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Peripheral Vascular Disease The University of Manchester | W.L. Gan | 2012

Signs of peripheral vascular disease - pulselessness, paralysis, paraesthesia, pain, pallor

Arterial ulcer Venous ulcer

History of intermittent claudication History of deep vein thrombosis, varicose

Located distally, usually dorsum of the foot Usually on the "gaiter" region of the legs

Punched out ulcer edge Sloping ulcer edge

Low exudate content High exudate content

Edema is uncommon Edema is common

Pain especially at night when supine Mild pain relieved by elevation

Peripheral arterial disease Chronic venous insufficiency

Cold skin Warm skin

Pale skin Red skin

Hair loss occurs Hairs present

Pulse absent Pulse present

Intermittent claudication Throbbing, heaviness, restless legs

Causes : Causes :

Atherosclerosis Valve incompetency

Smoking, diabetes, hypertension, DVT - deep venous insufficiency

hyperlipidemia

Investigations / tests : Investigations / tests :

Ankle-brachial pressure index Duplex ultrasonography

Angiography Direct contrast venography

Trendelenburg test - locate the level of

valve incompetency

Treatment and management : Treatment and management :Smoking cessation Compression stockings

Control of lipid profile, diabetes, hypertension Endovenous laser ablation, injection

Cilostazol, Pentoxifylline ( claudication ) sclerotherapy, vein stripping

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Peripheral arterial disease Deep vein thrombosis Varicose veins

General Inspection Inspection Inspection

Cyanosis / pallor Corneal arcus Erythema, swelling, Ask the patient to stand up

Tar staining Conjunctival pallor ulcer, scar, amputation and look at the leg veins -

Capillary refill Central cyanosis long, short saphenous veins

Radial pulse Carotid pulse Palpation - temperature, * asymmetry, swelling, scar,

Blood pressure Radio-radial delay tenderness, pitting edema, pigmentation, stasis eczema

Xanthelasma Radio-femoral delay pulses, capillary refill lipodermatosclerosis

Inspection - abdomen Measure mid-calf Palpation - gently press on the

Obvious pulsation, mass, scar circumference using varicosities and release,

Palpation - abdomen measuring tape watch them refill

Pulsatile, expansile mass and compare both legs Feel for temperature

Inspection - legs >3cm - significant Hard - thrombosis

Scar Ulcers Painful - phlebitis

Discolouration Gangrene Wells score ( 1 pt for each )

Amputation Fungal infection Active cancer Location of sphenofemoral

Hair distribution Motor function Paralysis, immobilisation junction - 5cm medial and

Palpation - legs Major surgery inferior to femoral pulse

Temperature Pulses Local tenderness * mid-inguinal line btw

Capillary refill Dorsalis pedis Entire swollen leg ASIS and pubic symphysis

Pulses Posterior tibial Calf swelling >3cm Feel for cough impulse at SFJ

Sensation Popliteal Pitting edema Percussion test

Auscultation Collateral superficial vein Tap distally on VV, and feel

Femoral, aortic, renal, carotids Alt Dx more likely -2 pts for impulse at SFJ

Special test High 3 pts

Buerger test Moderate 1-2 pts Trendelenburg testAnkle brachial pressure index Low0 Raise the patient's legs

> 1.2 Vessel sclerosis Place two fingers on SFJ

0.9 - 1.2 Normal If VV do not refill, SFJ

0.8 - 0.9 Mild incompetency

0.5 - 0.8 Moderate If VV do refill, incompetency

< 0.5 Severe arterial disease at lower level

The Fontaine Classification Tourniquet test

Stage I asymptomatic Perthes test- deep vein obs.

Stage II intermittent claudication DD : cellulitis, ruptured Apply tourniquet at mid-thigh

Stage III rest pain / nocturnal pain Baker's cyst, stand repeatedly on tip-toeStage IV necrosis / gangrene compartment syndrome pain and more prominent VV

Investigations - FBC, lipids, blood glucose Investigations - D-dimer to Investigations - doppler

U&E ( renal disease ), duplex imaging exclude DVT, FBC, clotting, USS probe

compression duplex USS

Rx - stop smoking, treat diabetes, Rx - LMWH, warfarin INR 2-3, Rx - compression stocking,

hypertension, antiplatelet ( aspirin ), compression stocking, injection sclerotherapy,

percutaneous transluminal angioplasty IVC filters endovenous laser ablation