Peripheral vascular disease (PVD) refers to narrowed, blocked, or spasming blood vessels outside the heart and brain. It is commonly caused by atherosclerosis which leads to the buildup of fatty plaques in the arteries (atherosclerotic plaques). Symptoms range from mild intermittent leg pain with walking (intermittent claudication) to severe leg or foot pain at rest or skin ulcers/gangrene of the lower leg or foot. Treatment involves lifestyle changes, medications to reduce pain, plaque, or blood clotting, and potentially minimally invasive or open surgical procedures to restore blood flow if more conservative options are ineffective.

1. Peripheral Vascular Disease

2. Definition
• Peripheral vascular disease (PVD) is a blood
circulation disorder that causes the
blood vessels to narrow, block, or
spasm outside the heart and brain.
• This can happen in arteries or veins
• Commonly used referring to peripheral arterial
disease (PAD)

3. What Is The Peripheral Vascular
System?
• The vessels not in chest ,
abdomen and brain
• These are the veins and
arteries in the arms,
hands, legs and feet

4. Difference Between PVD And PAD
• Peripheral Vascular Disease (PVD)
– There are problems altering the blood flow
through both the arteries and veins.
• Peripheral Artery Disease (PAD)
– is a type of PVD
– have problems only with arterial blood flow

5. Diseases commonly found in peripheral
vasculature
PVD
Arterial
Occlusive
Acute
ischemia
Emboli
Chronic
ischemia
Atheroscler
osis / micro
angiopathy
Functional
Vasospastis
Raynaud’s
disease
Venous
Thrombosis
Superficial Deep
Varicose
Mixed
Arterio-
venous
fistula

6. Atheroma
• Accumulation of
degenerative materials in
inner layer of arterial wall
• Materials: macrophage
cell debris, containing
lipid, Ca++ & connective
tissue
• What happened: intrude
into lumen
• Where found: in
atherosclerosis

7. Atheromatous plaque formation
• Accumulation between intima & media
• Atheroma don’t develop in veins
• Pathophysiology:
Accumulation of fatty streak
(macrophage takes up LDL and cholesterol)
Foam cell formed
Cell dies
Content release
Attracts more macrophage
Creates extra cellular lipid core
Peripheral calcification
Plaque formation

8. Arterial stenosis and occlusion
• Cause:
– Atheroma
– Emboli
– Trauma
• Type:
– Acute
– Chronic

9. RISK FACTORS
• Positive family history of premature heart attacks
or strokes
• Older than 50 years
• Male sex
• Overweight or obesity
• Inactive (sedentary) lifestyle
• Smoking
• Diabetes
• High blood pressure
• High cholesterol or LDL (the "bad cholesterol"), plus
high triglycerides and low HDL

10. Chronic ischaemia
• Features:
1. Intermittent claudication
2. Rest pain
3. Ulcer and gangrene
4. Colour change
5. Temperature
6. Sensation & movement
7. Capillary refill time
8. Peripheral pulses

11. Intermittent claudication
• Claudication means cramp like pain in
muscle during walking due to muscle
ischaemia
• Not in the 1st step (in osteoarthritis)
• Relieved by stand still/rest (in PLID
posture change/rest)
• Commonly felt in calf
• Leriche’s syndrome: Buttock claudication
+ Impotency due to aorto-ileac
obstruction

12. Grading of Intermittent claudication
• Grade 1:
– Pain goes away & patient continue walking (pain
producing substances washed away by collaterals)
• Grade 2
– Pain starts after some distance & can walk with pain
• Grade 3
– When pain starts patient can't walk without taking
rest

13. Rest pain
• Continuous pain occurs at rest
throughout day and night due
to severe ischaemia & felt in
foot
• exacerbate by lying down or
foot elevation
• Worse @ night due to
decreased heart rate.
• Comfort by hanging the foot
• This pain is due to ischaemia of
nerve (crying of dying nerve)

14. Ulcer & gangrene
• Ulcer due to severe ischaemia
• Painful ulcer
• Site: between toes, around maleoli
• Black, mummified
• may be wet if infection occurs

15. Colour change of foot (a) elevation
pallor and (b) dependent rubor

16. Relationship between occlusion site &
Clinical features
Aorto-iliac
⁻ Claudication both buttock
& thigh
⁻ Leriche’s syndrome
⁻ Absent femoral pulses
Iliac
⁻ Unilateral claudication in
thigh/ calf
⁻ Unilateral absent pulse
Femoro-popliteal
Distal obstructions

17. Stage of limb ischaemia: Fontainer’s staging
• Stage I: asymptomatic
• Stage II: Intermittent claudication
• Stage III: Rest pain
–IIIa: Rest pain + ABPI > 50 mm of Hg
–IIIb: Rest pain + ABPI < 50 mm of Hg
• Stage VI: Ulcer / Gangrene

18. Investigations
For diagnosis
Doppler USG
Duplex scanning
Angiography
CT angiography
MR
angiography
DSA
For assessment
CBC
S. Lipid profile
S. Creatinine
Blood sugar
S. Electrolite
ECG
CXR

