- Peripheral vascular disease (PVD) refers to disorders affecting arteries, veins and lymphatics outside the heart and brain. More commonly it affects the arteries. - PVD ranges from asymptomatic to critical limb ischemia with pain, ulcers or gangrene. Risk factors include smoking, diabetes, hypertension, hyperlipidemia, age and family history. - Clinical features depend on location and severity, from intermittent claudication to critical limb ischemia. Investigations include ankle-brachial pressure index and imaging of arteries. - Management involves risk factor modification, exercise/drugs for claudication, endovascular procedures, surgery like bypass, and amputation for critical cases. Compression therapy

1. Peripheral
Vascular Disease
- Santa Gurung , CT1
General Surgery
Causeway Hospital

2. Contents
1. Definition
2. Spectrum
3. Pathogenesis of atherosclerosis
4. Contributory factors
5. Clinical features
6. Vascular investigations
7. Non surgical management
8. Surgical interventions
9. Venous disorders
10. Case presentation

3. - In general, peripheral vascular disease (PVD) refers to all the disorders affecting the
affecting the arteries, vein and lymphatics of the peripheral vasculature.
- More commonly, we refer to those diseases only affecting the arteries such as
atherosclerosis, aortic aneurysm, Beurger’s disease, Raynaud’s syndrome, etc.
- Depending on the location of the disease, conditions that affect the arteries serving
the lower limbs, sometimes the upper limbs, and less commonly the carotid and
renal
Definition

4. Spectrum of PVD
Peripheral arterial disease Peripheral venous disorders
Atherosclerotic
- IC
- CLI
- Acute limb
ischemia
- Carotid artery
disease
Non atherosclerotic
- Raynaud’s disease
- Popliteal artery
entrapment
- Fibromuscular dysplasia
- Chronic venous ulcers
- Varicose veins
- DVT

6. Pathophysiology
- not fully understood
- initiated by inflammatory processes in the endothelial cells of the vessel wall
associated with LDL
- Plaque formation comprising of central atheroma(macrophages), cholesterol crystals
and outer areas of calcification
- the plaque -> blood vessel to stretch, compensating for the additional bulk, and the
endothelial lining thickens, increasing the separation between the plaque and lumen.
This somewhat offsets the narrowing caused by the growth of the plaque, but it
causes the wall to stiffen and become less compliant
- partial or complete occlusion
- Embolisation (but more commonly cardiac in origin)

7. 1. Hyperlipidemia
a. Atherosclerotic plaque formation
2. Hypertension
a. Elastic tissues replaced by fibrous collagen tissues - stiff arterial wall -> increased PVR - >
increased BP
3. Smoking
4. Diabetes
5. Age
6. Obesity
7. Lack of physical activity
8. Family history of atherosclerosis
Contributory factors

8. Clinical manifestations
- Asymptomatic
- Intermittent claudication
- Critical limb ischemia
- Acute limb ischemia

9. Lower limb ischemia
1. Intermittent claudication (IC) – Ischaemic muscle discomfort in the lower limb
reproducibly produced by exercise and relieved by rest within 10 min6
2. Critical limb ischaemia (CLI) – Ulcers, gangrene or ischaemic rest pain for more
than 2 weeks attributable to objectively proven arterial occlusive disease6
3. Acute limb ischaemia (ALI) – A sudden decrease in limb perfusion that threatens
viability of the limb6

10. Assessment
- History : onset, duration, progressions, associated symptoms, aggravating and
relieving factors
- Claudication
- Rest pain ? able to sleep at night
- Tendency to hang the symptomatic leg out of bed whilst sleeping?
- History of smoking
- Medical history
- Medications

11. ..cont(Assessment)
General / systemic examination
Physical examination
- Overlying skin
- ? ulcers - characteristics
- Associated findings : edema
- Pulses
- CRT
- Beurger’s test ( assess for elevation pallor in arterial insufficiency)

12. ..cont(Assessment)
NB : 6 Ps(perishingly cold, pulseless, pain, pallor, paraesthesia, power)
Acute limb ischemia
- < 6 hrs : mild sensorimotor deficit
- 6 - 12 hrs : signs of skin mottling and calf tenderness +/- tense fascial compartments
- > 12 hrs : fixed skin mottling with sensorimotor deficit

