Peripheral Vascular Disease

Atherosclerosis

  • Affects medium and large arteries
  • Caused by chronic inflammation and activation of the immune system in the artery wall
  • This cause deposition of lipids in the wall, followed by fibrotic plaques
  • These plaques can cause:
    • Stenosis leading to reduced blood flow (e.g. in claudication)
    • Rupture giving off a thrombus that blocks a distal vessel leading to ischaemia (e.g. in acute coronary syndrome)

 

Atherosclerosis Risk Factors

  • Older age
  • Family history
  • Male
  • Smoking and alcohol consumption
  • Poor diet (i.e. high trans-fat and reduced fruit and vegetables and omega 3 consumption)
  • Low exercise
  • Obesity
  • Diabetes

 

End Results of Atherosclerosis

  • Angina
  • Acute Coronary Syndrome
  • Transient Ischaemic Attacks
  • Strokes
  • Peripheral Arterial Disease
  • Chronic Mesenteric Ischaemia

 

Definitions

Peripheral Arterial Disease results from atherosclerosis and narrowing of the arteries supplying the limbs and periphery

Critical Limb Ischaemia is the end-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest.

Intermittent Claudication is the symptom of having ischaemia in a limb during exertion that is relieved by rest. It is typically a crampy, achy pain in the calf muscles associated with muscle fatigue when walking beyond a certain intensity.

 

Leriche’s Syndrome

  • Associated with occlusion in the distal aorta or proximal common iliac artery
  • A clinical triad:
    • Thigh / buttock claudication
    • Absent femoral pulses
    • Male impotence

 

Examination

  • Weak peripheral pulses
    • Radial
    • Brachial
    • Carotid
    • Aorta
    • Femoral
    • Popliteal
    • Dorsalis Pedis
    • Femoral
  • Pallor
  • Cold
  • Skin changes (ulceration, hair loss)
  • Buerger’s Test
  • You can use a handheld doppler to more accurately assess pulses

 

Investigation

  • Ankle-Brachial Pressure Index (ABPI)
  • Arterial Doppler
  • Angiography (CT or MRI)

 

Ankle-Brachial Pressure Index

  • The ratio of systolic blood pressure in the ankle (around the lower calf) vs the arm
  • E.g. an ankle SBP of 80 and an arm SBP of 100 gives a ratio of 0.8
  • Results
    • >0.9 is normal
    • 0.6 – 0.9 is mild disease
    • 0.3 – 0.6 is moderate to severe disease
    • <0.3 is severe disease to critical ischaemic

 

Critical Limb Ischaemia (6 P’s mnemonic)

  • Pain
  • Pallor
  • Pulseless
  • Paralysis
  • Paraesthesia
  • Perishing cold

 

Management of Intermittent Claudication

  • General lifestyle changes to reverse modifiable risk factors (diet, smoking, exercise etc)
  • Optimise medical treatment of comorbidities (hypertension, diabetes etc)
  • Medical treatments
    • Atorvastatin 80mg
    • Clopidogrel 75mg once daily (alternatively aspirin plus dipyridamole)
    • Naftidrofuryl oxalate (peripheral vasodilator)
  • Surgical treatments
    • Angioplasty and stenting
    • Bypass Surgery

 

Managing Critical Limb Ischaemia

  • Urgent referral to vascular team
  • Analgesia
  • Urgent revascularization by
    • Angioplasty and stenting
    • Bypass surgery
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