FAMILY MEDICINE

Lecture

Peripheral Arterial Disease

Atherosclerotic peripheral vascular disease (PVD) =

underdiagnosed, undertreated, age-dependent disease

Profoundly impacts patient quality of life
An independent predictor of mortality
Atherosclerosis chronic low-grade inflammation +
superimposed acute thrombotic events
Increased risk of cardiovascular and cerebrovascular
events (sudden death, MI, stroke)
The clinical continuum of PVD ranges from
asymptomatic stenosis to limb-threatening ischemia

Does Asymptomatic PAD Really

matter?
Coronary Artery Surgery

Study (CASS) in patients

with known CAD the
presence of PAD
increased Cardiovascular
mortality by 25% during
a 10-year follow-up
(J AM Coll
Cardiol 1994:23:1091-5)

PAD, symptomatic or

asymptomatic, is a
powerful independent
predictor of CAD and
CVD
(Vasc. Med. 3, 241, 1998)

PAD
severity

ABI

Mortality Rate
/ CAD Death
(10 year)

WNL

11%

Mild to
Moderate

0.9 - 0.6

40%

Moderate
to Severe

< 0.6

60%

None

Does Asymptomatic PAD Really Matter?

Vascular Screening
Recommendations
ADA Consensus Panel

recommends ABI Screening

for:
Patients over the age of 50

years who have diabetes

Patients with diabetes
younger than 50 years of
age who have other PAD risk
factors (i.e. smoking,
hypertension,
hyperlipidemia, diabetes
more than 10 years)

ABI should be repeated in 5

years if normal
If ABI is abnormal, then
patient should be referred

TASC II recommends ABI

Screening for:

All patients who have

exertional leg symptoms

All patients between the
age of 50-69 and who have
a cardiovascular risk factor
All patients age greater
than 70 years regardless of
risk factor status
All patients with a
Framingham risk score of
10%-20%

Peripheral Arterial Disease

Asymptomatic disease
- identified by noninvasive testing the ankle-brachial

index (ABI)
- Resting ABI less than 0.9 as the criterion for the
diagnosis of PVD this definition will miss mild to
moderate disease in patients with normal resting ABIs, but
who may have a considerable ischemic drop in the ABI
with exercise
- heavily calcified vessels, particularly in diabetic patients,
will have falsely elevated ABIs from inability to compress
the vessel

Peripheral Arterial Disease

Traditional risk factors:
- Smoking
- Diabetes mellitus
- Hyperlipidemia
-

(high levels of LDL-cholesterol,

tryglicerides, low levels of HDL-cholesterol)
Hypertension
Obesity
Gender (male)
Age

Peripheral Arterial Disease

Non-traditional risk factors:
- High-Sensitivity C-Reactive Protein
- Lipoprotein(a) [Lp(a)]
- Fibrinogen
- Natural history
- Coexisting vascular disease

Vascular diseases overlap

History
Medical history should include a review of the

different vascular beds and their specific symptoms:

Family history of CVD.
Symptoms suggesting angina.
Any walking impairment, e.g. fatigue, aching,
cramping, or pain with localization to the buttock,
thigh, calf, or foot, particularly when symptoms are
quickly relieved at rest.
Any pain at rest localized to the lower leg or foot
and its association with the upright or recumbent
positions

History
Any poorly healing wounds of the extremities.
Upper extremity exertional pain, particularly if

associated with dizziness or vertigo.

Any transient or permanent neurological
symptom.
History of hypertension or renal failure.
Post-prandial abdominal pain and diarhoea,
particularly if related to eating and associated
with weight loss.
Erectile dysfunction

Peripheral Arterial Disease

Differential Diagnosis
History
- limb pain or discomfort three etiologies:
Vascular
Musculoskeletal
Neuropathic
- limb swelling
venous obstruction or insufficiency
increased venous pressure (e.g., CHF)
decreased

oncotic
hypoalbuminemia)
Lymphedema
Lipedema

pressure

(e.g.,

hypoproteinemia,

Peripheral Arterial Disease

Diagnosis
The etiology of leg pain can be determined by:
- Characteristics
- Severity
- Location
- Duration
- Frequency
- precipitating or alleviating factors

One should remember that many patients, even

with
advanced
disease,
will
remain
asymptomatic or report atypical symptoms.

