Peripheral Vascular

Disease
Booklet to accompany PALS tutorial
James Giles, Mary-Jo McLaughlin, Daniel Newbery & Madhurima Rai
Peer-Assisted Learning Scheme (PALS) Vascular Group 2008-2009

Thanks to Mr Robert Salaman & the PALS Vascular Group 2007-2008

for their help in producing this booklet

Contents

Peripheral Arterial Disease 2

Chronic Lower Limb Ischaemia 2
Acute Lower Limb Ischaemia 3

Deep Vein Thrombosis 5

Varicose Veins 9
 1. Peripheral Arterial Disease
Peripheral Arterial Disease (PAD) encompasses disorders that obstruct arterial blood flow.
Peripheral Arterial Disease affecting the legs is of overwhelming importance and is the focus of
this booklet.

PAD is a major indicator for premature cerebral and cardiovascular events.

Epidemiology
• Prevalence is 6.9% among 25-74 year olds (22% of these are symptomatic)
• The male to female ratio (of patients requiring surgical intervention) is 5:1
• The most common cause of arterial obstruction (and therefore PAD) is atherosclerosis.

Risk Factors (essentially the same as those for atherosclerosis)

• Increasing age
• Male sex

• Smoking
• Hypertension
• Diabetes Mellitus
• Hyperlipidaemia
• Hyperhomocysteinaemia

Chronic Lower Limb Ischaemia

Stage 1 - Asymptomatic Disease

Stage 2 – Intermittent Claudication

• Severe cramping pain in the calf (it may also occur in the thigh and/or buttock)
• The pain is exacerbated by walking/exercise and relieved only by rest
• The usually occurs after walking a specific distance (claudication distance)
• The pain goes away quickly with rest and starts again upon walking the same
distance
• Intermittent claudication indicates ischaemia of muscle on exercise

Stage 3 - Rest/Night Pain

• Fist noticed as severe pain (usually felt in the foot that stops the patient from
sleeping)
• Aggravated by elevating leg and partially relieved by hanging leg over the side
of the bed.
• Rest pain indicates ischaemia of the skin and underlying tissue

Stage 4 - Arterial ulceration of the leg and foot

• Minor injuries fail to heal and progress to ulceration
• Ulcers tend to occur on distal extremities (toes) and pressure areas (heel/ball of
foot)

Stage 5 - Gangrene of the leg and foot

• Left untreated, rest pain and ulceration may lead to gangrene
• The necrotic tissue may become infected, resulting in wet gangrene. This may
lead to septicaemia and death.

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Other Signs
• Lower limbs are cold and pale
• Skin may be dry with a lack of hair on toes and dorsum
• Pulses may be diminished or absent
• There may be peripheral cyanosis in the toes (associated with ulceration and gangrene)

Differential Diagnosis
 Spinal canal claudication
 Osteoarthritis of the hip/knee (knee pain often at rest)
 Peripheral neuropathy (may be associated with tingling and numbness)
 Entrapment of the popliteal artery (pulses usually normal and patients tend to be
younger)
 Venous claudication (‘bursting’ pain on walking +/-history of previous DVT)
 Beurger’s disease (young males who are heavy smokers)
 Compartment syndrome (swelling of muscles within a fascial compartment resulting in
tissue ischaemia, often following trauma)

Acute Lower Limb Ischaemia

Signs & Symptoms – The 6 P’s
Pain on squeezing the calf indicates muscle infarction and  Pain
impending irreversible ischaemia.  Pallor
Paraesthesia and paralysis indicate that there is nerve  Paraesthesia
ischaemia, and unless there is rapid revascularisation the  Paralysis
damage may be reversible.
 Perishing cold
There may also be mottling/marbling of the skin and a  Pulselessness
compartment syndrome may develop (with calf pain upon
compression).

Causes
1. Embolic Disease
• Common due to cardiac thrombus and cardiac arrhythmias
• Rheumatic fever is an uncommon cause
• Embolisation may also secondary to thrombus on atherosclerotic plaques or aneurysms

2. Thrombotic Disease
• Acute thrombus may form on a chronic atherosclerotic stenosis
• Thrombus may also form in normal vessels if a hypercoagulable state exists
• Prosthetic or venous grafts may be targets for thrombosis
• Popliteal aneurysms may thrombose ( and also embolise distally)

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Investigations for Lower Limb Ischaemia (acute and chronic)
Blood Tests 1. FBC (Anaemia and infection)
2. U&Es (renal disease)
3. Lipids (dyslipidaemia)
4. Blood glucose (to exclude diabetes)
5. ESR/CRP (to exclude arteritis)

Echocardiogram – detection of a source of embolus

Ankle:Brachial Pressure Index (ABPI)

This measures disease severity. It is done by measuring the highest cuff pressure at which
blood flow is detectable by Doppler in the most distal palpable pulse (in the leg/foot)
compared to that of the brachial artery.

