This document defines peripheral vascular disease and describes the differences between peripheral arterial and venous disorders. It lists various risk factors for PVD like age, smoking, hypertension, and diabetes. Tests for assessing arterial insufficiency include ankle brachial index, treadmill testing, and skin perfusion pressure measurement. Tests for venous insufficiency include venous filling time, Homan's sign, and Trendelenburg test. Signs and symptoms of arterial disease include pale skin, absent pulses, and painful ulcers. Venous disease presents with warm skin, edema, and less painful ulcers. Grading scales assess severity of venous disease based on symptoms and ulcer characteristics.

1. - NITHIN NAIR (MPT – 1)
UNDER GUIDANCE OF Dr. VIJENDRA R. (PT)

2. After this session, the students will be able to:
Define Peripheral vascular disease.
Differentiate between peripheral venous and arterial
disorder
Enlist the risk factors
Enumerate various tests for arterial and venous
insufficiency.

3. Peripheral Vascular Disease (PVD) is a general term used to
describe any disorder that interferes with arterial or venous blood
flow to extremities.
Peripheral
Vascular
Disease
Arterial
Insufficiency
Venous
Insufficiency

4. Arterial Insufficiency
 There is a deceased blood flow toward the tissues, producing
ischemia
 Pulses are usually diminished or absent
 Sharp, stabbing pain occurs because of the ischemia,
particularly with activity
 There is interference with nutrients and 02 arriving to the
tissues, leading to ischemic ulcers and changes in the skin.
Venous Insufficiency
 There is deceased return of blood from the tissues to the heart
 Leads to venous congestion and stasis of blood
 Pulses are present
 Lead to oedema, skin changes and stasis ulcers

5. Arterial Disease Venous Disease
Skin cool or cold, hairless,
dry, shiny, pallor on
elevation, rubor on
dangling
warm, tough,
thickened,
mottled, pigmented
areas
Pain sharp, stabbing,
worsens w/ activity and
walking, lowering feet
may relieve pain
aching, cramping,
activity and walking
sometimes help,
elevating the feet
relieves pain
Ulcers severely painful, pale,
grey base, found on
heel, toes, dorsum of
foot
moderately painful, pink
base, found on medial
aspect of the ankle
Pulse often absent or
diminished
usually present
Oedema infrequent frequent, esp. at the
end of the day and in
areas of ulceration

9. 0 1 2
PAIN None/Mild Moderate – no
analgesics
Severe – analgesics
required
EDEMA None Mild/Moderate Severe
VENOUS
CLAUDICATION
None Mild/Moderate Severe
PIGMENTATION None Localized Extensive
LIPODERMATO-
SCLEROSIS
None Localized Extensive
ULCER SIZE None < 2cm diameter > 2cm diameter
DURATION OF
ULCER
None < 3 months > 3 months
ULCER
RECURRENCE
None Once More than once
ULCER NUMBER None One Multiple

10.  Age (elderly) – blood vessels become less elastic, become thin
walled and calcified – ↑ PVR – ↑ BP
 Gender : (male-testosterone)
 Family history
 Cigarette smoking: – nicotine causes vasoconstriction and
spasm of the arteries – ↓ circulation to the extremities – CO binds
with haemoglobin – producing carboxy haemoglobin. ↑
Fibrinogen level thereby leading to Platelet aggregation and
thrombus formation.
 Hypertension – cause elastic tissues to be replaced by fibrous
collagen tissue → arterial wall become less distensible → ↑
resistance to blood flow → ↑ BP

11.  Hyperlipidaemia – atherosclerotic plaque
 Obesity – places added burden on the heart & blood vessels –
excess fat contribute to ↑ venous congestion
 Lack of physical activity – Leads to ↓ insulin sensitivity, ↓
glucose tolerance, ↓ HDL cholesterol, ↑ triglyceride and LDL
cholesterol level.
 Emotional stress – stimulates sympathetic N.S. – peripheral
vasoconstriction → ↑ BP
 Diabetes mellitus – changes in glucose & fat metabolism
promote the atherosclerotic process

12. Arterial Insufficiency Venous Insufficiency
Palpation Of Peripheral Pulses Venous Filling Time
Capillary Refilling Test Homan’s sign
Ankle Brachial Index Moses Test
Treadmill Test Percussion Test (Schwartz)
Rubor of Dependency Cough Impulse Test (Morrisey’s Test)
Air Plethysmography Trendelenburg Test
Transcutaneous Oxygen Multiple Tourniquet Test
Skin Perfusion Pressure Measurement Pratt’s Test
Edinburg Claudication Questionnaire Perthe’s Test (Modified)
Buerger’s Postural Test Lowenberg’s Test
Allen’s Test (Modified) Fegan’s Test

