Peripheral Vascular Disease

• In claudication (chronic limb ischemia) Hx, it will be the same distance every time, not progressive, b\c fixed lesion

Classification of chronic limb ischemia depends on distance:

• Mild > 200 m
• Moderate 100-200 m
• Severe < 100 m
• If claudication + gangrene or ischemic ulcer -> chronic critical limb ischemia -> urgent revascularization

Six P’s of acute limb ischemia:

1. Pain
2. Pallor
3. Perishingly cold
4. Pulseless
5. Paresthesia
6. Paralysis

• Most are not severe enough to cause all 6 sx, the essential ones are the first 4 (pain, pallor, coldness, pulseless)
• No collateral circulation -> paresthesia and paralysis (the most severe signs)
• To assess severe ischemia -> ask pt to move toes, why? Short muscles are the first group to be affected by ischemia
• In acute severe type, you have less than 6 hrs to save the limb -> after 6 hrs:
  • If there’s paresthesia and paralysis -> means SEVERE: complete cut of blood supply -> so you need revascularization w\in 6 hrs!
  • If still no paralysis of paresthesia -> means MODERATE acute ischemia: there’s development of collaterals, limb can survive for 1 wk -> you have time, start with heparin then go for embolectomy

Acute limb ischemia

• Irreversible: severe + more than 6 hrs -> the pain disappears, still cold and absent pulse -> bad sign = dead limb (pain means viable limb) -> don’t revascularize -> demarcate and amputate
• Reversible:
  • Threatened: severe + less than 6 hrs -> revascularize ASAP!
  • Non-threatened: moderate + at any time “no golden hours” -> heparin + postpone intervention

How to describe an ulcer?

• Number
• Shape
• Dimensions
• Location
• Border
• Edge
• Floor
• Base
• Discharge

	ARTERIAL	VENOUS	NEUROPATHIC
Location	Distal (web space, dorsum of the foot)	Medial malleolus (+lipodermatosclerosis)	Planter
Pain	+	+\-	–
Pulse	No pulses	Intact	Intact
Margins	Sharp	Irregular\sloping	Punched out

 

Why differentiate types of gangrenes (chronic critical limb ischemia)? Both need revascularization:

• Wet gangrene: bacterial overgrowth + infection -> pt can go to septic shock -> so do minimal drainage of infection (to prevent sepsis) -> revascularization -> then do full debridement
• Dry gangrene: don’t intervene until revascularization first -> then amputate, why? You need good vessels for the stump to heal

 

Pedal pulses:

• Dorsalis pedis -> lateral to extensor hallucis longus
• Posterior tibial -> behind medial malleolus

Special tests in limb ischemia:

• Capillary refill: normal is < 2 secs
• Buerger’s test: lift leg passively -> until it turns pale or the pain disappears -> measure the angle:
• Normally lifting it to 90° -> no change (the smaller -> the worse)

Ankle-brachial index: 

• Normal is > 0.9
• If absent pulse + ABI is 1.6 -> false result; can happen in some of diabetic pt b\c of heavy calcification -> measure the toe pressure (no calcification)

Wave form: 

• Normal is triphasic (abnormal is biphasic or monophasic)

 

Venous drainage of lower limb:

• Superficial: Saphenous veins
• Deep: parallel to the artery
• Flow is from superficial to deep, controlled by valves and muscle contractions
• Superficial to deep: perforators
• Superficial to superficial: communicators

Varicose veins: 

• ortious dilated veins along the course of great saphenous V
• Examined first by standing -> then ask the pt to lay down
• If disappears -> primary varicose veins -> means venous valve failure
• If doesn’t disappears -> secondary varicose veins -> means obstruction by DVT (post-thrombotic limb) (takes time to disappears b\c drains through tributaries)

 

 

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Download the PDF version: here

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References:

• Dr Kaialy’s lecture