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?

  • NumberPVD 1
  • 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)

 

 


Download the PDF version: here


References:

  • Dr Kaialy’s lecture

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