovascular events. In addition, the patient must be told to change lifestyle, discontinue smoking and exercise regularly.
Statins are now prescribed to lower cholesterol and triglycerides preliminary evidence indicates that statins may slow the progression of atherosclerosis.
Peripheral vascular disease (PVD) is a very common medical disorder, which has the potential to lead to loss of limb or even life, if not properly treated. PVD, when moderate to severe, can lead to decrease in tissue perfusion, and this in turn can lead to pain, non-healing ulcers and decreased ability to walk. While in most cases PVD is due to progressive atherosclerosis, in other cases, it may be due to emboli. Millions of people have varying degrees of PVD, but the disorder can suddenly become acute and the patient will present to the ED with a cold extremity. Immediate treatment is required when treating acute limb occlusion as it can result in very high morbidity and mortality   .
PVD is common in many people who smoke, have diabetes or hyperlipidemia. The disorder results in narrowing of the blood vessels, which decreases blood supply to the tissues. Almost any organ can be affected in PVD but the most common are the kidneys, legs, and brain. Risk factors for PVD include smoking, diabetes, hypertension, hyperlipidemia and an unhealthy diet. The disorder results in cholesterol deposition over the blood vessels, which gradually leads to narrowing or obstruction of blood flow. The patient may present with pain in the buttock area while walking or in severe cases may present with nonhealing ulcers in the leg, blush and cold legs and rest pain. The diagnosis is made by ultrasound and invasive studies like the CT scan. The treatment depends on the degree and severity of the disease. In patients who suddenly develop a cold leg, immediate surgery is required to remove the blood clot. In those with chronic disease, one should avoid smoking, control blood sugars, ensure better control of blood pressure, exercise and eat a healthy diet. Drugs like aspirin may be useful in some patients.
1. Benitez E, Sumpio BJ, Chin J, Sumpio BE. Contemporary assessment of foot perfusion in patients with critical limb ischemia. Semin Vasc Surg. 2014 Mar;27(1):3-15.
2. Patel MR, Conte MS, Cutlip DE, et al. Evaluation and treatment of patients with lower extremity peripheral artery disease: consensus definitions from Peripheral Academic Research Consortium (PARC). J Am Coll Cardiol. 2015 Mar 10;65(9):931-41.
3. Society for Vascular Surgery Lower Extremity Guidelines Writing Group, Conte MS, Pomposelli FB, Clair DG, Geraghty PJ, McKinsey JF, Mills JL, Moneta GL, Murad MH, Powell RJ, Reed AB, Schanzer A, Sidawy AN; Society for Vascular Surgery. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication. J Vasc Surg. 2015 Mar;61(3 Suppl):2S-41S.
5. Malgor RD, Alalahdab F, Elraiyah TA, et al. A systematic review of treatment of intermittent claudication in the lower extremities. J Vasc Surg. 2015 Mar;61(3 Suppl):54S-73S.
6. Gulati A, Botnaru I, Garcia LA. Critical limb ischemia and its treatments: a review. J Cardiovasc Surg (Torino). 2015 Apr 14.
7. Tu C, Das S, Baker AB, Zoldan J, Suggs LJ. Nanoscale Strategies: Treatment for Peripheral Vascular Disease and Critical Limb Ischemia. ACS Nano. 2015 Apr 10.
8. Bedenis R, Lethaby A, Maxwell H, Acosta S, Prins MH. Antiplatelet agents for preventing thrombosis after peripheral arterial bypass surgery. Cochrane Database Syst Rev. 2015 Feb 19;2:CD000535.
9. Menard MT, Farber A. The BEST-CLI trial: a multidisciplinary effort to assess whether surgical or endovascular therapy is better for patients with critical limb ischemia. Semin Vasc Surg. 2014 Mar;27(1):82-84.
10. Andrews KL, Houdek MT, Kiemele LJ. Wound management of chronic diabetic foot ulcers: from the basics to regenerative medicine. Prosthet Orthot Int. 2015 Feb;39(1):29-39.