Peripheral Arterial Disease

Intermittent claudication (IC)

= ischemic limb pain in one or both legs that occurs with

exertion and is alleviated with rest
- Symptom of PVD, can be misleading in assessing the
prevalence of the disease
- World Health Organization (WHO)/Rose, Edinburgh
Claudication, and Walking Impairment questionnaires,
have been developed to identify patients with IC
- Asymptomatic patients are not at all detected by
questionnaire screening noninvasive or invasive
imaging

Peripheral Arterial Disease

Clinical Categories of Chronic Limb Ischemia
Fontaine
Stage
I
IIa

IIb

III

IV

Clinical
Asymptomati
c
Mild
claudication
>200 m
Moderatesevere
claudication
<200 m

Grade
0

Rutherford
Category
0

Moderate
claudication

Severe
claudication
Ischemic rest
pain
Minor tissue
loss
Major tissue
loss

Ischemic rest II
pain

III

Ulceration or III
gangrene

Clinical
Asymptomati
c
Mild
claudication

Physical examination
- asymmetry between the limbs, joint deformities, varicose

veins, skin discoloration, absence of hair, swelling,

ulcerations, tissue loss, and gangrene
palpation of the pedal pulses should be a mandatory part
of the routine physical examination
significant temperature gradient
the carotid arteries, abdomen, and femoral arteries should
be auscultated for bruits
Measurement of blood pressure in both arms
and notation of inter-arm difference.

A
B

Peripheral Arterial Disease

Non-invasive testing

Noninvasive Vascular Study

- the ABI
- when physically possible, the ABIs should also be ordered

with exercise to assess for an ischemic response

- segmental BPs
- pulse-volume recordings (PVR) obtained at rest

ABI (Ankle-Brachial Index)

Simple, reliable means for

diagnosing PAD.

The ABI = the highest systolic

blood pressure (SBP) of either the

DP artery or PT artery divided by
the higher of the SBP from either
the right or left brachial artery
Inexpensive equipment.
300- 400 EUR

Peripheral Arterial Disease

Non-invasive testing

Ankle-Brachial Index (ABI) and Severity of Disease

ABI
>1.30

Disease
Classification
Noncompressible

0.90-1.30

Normal

0.80-0.89

Mild

0.60-0.79

Moderate

0.40-0.59

Severe

<0.40

Critical ischemia

Normal ABI Exceptions

Normal resting ABI does not exclude PAD in

patients with symptoms of PAD

Exercise induced claudication

Patients with diabetes with arterial

claudication
Toe pressures

Non-invasive testing
Segmental BPs more specific information as to the

location of the stenosis/obstruction

- BP readings are obtained at the high-thigh, low-thigh, calf,
ankle, metatarsal, and toe level
Pulse-volume
recordings
=
plethysmographic
measurements that detect changes in the blood volume
flowing through the limb
- normal PVR tracing resembles a normal arterial pulse
wave tracing with a rapid upstroke, prominent dicrotic
notch, and rapid downstroke
- as the severity of the disease increases, the waveforms
become more blunted, the dicrotic notch disappears, and
ultimately the waveforms become flat

Non-invasive testing
Doppler ultrasound
- arterial

duplex Doppler sonography utilizes highfrequency sound waves (typically 5.0-7.5 MHz) to
provide real-time vascular images that can accurately
localize atherosclerotic disease
- particularly useful for assessing stent or graft patency after
a revascularization procedure
- difficulties in visualizing the tibial vessels, which are
relatively small and deep in the calf, and visualizing
highly calcified vessels, which are acoustically shadowed
by the calcium

Non-invasive testing
Computed Tomography
Magnetic Resonance Angiography
- they

have essentially replaced traditional invasive

diagnostic angiography
- accurate anatomic information
- provide highly detailed images that can be used to plan
revascularization procedures, assess the size and location
of aneurysms
- occasionally find incidental pathology such as occult
malignancy

Multistation contrastenhanced magnetic

resonance angiography
(A)Major stenoses are
observed at the origin of the
left external iliac artery and in
the proximal segment of the
right superficial femoral artery
(arrows).
(B) A patient with a
peripheral bypass. Bilateral
occlusion of the superficial
femoral arteries with a patent
femoro-distal bypass graft
extending in the right leg from
the common femoral artery to
the dorsalis pedis artery
(arrowheads).

