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 Chronic Lower Limb Ischaemia Acute Lower Limb Ischaemia Deep Vein Thrombosis Varicose Veins 2 2 3 5 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.

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) Beurgers 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 Ps
Pain on squeezing the calf indicates muscle infarction and impending irreversible ischaemia. Paraesthesia and paralysis indicate that there is nerve ischaemia, and unless there is rapid revascularisation the damage may be reversible. There may also be mottling/marbling of the skin and a compartment syndrome may develop (with calf pain upon compression).

Pain Pallor Paraesthesia Paralysis Perishing cold Pulselessness

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)

Investigations for Lower Limb Ischaemia (acute and chronic)

Blood Tests 1. 2. 3. 4. 5. FBC (Anaemia and infection) U&Es (renal disease) Lipids (dyslipidaemia) Blood glucose (to exclude diabetes) 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 patients quality of life IV drugs e.g. vasodilators Percutaneous balloon angioplasty Surgery Amputation Palliation

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 Virchows 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

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 Bakers 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

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

Clinical Parameters
Active cancer or within last 6 months Paralysis or recent plaster immobilisation Bedridden or major surgery for >3 days in the last 4 weeks Localised tenderness along the distribution of deep veins Entire leg swollen Calf swollen >3cm compared to the other leg Pitting oedema Collateral superficial veins (non-varicose) Alternative diagnosis more likely than DVT Calculate Wells Score: High probability = 3 or more Moderate probability = 1 - 2 Low probability = 0 or less

Score
1 1 1 1 1 1 1 1 -2

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 Normal Elevated

No D-Dimer required

Exclude DVT

Scan and Treat

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)

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

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

10