13. The following arteries are to be examined:
Dorsalis pedis artery
Posterior tibial artery
Popliteal artery
Femoral artery
Radial
Brachial artery
Subclavian artery
Common carotid artery
Superficial temporal artery
Aortic artery
Grade Quality
0 No Pulse
1+ Weak Pulse, Difficult to palpate
2+ Palpable but diminished
3+ Normal, Easy to palpate
4+ Bounding, Very Strong

14.  After elevating the legs, the patient is asked to sit up and
hang his leg down by the side of the table. A normal leg will
remain pink. But an ischaemic leg will change its colour from
pallor to pink. This change of colour takes place slowly and is
called capillary filling time. An ischaemic limb further
changes its colour and becomes purple-red. This is due to
the filling of dilated skin capillaries with blood.
 Capillary Nail Refilling Test

15.  The patient is in supine position. Ask the patient to raise the
leg one after the other keeping the knees straight. The legs of
normal individual remain pink even if raised to 90°. But in
case of an ischaemic limb elevation to a certain degree will
cause marked pallor.
 The angle between the limb at which such pallor appears and
the horizontal plane is known as Buerger’s angle or vascular
angle. Vascular angle < 30° - severe indicates arterial
occlusion

16.  The ABI is the most frequently performed test using Doppler ultrasound
A blood pressure cuff is initiated to occlude blood flow temporarily then
deflated as the examiner listens for the return of flow. This is performed
on the upper extremity (UE) at the brachial artery and on the LE at the
posterior tibial and the dorsalis pedis arteries. The ABI is a ratio of the
LE pressure divided by the UE.

17. ABI Ranges Indications
> 1.2 Falsely elevated, Arterial
disease, Diabetes
1.19 – 0.95 Normal
0.94 – 0.75 Mild Arterial Disease +
Intermittent Claudication
0.74 – 0.50 Moderate Arterial Disease +
Rest Pain
< 0.50 Severe Arterial Disease

18.  Protocol: slower speed and Less rapidly increasing grade.
 Most common protocol, conducted at Speed of 1.5-2 mph, with a
fixed grade of 8-12 %.
Graded Treadmill Protocol test:
 1st Protocol: Speed of 2.0 mph, Grade 3.5% increased every 3
mins.
 2nd Protocol: Speed of 2.0 mph, Grade 2.0% increased every 2
mins.

19.  A noninvasive test that examined the LE for the presence of
ischemia. Following elevation of the limb. lowering of the limb
should return the skin of the limb to a pink color. If the color is
dark red and takes more than 30 seconds to appear, the test is
positive for arterial insufficiency.

20.  A noninvasive test of both the arterial and venous circulation.
Changes in leg volume are measured using a pressure cuff that
quantifies volume changes during rest, standing and light
walking. Venous obstruction and arterial inflow can be observed
with this test.

21.  A noninvasive examination tool for arterial circulation. A special
probe and a heating element measure profusion. Measurement of
oxygen at the skin level gives information about what is happening
at the cellular level. Also found in the literature as transcutaneous
partial pressure of oxygen and transcutaneous oxygen tension
measurement. The results are predictive for healing of ulcers and
amputation wounds.

22.  A noninvasive test that measures blood flow in the skin. To take
the measurement a modified laser Doppler probe is secured in the
bladder of a specialized blood pressure cuff. Results are predictive
for healing of ulcers and amputation wounds.

23. CHARACTERISTIC NEUROGENIC VASCULAR
PAIN LOCATION Back, Buttocks, Thighs, Calves –
Travels in a proximal to distal
direction
Pain develops in calves – travels
in a distal to proximal direction
PAIN QUALITY /
ONSET
• Sharp or crampy may be
associated with burning,
numbness, tingling
• Immediate onset
• Cramping
• Gradual Onset, consistent
PRECIPITATING /
AGGRAVATING
FACTORS
• Pain occurs with standing
and walking
• Pain improves from flat to
inclined treadmill walking
• Pain is worse in descending
stairs
• Pain does not occur during
bicycle test.
• Pain occurs with walking
• Pain equally severe with flat
or inclined treadmill walking.
• Pain is equal in ascending &
descending stairs
• Pain occurs during bicycle
test.