A normal value for a healthy individual is 1.

ABPI of 0.4-0.9 is associated with intermittent claudication.
A value of <0.4 indicates critical limb ischaemia.

Arteries that are heavily calcified and therefore incompressible will produce falsely elevated
results.

Angiograms
Angiograms can be preformed via percutaneous arterial catheterisation. However, these are
rarely used diagnostically. Doppler ultrasound and duplex imaging are less invasive and can
give accurate anatomical assessment of the degree of disease.

Management
a. Mild Disease
Aim – To prevent progression of the disease
• Manage risk factors
• Lifestyle adaptations (exercise, smoking, diet)
• Avoid injury
• Medication: Anti-platelet (aspirin)
Statin (if required)
Hypertensive drugs
Peripheral Vasodilators (Naftidrofuryl, Cilostazol)
b. Moderate Disease
Aim - conservation
• Percutaneous balloon angioplasty
• Fibrinolytics (TPA; used only for acute or acute-on-chronic ischaemia)
• Surgery

c. Severe Disease
Aim – minimise impact on patient’s quality of life
• IV drugs e.g. vasodilators
• Percutaneous balloon angioplasty
• Surgery
• Amputation
• Palliation

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 2. Deep Vein Thrombosis (DVT)
Definition
Deep vein thrombosis is a condition in which a blood clot forms in a vein which is deep inside
the body. The clot may interfere with blood flow or break off and cause an embolus, which
may travel through the vascular system. Venous emboli always go to the lungs unless there is a
patent foramen ovale or ventriculo-septal defect (VSD), causing a paradoxical embolus from the
venous to arterial system.

Epidemiology
• There is a 1 in 20 lifetime of developing a DVT
• Male : Female = 1.2 : 1
• Most common in people over 40 years, but can occur in any age group.

Aetiology
Think of Virchow’s Triad to remember the causes of thromboses:

Stasis of Blood

Hypercoagulability Vessel Wall Trauma/Change

1. Stasis of Blood:
• Increasing age
• Immobilisation longer than three days i.e. hospital admission
• Major surgery in the past four weeks
• Long plane or car journey in the previous four weeks

2. Hypercoaguability:
• Medical conditions e.g cancer, myocardial infarction (MI)
• Haematological disorders e.g. protein C or S deficiency, Factor V Leidin,
polycythaemia rubra vera, inherited coagulation disorders, systemic lupus
erythematosus (SLE)
• Pregnancy and the post-partum period
• Oestrogens and the combined oral contraceptive pill (COCP)

3. Vessel Wall Trauma/Change:

• Previous DVT
• Trauma to leg/vessel e.g. fractures
• Vasculitis

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Pathology
DVT of the leg usually occur in the deep veins of the calf around the valve, and a minority of
cases are in the ileo-femoral area due to direct trauma (e.g. surgery or a catheter).
• 80% dissolve completely without therapy.
• 20% propagate proximally. Propagation usually occurs before embolisation, whilst the
thrombus is still forming and so is not fixed.

Signs & Symptoms (only in the affected leg)

• Pain
• Tenderness
• Swelling/oedema
• Discolouration
o Normally red/purple indicating engorgement and obstruction
o Phlegmasia cerula dolens : Painful blue inflammation indicating ischaemic
cyanosis
o Phlegmasia alba dolens : Painful white inflammation indicating ileofemoral
obstruction and arterial spasm
• Increased local temperature
• Mild fever
• Asymptomatic - 65% of lower leg DVTs are asymptomatic and rarely embolise
• Shortness of breath - Suggestive of pulmonary embolism (PE)

Differential Diagnosis
• Cellulitis
• Ruptured Baker’s Cyst - also known as a popliteal cyst, a benign swelling found behind
the knee joint.
• Compartment syndrome

Investigations
General Investigations:
• FBC
• U&Es
• Lipids
• Clotting
• Coagulation screen

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Clinical Scoring System – Wells Score
The Wells Score is a clinical probability scoring system carried out before specific tests:

Clinical Parameters Score

Active cancer or within last 6 months 1
Paralysis or recent plaster immobilisation 1
Bedridden or major surgery for >3 days in the last 4 weeks 1
Localised tenderness along the distribution of deep veins 1
Entire leg swollen 1
Calf swollen >3cm compared to the other leg 1
Pitting oedema 1
Collateral superficial veins (non-varicose) 1
Alternative diagnosis more likely than DVT -2

Calculate Wells Score: High probability = 3 or more

Moderate probability = 1 - 2
Low probability = 0 or less

D-Dimer Blood Test

This blood test measures the concentration of D-Dimer, a fibrin degradation product. It is a
small protein fragment, which is present in the blood after a blood clot is degraded by
fibrinolysis. It is helpful to RULE OUT but NOT CONFIRM DVT. It is raised in many other
things.