Dellegrottaglie S et al. (2007) Technology Insight: magnetic resonance angiography for the evaluation of
patients with peripheral artery disease
Nat Clin Pract Cardiovasc Med 4: 677687 doi:10.1038/ncpcardio1035

Invasive imaging
It has been the gold standard for diagnosing PVD since

the 1950s
Potential complications vascular access site injury,
pseudoaneurysm or arteriovenous fistula formation,
bleeding, dissection, and atheroembolization
Routine diagnostic stand-alone invasive angiography is
not routinely recommended
Remaining indications for a conventional diagnostic
angiogram:
- an inconclusive or indeterminate CTA/MRA
- a planned endovascular intervention

Arteriografie

aratand ocluzia
arterei poplitee dr.

Arteriografie

Ocluzie
A.femurala
spf.

Ocluzie
A.femurala
spf

Ocluzie
A.poplitee

Arteriografie

A.Iliaca
ocluzie/stenoz
a

Acute limb ischemia

Diagnosis
5P - Pain, Pulseless, Pale, Parestesia, Paralysis
Acute limb ischemia

resting pain, constant

throughout the day and night

moderate to severe aching

paresthesia/dysesthesia while lying horizontal, alleviated
by dangling the leg over the side of the bed
Acute loss of motor and sensory function in the distal

extremities + acute severe pain, pallor, and coolness of the

limb sign of acute arterial occlusion

Peripheral Arterial Disease

Clinical Categories of Acute Limb Ischemia
Category

I. Viable

Description Findings
/ Prognosis Sensory Loss Motor
Weakness
Not
None
None
immediately
threatened

II.

Threatened
a.
Salvageable
Marginally if promptly
treated

Doppler Signals
Arterial
Venous
Audible

Audible

Minimal
(toes) or
none

None

Inaudible

Audible

b.
Salvageable More than
Immediately with
toes,
immediate associated
revasculariz with rest
ation
pain

Mild,
moderate

Inaudible

Audible

III.
Major tissue Profound,
Irreversible loss, or
anesthetic
permanent
nerve
damage
inevitable

Profound,
paralysis
(rigor)

Inaudible

Inaudible

Peripheral Arterial Disease

Critical limb ischemia (CLI)

= the presence of ischemic resting pain in the distal foot,

ischemic nonhealing ulcerations, or gangrene
- lower extremity amputations can be avoided through early
revascularization and aggressive risk factor management
- high rate of long-term morbidity and mortality
- the level of amputation also dictates the overall prognosis

CLI: Vascular
Compromise
Often due to diffuse, multi(Impact
+ Mortality)
level arterial involvement

Mortality rates for CLI

patients at:

Frequently involves infra-

popliteal arteries with sever

diffuse disease and/or total
occlusion
Diabetics often have

entirely infra-popliteal
disease

One year

25.0%

Two years

31.6%

Three years

60.0%

PAD Treatment Options

Medical
Risk Factor Modification
Exercise Therapy
Drug Therapy
Endovascular Therapy
Peripheral Transluminal Therapy
Peripheral Stenting
Angioplasty
Laser
Cryoplasty
Atherectomy
Thrombolic Therapy (adjunctive)
Surgery
Bypass Grafts
Amputation
Endarterectomy

Peripheral Arterial Disease

Therapy

Risk factor management

- Smoking cessation
- Exercise
- Low fat diet, hyperlipidemia control
- Weight loss management
- Pharmacological control of risk factors (anti-hypertensive

drugs, hypolipemiant drugs)

Peripheral Arterial Disease

Exercise
Daily walking.
walk to the point of discomfort, stop briefly, and then resume walking.
At least 30 minutes of relatively continuous walking each day.
A weekly group session can be extremely useful.
An exercise bicycle can be used as an alternative mode of exercise.
It is important to emphasize to the patient that pain does not indicate
harm or damage to the leg and that exercise can help rather than
aggravate the condition.
Any tendency to restrict activity, sometimes to the point of invalidism
or confinement to the home, should be avoided, unless severe
ischemia is present.

