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Peripheral Vascular Disease

From Mediwikis

Lower limb ulceration due to PVD

Chronic Lower Limb Ischaemia

Atherosclerosis causes occlusion commonly affecting the aorto-iliac/ infrainguinal arteries. As with Ischaemic Heart Disease, vascular risk factors include: Modifiable

  • Smoking
  • Obesity
  • Diabetes (+ Diabetic control)
  • Hypercholesterolaemia
  • Hypertension
  • Oral contraceptive Pill
  • Alcohol

Non modifiable

  • Age
  • Gender (male)
  • Family history of IHD (especially age <50 )

Symptoms

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

Signs

  • Cold, dry legs with little hair growth.
  • Absent pulses
  • Ulceration
  • Discolouration
  • Buerger's tests positive.

Investigations

Differential Diagnosis

Management

  • 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.

Causes

Thrombotic Disease

  • Previous claudication leading to acute thrombus
  • Thrombophilia
  • Malignancy
  • Popliteal aneurysm

Embolism

  • Cardiac thrombus
  • Cardiac Arrhythmias
  • Aneurysm thrombus
  • Rheumatic heart disease

=Investigation/Management

Investigate as for chronic disease, and treat:

  • Heparin
  • Thrombolysis
  • Angioplasty
  • Embolectomy

Beware reperfusion injuries- sudden reperfusion can lead to a toxic compartment syndrome, so a fasciotomy may be warranted.

Raynaud's Disease

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).

Management

  • 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.

=Symptoms

Asymptomatic, or varied presentation of:

  • Epigastric pain radiating to the back (or back alone)
  • Nausea, tenderness
  • Embolic disease (see above)

Rupture:

  • Hypotension
  • Tachycardia

Pulsatile, expansive mass in the abdomen, or popliteal aneurysms, or lower limb ischaemia

Investigations

  • Screening age 65 for men
  • MRI/ CT

Management

Balance risk- consider if this is for palliation

  • Control risk factors- smoking, hypertension, statins.
  • Surgical aneurysm repair
  • Endovascular stent

Varicose Veins

Engorged calf veins, due to reflux of venous blood through failed leaflet valves in the leg. Other signs include pain, swelling, erythema, and discoloration.

Signs/ Symptoms

Investigations

Management