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Determining a vascular cause for leg pain and referrals

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Determining a vascular cause for leg pain and referrals

Published in: Health & Medicine

Determining a vascular cause for leg pain and referrals

  1. 1. Peripheral Overview
  2. 2. Peripheral Overview Learning Objectives 1. Understand epidemiology and presentation of common vascular causes of lower limb pain 2. Review basic anatomy and diagnostics 3. Discuss referrals and treatment
  3. 3. Peripheral Overview
  4. 4. Peripheral Overview Differential for leg pain 1. Vascular •Peripheral Vascular Disease – acute/chronic •Chronic venous disease •DVT 2. Neurospinal •Spinal stenosis •Disc disease 3. Neuropathic •Diabetic •Chronic EtOH 4. Musculoskeletal •OA of hip or knee •Chronic compartment syndrome
  5. 5. Peripheral Overview Differential for leg pain 1. Vascular •Peripheral Vascular Disease – acute/chronic •Varicose veins •Chronic venous insufficiency •DVT 2. Neurospinal •Spinal stenosis •Disc disease 3. Neuropathic •Diabetic •Chronic EtOH 4. Musculoskeletal •OA of hip or knee •Chronic compartment syndrome 1. Vascular •Peripheral Vascular Disease – acute/chronic •Chronic venous disease •DVT
  6. 6. Peripheral Overview
  7. 7. Peripheral Overview Risk factors ARTERIAL DISEASE •Advancing age •Hypertension •Hyperlipidaemia •Family history •Diabetes •Smoking VENOUS DISEASE •Advancing age •Increased BMI •Pregnancy •Family history •Standing occupation •Smoking •Trauma •Previous DVT
  8. 8. Peripheral Overview Risk factors ARTERIAL DISEASE •Advancing age •Hypertension •Hyperlipidaemia •Family history •Diabetes •Smoking VENOUS DISEASE •Advancing age •Increased BMI •Pregnancy •Family history •Standing occupation •Smoking •Trauma •Previous DVT
  9. 9. Peripheral Overview Clinical presentation of PAD ~15% Classic (Typical) Claudication ~33% Atypical Leg Pain (functionally limited) 50% Asymptomatic 1%-2% Critical Limb Ischemia
  10. 10. Peripheral Overview Claudication vs Pseudoclaudication Claudication Pseudoclaudication Characteristic of discomfort Cramping, tightness, aching, fatigue Same as claudication plus tingling, burning, numbness Location of discomfort Buttock, hip, thigh, calf, foot Same as claudication Exercise-induced Yes Variable Distance Consistent Variable Occurs with standing No Yes Action for relief Stand Sit, change position Time to relief <5 minutes ≤30 minutes
  11. 11. Peripheral Overview 30% Buttock & Thigh Claudication ±Impotence – Leriche’s Syndrome Thigh Claudication 60% Upper 2/3 Calf Claudication Lower 1/3 Calf Claudication
  12. 12. Peripheral Overview Symptoms in PAD • Chronic – Claudication – Restpain – ulcers / tissue loss • Acute – 6 P’ s – Pain – Pallor – Poikilothermia – Pulselessness – Paraesthesia – Paralysis
  13. 13. Peripheral Overview Pathology of PAD Chronic Causes • Atherosclerosis • Vasculitis • Takayasu’s disease • Buerger’s disease • Trauma • Raynaud’s disease • Fibromuscular dysplasia Acute Causes • Embolism • Thrombosis • Dissection • Trauma • Vasculitis
  14. 14. Peripheral Overview Clinical presentation of venous disease Varicose veins Oedema Skin changes Ulcers
  15. 15. Peripheral Overview Symptoms of chronic venous disease • Limb discomfort – tired, heavy legs, aching • Oedema • Discolouration • Erythema • Muscle cramps • Itching • Tingling/numbness • Spontaneous bleeding
  16. 16. Peripheral Overview CEAP Classifications Clinical Classification of Venous Insufficiency •Class 0 No visible or palpable signs of venous disease •Class 1 Telangiectasias or reticular veins •Class 2 Varicose veins •Class 3 Oedema •Class 4 Skin changes – a Including pigmentation or venous eczema – b With lipodermatosclerosis •Class 5 Healed ulceration •Class 6 Active ulceration
  17. 17. Peripheral Overview Telangiectasia/reticular veins
  18. 18. Peripheral Overview Varicose veins
  19. 19. Peripheral Overview Oedema
  20. 20. Peripheral Overview Skin changes
  21. 21. Peripheral Overview Skin changes
  22. 22. Peripheral Overview Diagnostic Test - ABI Ankle Brachial Index (ABI): Blood pressures measured in both ankle & arm – Blood pressure is compared – Pressures should be equal ABI Classification Severity of PVD >1.3 Non-compressible / CA++ ≥0.9 Normal 0.70-0.89 Mild 0.50-0.69 Moderate <0.5 Severe ÷ Ankle pressure Arm pressure
  23. 23. Peripheral Overview Diagnostic Test- Ultrasound Ultrasound/Duplex Ultrasound: • Detects blood flowing through the vessel • Can detect if flow is severely blocked • Speed and direction of blood flow • Assess valve competence • Readily available in many offices