• Negative D-Dimer with low to moderate Wells score rules out DVT.
• Increased D-Dimer levels plus moderate or high Wells score means further tests are
needed.

Clinical suspicion of DVT?

Perform Wells Score

<3 ≥3

Perform D-Dimer No D-Dimer

required
Normal Elevated

Exclude Scan and Treat

DVT

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Compression Duplex Ultrasound
Compressing the leg usually leads to venous flow. If there is an occluding thrombus, no venous
flow will occur, and Doppler signals will be absent.

Plethysmography
Plethysmography is used to measure changes in blood flow or volume in different parts of the
body. Limb plethysmography is a technique where blood pressure cuffs are wrapped around the
arms and legs and any difference in blood pressure us noted. There should be a less than 20
mmHg difference in the pressure between the arms and the legs.

Management
Aims
• Prevent pulmonary emobolism and gangrene
• Reduce morbidity
• Prevent and minimise the rest of developing the postphlebitic syndrome

Treatment
• Anticoagulation - LMWH for 5 days, and Warfarin, aim for INR 2.5
• Thromboembolism deterrent stockings (TED stockings)
• Thrombolyic therapy for DVT (rarely used)
• Surgery for DVT (rarely used)

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 3. Varicose Veins

Definition
Varicose veins are excessively dilated, tortuous superficial leg veins, with resultant pooling of
blood. These develop due to increased pressure secondary to valvular insufficiency.

Aetiology
1. Valvular insufficiency in perforating veins:
Perforating veins link the high pressure deep venous system with the low
pressure superficial veins. If valves in these veins are incompetent, high
pressures are transmitted to the superficial veins.

2. Defective valve in sapheno-femoral junction:

Reflux through this valve directly increases pressure within the superficial venous
system of the leg.

3. A defect in the muscle pump system

Thrombophlebitis leading to vessel wall/valve damage and reflux:

• Stasis
• Previous DVT

Direct mechanical damage to the vein and valves:

• Trauma
• Hereditary
• Pregnancy
• Obesity

Women are 2-8 times more likely to suffer from varicose veins. This female disposition is
thought to be a result of cyclical hormonal changes (oestrogen & prostaglandins). These
changes lead to muscular and connective tissue dilatation, affecting the lower limb venous
system. In pregnancy, direct compression of the IVC by the fetus can lead to increased pressure
and reflux.

Signs and Symptoms

• Visibly enlarged veins
• Aching, worse on standing
• Mild swelling of the ankles

Complications
• Phlebitis, caused by chronic inflammation of the vein
• Leg ulcers cause by venous insufficiency
• Rupture of the varicosity

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Investigations
Not all patients will undergo investigation. In some centres diagnosis is made and surgery
performed on clinical grounds.
Duplex ultrasound allows accurate mapping of veins and venous blood flow in the leg prior to
surgery.

Management
This depends on the severity of symptoms and patient choice.

Conservative
The patient puts up with the discomfort, alleviating the symptoms by resting. Compression
stockings provide some relief.

Medical
Injection of a sclerosing substance into the varicosities causing endothelial damage, sclerosis
and degradation of the vein. This is only effective in mild cases. Sclerotherapy is done while
the patient is standing – an elastic band is wrapped around the legs after the procedure.

Surgical
 Vein-Stripping
The surgeon makes a cut at the bottom (ankle end) and the top (groin end) of the varicose vein.
A thin, plastic tube-like instrument is placed into the vein and tied around it. When the tube is
pulled out, it pulls the vein from out under the skin. Small surgical cuts can also be made over
individual veins to remove them.

 Endovenous Ablation therapy

This therapy uses heat to destroy vein tissue. A thin catheter (or tube) is inserted into the vein
through a tiny skin incision under local anaesthetic. Then, using laser or radiowave
(radiofrequency) energy, the vein is heated and cauterized closing off the vein. This procedure
is less invasive than vein stripping with equal or better outcomes. Patients have significantly
less pain and a quicker recovery.

References:
Front cover picture: http://jama.ama-assn.org/content/vol291/issue7/images/medium/jmn40022f1.jpg

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