19. Doppler USG
Measured by Doppler USG
Blood flow
Site of stenosis
Systolic pressure of small arteries
ABPI

20. ABPI
• Ratio of systolic pressure @ ankle to arm
• Measured by Doppler USG
• Measured artery: dorsalis pedis, ant. tibial, &
post. Tibial
• Value:
– Normal= 1
– Claudication = < 0.9
– Rest pain = < 0.5
– Imminent necrosis = <0.3
– Calcification = > 1

21. Duplex scanning
• Combination of Doppler
study & B mood USG
• Gives idea about-
– Stenosis
– Visual impression of small
vessel
– Turbulence
– Velocity of flow
– Changes in direction of flow

22. Angiography
• Invasive & indicated when
intervention is think about
• Using Sheldinger technique
• Usually through femoral artery
• Advantages
– Visualization of artery, site of
occlusion, collaterals seen
• Disadvantages
– Bleeding, haematoma,
thrombosis, embolism
– Arterial dissection, false aneurism

23. Angiography
• CT Angiography • MR Angiography

24. DSA (Digital subtraction angiography)

25. Treatment
• Nonsurgical
– General
– Drugs
• Interventional
• Surgical

26. Non surgical treatment
• General
1. Stop smoking
2. Walk within limit of disability
3. Dietary advice to loss weight
4. Care of ischaemic foot, avoid trauma

27. Non surgical treatment
• Drugs
1. Pentoxiphylin ↓blood viscosity , improve
circulation; 400 mg bd.
2. Cilostazole  inhibit platelet aggregation; 100mg bd
3. Analgesic
4. Low dose aspirin
5. Clopidogrel
6. Anti HTN
7. Anti DM
8. Statin  lipid lowering
9. Antibiotics
Anti platelet; 75 mg daily

28. Interventional treatment
• PTA: Percuteneoans
transluminal
angioplasty
– By balloon Catheter
– Via femoral artery
– Fluoroscopic
guidance
– Suitable for short
segment, < 5 cm

29. Transluminal stenting
• Self expanding metallic
stent
• Suitable for long
segment; > 5 cm
• PTA failure

30. Surgical treatment
Indication:
– Severe symptom
– Angioplasty failed/not possible
Option:
1. Bypass graft
– Natural
• Saphanous (long/short) graft
• Arm vein graft
– Synthetic
• Dacron
• PTFE
2. End arterectomy
3. Lumber sympathetectomy
4. Amputation

31. Surgical treatment
Natural Graft Synthetic graft

32. End arterectomy

33. Lumber sympathetectomy

34. Amputation

35. Critical Limb Ischaemia
Def:
Critical limb ischaemia is a late sign of progressive
limb ischaemia, characterized by-
—Rest pain; requiring regular analgesic >2 weeks
—Ulcer due to arterial insufficiency
—Gangrene
—Systolic pressure of limb < 50 mm of Hg
• Management: same as chronic limb
ischaemia

36. Acute occlusive condition
• Causes
– Emboli
– Thrombi
– Trauma

37. Embolus
An embolus is a body that is foreign to the blood stream & which
may lodge into blood vessel & cause obstruction.
Type
• Thrombo-embolic
• Lt. atrium  fibrillation/MI/ endocarditis
• Aneurism
• Atherosclerotic plaque
• Fat
• Air
• Infective
• Parasitic
• Malignant

38. Site of acute arterial occlusion
Limbs
Brain - middle cerebral artery
Retina – central retinal
artery Amourosis fugux
Gut
Kidney

39. Symptoms
• Sudden, severe onset of constant
pain/numbness
• May have H/O cardiac disease
• May have H/O trauma/ arterial catheterization
• May have H/O arterial graft

40. Signs
5P
• Pain, pallor, paralysis, pulselessness &
parasthesia
• Limb is cold, tender, swollen
• Toe cannot be moved
• If occlusion is > 6 hours  irreversible damage
occurs & line of demarcation may present

41. Immediate management
• It is a surgical emergency, so if a patient have
a H/O cardiac disease with acute limb
ischaemic features immediate management
should be done
• So the Mx is:
1. 5000 U of heparin I/V
• To reduce extension of thrombi
• To maintain patency of vessel
2. Analgesic

42. Investigation
• In treating acute limb ischaemia (ALI) TIME is
everything
• in worst case ALI may progress to critical limb
ischaemia
So the choice of INV. Is
Colour Doppler study
Evaluates lesion into 3 categories
1. Viable
2. Threatened
3. Irreversible

43. Surgical management
1. Embolectomy
– Rx of choice
– Under LA
– By Fogarty balloon catheter
2. Intra arterial
thrombolysis
– With tissue plasminogen
activator
– Or streptokinase/ urokinase

44. Intra arterial thrombolysis….cont.
• Injected into clot via catheter
• Success achieved within 24 hours
• Regular angiogram should be done
• Contraindication
– Recent stroke
– Bleeding diathesis
– Pregnancy
– Age> 80
After managing ALI total evaluation of the cause
should be attempted & managed accordingly