  24. 24. Peripheral Overview Treatment Options - PAD • Lifestyle change – Exercise regularly – Smoking cessation – Diet -Low-fat to reduce cholesterol • Medications – Blood pressure control – Antiplatelet therapy – Cholesterol-lowering agents – Vasodilators to dilate arteries • Endovascular therapy – Angioplasty – Stenting • Surgery – Surgical bypass – Endarterectomy – Amputation
  25. 25. Peripheral Overview Treatment Options – Chronic venous disease• Lifestyle change – Exercise regularly – Smoking cessation – Leg elevation • Skin care – Emollients e.e fatty cream, vaseline – Barrier preparations e.g. vaseline, zinc oxide – Topical coritcosteroids – COMPRESSION THERAPY • Endovenous therapy – Endovenous ablation – RFA, EVLT – Ultrasound guided sclerotherapy • Surgery – Debridement +/- skin grafting for ulcers – Historically vein stripping and avulsions
  26. 26. Peripheral Overview COMPRESSION STOCKINGS CLASS PRESSURE LEVEL OF SUPPORT INDICATION CEAP OTC <15 mmHg Minimal Asymptomatic, comfort only. 0, 1 I 15-20 mmHg Mild Minor varicosities, tired aching legs, minor swelling. 1, 2, 3 II 20-30 mmHg Moderate Moderate to severe varicosities, swelling, phlebitis, following ablation or DVT 3, 4, 5 III 30-40 mmHg Firm Lymphoedema N/A
  27. 27. Peripheral Overview Referral guidelines – Intermittent claudication Red flags Urgent vascular assessment is required if: •Critical limb ischaemia ie. rest pain and/or tissue loss with absent pulses •Acute limb ischaemia Assessment •A typical history will usually make the diagnosis – cramp like pain brought on by walking exercise at fixed distance and relieved by rest •Risk factors – high risk of coronary and cerebrovascular events, 20% have diabetes, smoking •Assess impact on quality of life •Peripheral pulses
  28. 28. Peripheral Overview Referral guidelines – Intermittent claudication Investigations •Blood tests – CFC, fasting lipids, glucose, renal function •ABI if available •Duplex scan Suggested GP management •Management of risk factors – smoking cessation advice – statins, even in patients with normal lipids – anti-platelet medication to reduce cardiovascular risk – aggressive control of blood sugars in diabetes – hypertension treatment – Beta blockers do not worsen PVD •Targeted walking exercise – green prescription
  29. 29. Peripheral Overview Referral guidelines – Intermittent claudication When to refer •If any red flags – acute referral •Refer to outpatient if: – after 6 months of targeted exercise and risk factor reduction, the pain is worse or there is no improvement – the patient’s quality of life is severely affected by symptoms – a young, otherwise healthy adult presents with symptoms of claudication
  30. 30. Peripheral Overview Referral guidelines – varicose veins and chronic venous insufficiency Practice Point •Evidence indicates that 80% of patients gain relief from vein ablation therapy. Offer options to everyone with symptomatic varicose veins even if public funding may not available, as patients may believe they need to tolerate their symptoms. Assessment •Risk factors. •History of varicose vein complications – skin changes, thrombophlebitis, ulceration, bleeding. •Severity of symptoms and if controllable with compression – level of disability. •Determine patient’s wish for cosmetic treatment.
  31. 31. Peripheral Overview Referral guidelines – varicose veins and chronic venous insufficiency Investigations •ABI if arterial disease suspected by absent pulses and compression stockings being prescribed – ABI>0.8 •Duplex ultrasound Suggested GP management •Lifestyle modification – weight management – smoking cessation – exercise to improve calf muscle pump – leg elevation •Manage varicose eczema – soap substitutes, regular emollients, topical steroids. •Compression hosiery
  32. 32. Peripheral Overview Referral guidelines – varicose veins and chronic venous insufficiency Suggested GP management •Thrombophlebitis – treat with anti-inflammatories, no role for antibiotics – if focal on duplex – rescan if getting worse – if extensive on duplex – anticoagulate with clexane if no contraindications for 3 months
  33. 33. Peripheral Overview Referral guidelines – varicose veins and chronic venous insufficiency When to refer •Complications of varicose veins: – recurrent cellulitis CCDHB patients – recurrent thrombophlebitis offered endovenous – healed/current ulcers treatment – recurrent bleeding •Thrombophlebitis – If duplex demonstrates extensive STP and contraindication to anticoagulation – If progression on duplex despite anticoagulation

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