Peripheral Vascular Disease
- 1 Chronic Lower Limb Ischaemia
- 2 Acute Lower Limb Ischaemia
- 3 =Investigation/Management
- 4 Raynaud's Disease
- 5 Abdominal Aortic Aneurysm
- 6 =Symptoms
- 7 Varicose Veins
Chronic Lower Limb Ischaemia
Atherosclerosis causes occlusion commonly affecting the aorto-iliac/ infrainguinal arteries. As with Ischaemic Heart Disease, vascular risk factors include: Modifiable
- Diabetes (+ Diabetic control)
- Oral contraceptive Pill
- Gender (male)
- Family history of IHD (especially age <50 )
Intermittent claudication- exertional cramping pain in the calf, thigh, hip or buttock, relieved with rest.
- Erectile dysfunction, plus pain higher up the leg suggest Aorto-iliac disease
Rest pain- severe pain in the foot, worse when lying down.
- Severe cases may show ulceration or necrosis of the foot
- Cold, dry legs with little hair growth.
- Absent pulses
- Buerger's tests positive.
- Full Peripheral Vascular Examination
- Ankle/Brachial Pressure Index (ABPI) <0.9
- Digital Subtraction Angiography
- Duplex Ultrasound
- MRI Angiography
- Peripheral neuropathy
- Spinal canal claudication
- Reduce risk factors- stop smoking, lose weight, control diabetes, lower cholesterol
- Statin Therapy
- Aspirin to reduce risk of IHD
- Cilostazol- Phosphodiesterase 3 Inhibitor
- Naftidrofuryl- Vasodilator
If severe symptoms, Percutaneous Angioplasty, arterial stents, bypass or amputation may be considered
Acute Lower Limb Ischaemia
Acute unbearable Pain, Pallor, Paraesthesia, Paralysis and Perishing cold should alert you to this emergency. The limb will be cold, with mottled skin and absent pulses.
- Previous claudication leading to acute thrombus
- Popliteal aneurysm
- Cardiac thrombus
- Cardiac Arrhythmias
- Aneurysm thrombus
- Rheumatic heart disease
Investigate as for chronic disease, and treat:
Beware reperfusion injuries- sudden reperfusion can lead to a toxic compartment syndrome, so a fasciotomy may be warranted.
Digital artery spam, precipitated by cold, causes bilateral skin pallor and cyanosis, then numbness, a warm sensation, and redness as the fingers warm up. If chronic, may lead to infarction/ amputation. Raynaud's may be caused by systemic sclerosis or occupations using vibrating tools (think roadworks).
- Avoid cold, wear gloves
- Reduce risk factors- stop smoking
- Vasodilators if severe- but they cause headaches
Abdominal Aortic Aneurysm
An aneurysm is defined as a permanent doubling in the artery diameter. Incidence increases with age, and in men, with most aneurysms being infrarenal.
Asymptomatic, or varied presentation of:
- Epigastric pain radiating to the back (or back alone)
- Nausea, tenderness
- Embolic disease (see above)
Pulsatile, expansive mass in the abdomen, or popliteal aneurysms, or lower limb ischaemia
- Screening age 65 for men
- MRI/ CT
Balance risk- consider if this is for palliation
- Control risk factors- smoking, hypertension, statins.
- Surgical aneurysm repair
- Endovascular stent
Engorged calf veins, due to reflux of venous blood through failed leaflet valves in the leg. Other signs include pain, swelling, erythema, and discoloration.