24. CHARACTERISTIC NEUROGENIC VASCULAR
RELIEVING FACTORS Pain is relieved with sitting or
bending forward and by lying,
particularly on side
Shopping cart sign: Present
Relief with standing still
(Cessation of walking)
Shopping cart sign : Absent
LATERALITY Often Bilateral Usually unilateral if femoro-
popliteal, bilateral if aortoiliac
disease
PHYSICAL FINDINGS • Pulses: Present
• Skin: Normal
• Pulses: Absent or
Diminished
• Skin: Pale/Shiny Hair loss

25. GRADES DESCRIPTION
I The patient walks for a distance, gets the pain,
continues to walk and the pain disappears.
II Patient walks for a distance, gets the pain and
continues to walk with the pain (Limping)
III Pain compels the patient to take rest.
IV Pain at rest (Due to involvement of Vasa Nervosum)
Claudication Distance: Distance a patient is able to walk
before the onset of pain.

27.  Ask the patient to clench his fist tightly and compress the
radial and ulnar arteries at the wrist with the thumbs. Wait
for 10 sec and ask the patient to open his hand, Pallor can be
seen in the palm. Now release pressure on the radial artery
and watch for blood flow. Repeat the test for ulnar artery. If
there is occlusion of either artery, colour changes occur in the
fingers slowly.

28.  The extremity is elevated and then lowered into a dependent
position. The time it takes for the veins on top of the foot to refill
is recorded. Normal filling time is 15 seconds. Greater than 15
seconds indicates arterial disease while less than 15 indicates
venous disease

29.  Support the patient’s thigh with one hand and his foot with
the other. Bend his leg slightly at the knee; then firmly and
abruptly dorsiflex the ankle. Resulting deep calf pain
indicates + ve Homan’s Sign

30.  Tenderness / Pain over calf muscles on squeezing the lower
calf muscles against tibia indicates DVT. Not done now due
to fear of embolism.

31.  With LE in a dependent position, the greater saphenous vein is
palpated distal to the knee with one hand while it is tapped 6
inches proximal to the knee with the other hand. If a wave of fluid
is detected under the distal palpation site, this indicates the
possibility of valvular incompetency.

32.  In this test, Limb is elevated to empty the veins. The patient
is asked to cough forcibly. An expansion impulse if felt in the
long saphenous varicose vein, it may be presumed that the
sapheno-femoral valve is incompetent. Similarly, if the
patient coughs and the sapheno-femoral junction is
incompetent a bruit may be heard on auscultation

33.  Test measures the time required to refill the veins in the dorsum
of the foot. The LE is elevated to allow venous blood to empty. A
tourniquet on the thigh prevent backflow. After 1 minute, the
individual stands. If veins fully distend within 5 seconds before
the tourniquet is released, valvular incompetence in the deep
veins is suspected. If distention occurs within 5 seconds after the
tourniquet is released, incompetence of superficial veins is
suspected.

34.  The patient is asked to lie supine. The vein is emptied by elevation. 3-5
tourniquets are applied at different levels as follows:
• 1st Tourniquet – At the level of SF junction
• 2ndTourniquet – At the level of midline of the thigh
• 3rd Tourniquet – Just below the knee
• 4th Tourniquet – Lower third of leg (Above medial malleolus)
 The patient is now asked to stand up. Observe the appearance of veins after
releasing the tourniquet one by one from below upwards.
 If the veins above the tourniquet fill up and those below it remain collapsed
(presence of incompetent vein above tourniquet) and vice versa.

35.  This test is performed to know the positions of the Leg
perforators. Apply an Esmarch elastic bandage from toes to the
groin. A tourniquet is then applied at the groin at the upper end of
elastic bandage. This causes emptying of the varicose veins. The
tourniquet is kept in position and the elastic bandage is taken off.
The same elastic bandage is now applied from the groin
downwards. At the position of the perforator, a blow out or a
visible varix can be seen.

36.  This test is primarily intended to rule out DVT (Patency of
deep veins). A tourniquet is tied just below the SF junction.
The patient is asked to walk for 5 min. If the patient
complains of severe pain in calf region or superficial veins
become more prominent , It is an indication of DVT (+ve
Perthe’s test is a contraindication for surgery.)

37.  Cuff from the sphygmomanometer is imposed on the leg.
 If at pressure of 80-100 mmHg a pain arises in the calf muscle,
then this test is considered to be positive for thrombophlebitis of
profound veins.

38.  On standing, the site where the perforators enter the deep
fascia bulges and this is marked. Then on lying down, with
affected limb elevated button like depression in the deep
fascia is felt at the marked out points which confirms the
perforator site.

40.  Physical Rehabilitation – Susan B O’Sullivan (6th ed)
 Cardiopulmonary Physical Therapy – Scot Irwin (4th ed)
 A concise textbook of Surgery – S. Das (8th ed)
 Manipal Manual of Surgery – R. Shenoy (3rd ed)
 R.D.B.’s Art of Clinical Presentation in Surgery – (3rd ed)
 www.scribd.com