Peripheral Vascular Disease (PVD)

Peripheral vascular disease (PVD) is due to atherosclerosis of arteries in the limbs. The level of arterial occlusion
present is proportional to the symptoms. The pathogenesis and risk factors are the same as for coronary artery
disease (CAD), and include:
Hypertension
Dyslipidaemia
High LDL and low LDL levels
Diabetes
Obesity
FH of arterial disease
Smoking
Age
Male gender

Epidemiology
Affects about 10% of the population
Usually CAD (coronary artery disease) is also present. About 75% of patients will have symptomatic CAD. In the
other group of patients it is believed the CAD is masked by PVD, as the PVD prevents patients from exerting
themselves to a degree which would initiate symptoms of CAD.

Classification
Mild PVD
Claudication this is limb pain (inc aching, cramping and tired feeling of the legs) upon exertion. It most commonly
occurs in the calves, but may also be present in the thighs, buttocks and even arms. The distance a patient can walk
before they experience symptoms is known as the claudication distance.
Claudication could be thought of angina of the limbs
Pain is usually relieved by rest
As claudication progresses, the distance that a patient can walk reduces.

Severe PVD
Can cause claudication / buttock pain at rest
Burning pain at night, due to elevation (which reduces limb perfusion), and is relieved by hanging the legs over the
side of the bed (very bad sign!)
Patients may have:
Punched out ischaemic ulcers usually on the toes and heels, rarely higher up the limb. These tend to occur
after a localised traumatic event. They are often painful, but diabetic and alcoholic patients may not notice.
Gangrene often black necrotic gangrenous tissue surrounds the punched out ulcer lesions. Infection of this areas
can occur (wet gangrene).
Reduced / absent peripheral pulses start distally, and work your way up until you find the pulse
Skin atrophy in chronic disease
Hair loss - in chronic disease
Cyanosis
Excessive sweating due to overactivity of the sympathetic nerves
Erectile Dysfunction Leriche syndrome the result of distal aortic disease. Other features of the syndrome are
buttock pain, and pale, cold legs. Surgery may be useful to reduce symptoms in these patients
Amputation may be necessary in patients with very severe disease. Usually only performed in patients with severe
unremitting leg pain + gangrene, to prevent sepsis. Amputation should be performed as distally as possible, hopefully
below the knee, as this provides the greatest flexibility with prosthetic replacement limbs, but must be high enough
to provide sufficient perfusion to allow healing of the stump. Thus above the knee amputation is likely to heal
better.
o Phantom limb pain is common, and usually treated with gabapentin. This is often used prophylactically, as this
improves efficacy.

Investigations
Examination
Elevating the leg may cause it to go pale and cold, as well as causing pain.
Increased vascular filling time - Upon lowering, the leg may become hot and red as reperfusion occurs. Perfusion
time tends to be reduced (>15s)
Beugers angle <20 the leg will go pale and cold upon raising it 20 off the couch.
Oedema is not usually present
ABPI Ankle-Brachial pressure index - This is usually diagnostic
Measure the blood pressure in both arms and take the highest value
Measure the blood pressure in both ankles and take the highest value
o Instead of the stethoscope, use a Doppler ultrasound probe to measure the pressure over the posterior tibial artery
record the pressure when your hear the first whoosh
Using only systolic values, divide the ankle pressure by the brachial pressure
A normal value is >1
A value of <0.9 is pathological for limb ischaemia (PVD). The lower the number, the greater the degree of PVD
Pain at rest ABPI = <0.6
High Risk of gangrene ABPI - <0.3, or ankle systolic pressure <55mmHg
CAUTION in very severe arteriosclerosis the vessels are incompressible, and thus falsely high readings may be
obtained (e.g. an ABPI >1.3)
Investigate for Diabetes
Bloods
Lipids
U+Es
ESR/CRP to exclude arteritis
ECG to check for cardiac involvement
Platelets and clotting
Arterial imaging
Should be performed to assess the extent of the disease
E.g. contrast arteriography, DSA (digital subtraction arteriography), colour duplex imaging
Stop METFORMIN before arterial imaging as it increases the risk of metabolic acidosis

Management
Conservative
Stop smoking
Lose weight
Increase exercise e.g. 30-60 mins, 4x week often undervalued as a treatment. May increase the claudication
distance,and improve QoL. Thought to be beneficial by increasing collateral circulation, improved endothelial
compliance (e.g. Better vasodilation), decreased blood viscosity.
o 1/3 of patients will improve
o 1/3/ will stay the same
o 1/3/ will get worse
Symptom management
o Raising the pillow 4-6 inches can help keep the legs below heart level and reduce leg pain at night
o Avoid cold weather if possible
o Foot care inspection every day for lesions, with prompt treatment. Careful washing of the feet everyday with
thorough drying
Control of risk factors
Diabetes
Dyslpidaemia
Hypertension -blockers are often advised to be avoided, but are safe unless PAD is very severe
Antiplatelet agent usually aspirin can improve claudication distance and reduce other symptoms.

Other Interventions
Percutaneous Transluminal angioplasty - PTA is useful for short lesions (usually <5cm) in big arteries. A balloon
is used to widen the artery, which in some cases, may be enough on its own. In many cases, a stet is also placed.
Particularly useful iniliac artery disease (successful in 75-90% of patients), and also successful in 50-70% of thigh
and calf disease patients.
PTA is not good for long lesions. These are more likely to occur in diabetic patients. Selection of patients is usually
based on arterial imaging.
PTA can result in thrombus formation and subsequent embolisation
Reccurrence is about 30% at 3 years
Surgery - thromboendarterectomy
is suitable for some patients. These are usually those with an obvious blockage, where the distal vessel is filled well
by collateral vessels (indicating that the distal vessel is still in good shape) similar to the indications for PTA
however patients must be able to tolerate surgery. May be used in those in whom PTA was not successful.
These patients may receive a bypass graft. These are usually made from venous tissue, but prosthetic structures
are also used.
o Aspirin improves the longevity / patency of prosthetic grafts
o Warfarin may be required after graft surgery in venous grafts
Sympathectomy may be used to relieve pain. This can be chemical or surgical, but as they are equally effective, and
generally used in those who cant tolerate other surgery, chemical sympathectomy is much more widely performed.
Particularly useful in diabetic patients.
Limb Compression
May help those with severe disease who are not candidates for surgery.
Inflatable cuffs are placed over the limb and inflated rhythmically for a period of 1-2 hours, several days per week
This is thought to improve both venous and arterial flow, thus reducing symptoms, but evidence is poor