Peripheral Arterial Disease

Therapy

Pharmacological

management

of

intermitent

claudication
Aspirin + Statin
- Cilostazol (Pletal) - has a consensus of benefit for the
relief of claudication
- phosphodiesterase III inhibitor
- increases the intracellular concentration of
cAMP significant antiplatelet and vasodilatory
properties + possibly antiproliferative properties
- Pentoxifylline (Trental) - no randomized data
demonstrate that it is better than placebo, so there is no
recommendation to use this agent for the treatment of
claudication

Peripheral Arterial Disease

Therapy

Revascularization
- indication:
relief of ischemic symptoms, including intermittent

claudication and resting ischemic pain

limb preservation in the setting of critical limb ischemia.
- with advances in endovascular technology, a percutaneous

approach is now considered first-line therapy

- revascularization has been performed surgically;

Tratament interventional

Intraarterilis sztentbeltets

Management algorithm for patients with peripheral vascular

disease

Venous diseases

Deep vein thrombosis

A DVT is the

formation of a
blood clot in a deep
vein of the body.

can become large

and obstruct the

normal flow of
blood in the vein.

Considerations
Deep veins of the lower

extremities are the most

common sites for a DVT.

If the clot breaks into

smaller pieces, it
becomes an embolus
which can travel to vital
organs and cause lifethreatening conditions
such as a heart attack,
stroke, or pulmonary
embolism.

Virchows Triad=Risk

Risk assessment
Patients at highest risk for DVT are those
who;
Have undergone major surgery including that
of the hip or knee
Suffered trauma
Are older
Have a history of having a DVT

Prevention/Interventions
Mobility-foot pumps,

exercise
Compression stockings
Early ambulation following
surgery
Close management of CHF,
HTN and/or Diabetes
Smoking cessation
Weight management
Prevent dehydration
Pharmacologic
interventions

Elastic compression

stockings
Foot pumps when
immobilized in bed or chair
Monitor anticoagulant
therapy
Monitor Vit K intake
Increase fluids and avoid
alcohol

Signs and Symptoms of

DVTs
Unilateral edema
Pain in extremity
Erythema
Calf tenderness
Pale leg & cool with diminished

arterial pulse
+ Homans sign (discomfort in
the calf muscles on forced foot
dorsiflexion w/ knee straight;
NOTE: Homans sign is neither
sensitive nor specific; Present
in <1/3 of patients with
confirmed DVT; Found in
>50% of patients without DVT)
(Schreiber, 2009)

Signs/Symptoms of PE
Recognize and report (call 112) for

signs/symptoms of a pulmonary emboli

(PE) including:
Unexplained sudden onset of shortness of
breath
Chest pain or discomfort that worsens with
deep breath or cough
Lightheadedness or dizziness
Hemoptysis
Anxiety

Deep venous thrombosis (DVT)

Clinical features of venous thrombosis

- Consistency of swelling browny
- Complete relief with elevation of the limb
- Maximal swelling in ankles, legs, feet spared
- Associated skin changes (atrophic

pigmentation, subcutaneous fibrosis)

- Heavy, aching, tight, bursting pain
- Ussually inequal, unilateral

Deep venous thrombosis (DVT)

Risk factors
- Hypercoagulability
- Venous injury
- Venous stasis
- Hystory pelvic surgery, orthopedic surgery, long term

immobilisation, trauma, etc.

Thrombophilia screening
Factor V leiden, Prot C/S deficiency
Antithrombin III deficiency
Idiopathic DVT < 50 years
Family history of DVT
Thrombosis in an unusual site
Recurrent DVT

Recommendation for
duration of warfarin
3-6 months first DVT with reversible risk

factors
At least 6 months for first idiopathic DVT
12 months to lifelong for recurrent DVT or first
DVT with irreversible risk factors
malignancy or thrombophilic state

Deep venous thrombosis (DVT)

Primary approach

Immobilisation, admission in hospital

Treatment
Prevention
Therapy adressed to the cause(s) that produced the DVT
Antiplatelet therapy
Anticoagulant (6 months in uncomplicated DVT)
NSAIDs, antibiotics

Deep venous thrombosis (DVT)

Primary approach
Proximal (Above-the-Knee) Deep Vein Thrombosis
Initiate treatment for secondary prophylaxis

promptly, provided there is no strong contraindication

to anticoagulation.
Consider outpatient treatment if the patient is
comfortable, is clinically stable, and has a conducive
home environment, available support, and preserved
renal function.
Begin initial anticoagulation either a low molecular
weight heparin preparation (e.g., dalteparin, 100 units/
kg SC once daily) or a factor Xa inhibitor (e.g.,
fondaparinux, 7.0 mg SC once daily for weight <50 kg,
7.5 mg SC for weight of 50 to 100 kg, and 8.5 mg SC
for weight >100 kg).

Deep venous thrombosis (DVT)

Primary approach

At the same time, begin oral anticoagulation

with warfarin (10 mg/d for 3 days and then as

per PT INR determination) while continuing
parenteral anticoagulation for a minimum of 5
days and until the INR is 2.0 or above for at
least 24 hours.
Adjust the warfarin dose to maintain an INR
between 2.0 and 3.0. Have PT INR monitored
regularly, with frequency based on stability of
the patients anticoagulation and clinical
status.

Deep venous thrombosis (DVT)

Primary approach
Consider as an alternative to extended-duration

warfarin therapy a direct thrombin inhibitor (e.g.,

dabigatran) or a factor Xa antagonist (e.g,
rivaroxaban, apixaban, or edoxaban) for patients
at increased bleeding risk or inability to comply
with demands of warfarin therapy.
Give preference to anticoagulation over CDT or
vena cava filters (unless there is a contraindication
to anticoagulation).
Encourage early ambulation rather than
prolonged bed rest; prescribe compression
stockings to limit risk of postphlebitic syndrome,
and recommend use for 2 years post DVT.

Deep venous thrombosis (DVT)

Primary approach
Treat with oral anticoagulation for a total of 3

months when there is provoked DVT caused by a

transient risk factor.
Treat with oral anticoagulation for at least 3
months when there is a first unprovoked DVT,
and reassess after 3 months, weighing the risks
and benefits of more extended therapy. Extend
treatment for an indefinite period when there is
repeat unprovoked DVT, reassessing annually.
Consider indefinite low-dose aspirin (100 mg/d)
as an alternative to cessation of oral
anticoagulation in persons with unprovoked VTE.

Superficial Vein Thrombophlebitis of the Lower

Extremity

Diagnosis: clinical
Confirmation with

echo Doppler
(frequently
associated with
DVT)

Superficial Vein Thrombophlebitis of the Lower

Extremity
Manage symptoms with a combination of local heat and

compression hose supplemented by a nonsteroidal agent

(e.g., naproxen 250 to 500 mg bid).
Advise women taking oral contraceptives to consider
discontinuing use.
When involving a major superficial vein (e.g.,
saphenous) and at least 5 cm in length, consider
prophylactic treatment with parenteral anticoagulant
therapy for up to 45 days to prevent propagation to the
deep system, using either a factor Xa inhibitor or a low
molecular weight heparin.
Monitor closely for signs of propagation close to the
deep system; if the process has extended while under
observation, refer for consideration of full anticoagulation
and/or ligation of the saphenous vein.

Chronic venous insufficiency

Venous claudication
- affects entire limb, usually worse in thigh and groin
- tight, tense sensation
- onset after exercise
- unrelated to standing
- relieved slowly
- relieved more quickly with elevation
- history of DVT, edema, or venous congestion

CEAP Classification
Class

Signs

C0

No visible palpable sign of venous

disease

C1

Telangiectasias or reticular veins

C2

Varicose veins

C3

Edema

C4

Pigmentation, eczema,
lipodermatosclerosis

C5

Healed venous ulcer

C6

Active venous ulcer

Varicous veins

Spider veins

Reticular veins

Varicous veins

Corona phlebectatica

hyperpigmentation

Stasis

Varicous veins

Lipodermatosclerosis Ulceration

Doppler us.

Doppler us.

Management varicose
veins
The initial management of varicose veins (CEAP
C2) is nonoperative, addressing valve
incompetence and poor soft tissue support.
Untreated, most varicose veins will slowly
worsen. All patients will benefit from proper
graduated compression hose of medium weight,
for example, 20 to 30 mm Hg, together with
periodic elevation of the extremity at intervals
during the day. Compression hose must be
properly measured by trained personnel to be
effective

Interventions
Only in patients with primary varicosity with

no deep venous reflux.

For patients with reflux of the GSV , SSV , or a
major tributary, removing this source of reflux
is mandatory
Sclerotherapy
Surgical ligation stripping
Laser ablation

Wish