13. Specific investigations
- ABPI
- Hand held doppler
- Duplex arterial scan
- CTA
- MRA lower limbs( gold standard)
- Diagnostic angiogram

14. ABPI
Values Interpretation
>1.2 Heavy vessel calcification
0.9 - 1.2 Normal
0.5 - 0.9 Peripheral arterial disease
<0.5 Critical limb ischemia*
*ulceration of the foot may occur at higher ABPIs in patients with diabetes because PAD is often only one component of
the multifactorial aetiology including infection, neuropathy microvascular dysfunction.

16. Management of limb ischemia
- Risk factor modification
- Management of claudication symptoms
- Surgical interventions
- Non surgical interventions
- Iloprost infusions

17. Management of limb ischemia
- Risk factor modification
- About 65% will also have associated significant cerebral or coronary artery disease
- 6 fold risk of death due to stroke, MI
- >10% with stroke or MI or death within 2 years of follow up
- Smoking cessation
- Group counselling sessions
- NRT
- Diabetes
- glycemic control is very important
- ~1% increase in HbA1C is associated with 26% increase in the risk of PAD accelerates the
progression of the disease
- 5 - 10 times more likely to end up with major amputation
- Hypertension control reduces the risk of cardiovascular events
-

18. ..cont(Management)
- Treatment with statins to lower cholesterol levels (cardiac related mortality is reduced
by approximately 20% with every 1 mmol/L reduction in LDL cholesterol irrespective of
the initial levels)
- Antiplatelet therapy
- Clopidogrel is preferred for simple PAD
- DAPT in prosthetic bypass graft

19. Management of claudication symptoms
- Exercise
- Structured or supervised exercise programmes
- Vasoactive drugs
- 2 drugs used in the UK
- Cilostazol( antiplatelet + vasodilator)
- Naftidrofuryl oxalate/ Nafronyl(vasodilator)

20. ..cont (Management)
- Surgical interventions
- Angioplasty
- Endarterectomy
- Arterial bypass
- Embolectomy
- Amputation
- Catheter directed thrombolysis

21. Angioplasty
- Ususally if stenotic segments are <3 cm
- Unsuitable for significant multifocal disease
- Long term outcomes inferior to endarterectomies
- Suitable for patients unable to undergo endarterectomy

22. Peripheral arterial bypass
- Commonly performed vascular interventions for PAD
- Depending where the bypass is done can be as follows :
- Aorto-bifemoral bypass
- Axillofemoral bypass
- Fem-fem crossover
- Fem-pop bypass
- Popliteal-pedal bypass

23. Chronic venous insufficiency
- Results from obstruction of venous valves in legs or reflux of blood through the valves
- Venous ulceration is a common and serious complication
- Management
- Elevate the limb, regular exercise, stop smoking, improve nutrition
- Antibiotics for superimposed infection
- Multilayer graduated compression bandaging therapy(40mmHg @ ankle and 17mmHg @
midcalf)
- Debridement may be need to promote healing

24. Varicose veins
- Abnormally dilated, tortuous veins with incompetent valves
- Causes
- Congenital absence of valves
- Incompetent valves due to external pressure on the veins from increased intra-abdominal
pressure
- Prevention
- Moderate exercise, elevation of legs
- Compression stockings
- Surgery
- Ligation and stripping
- Sclerotherapy
- RFA, EVLA, Cryoablation

25. DVT
- Blood clot within a deep vein
- More commonly in the lower limbs , less so in the upper venous system
- Pathology : Virchow’s triad - hypercoagulability, hemodynamic changes, endothelial
injury
- Clinical features : calf pain/swelling, unilateral pitting edema, pyrexia, Homan’s sign
- Well’s scoring system
- Investigations : D dimers, USS
- Prevention : TEDS, Prophylactic LMWH(clexane, fragmin)
- Treatment : LMWH + Vit K anticoagulants/NOAC(duration depending upon provoked
or unprovoked)
- Consideration for IVC filters

26. Case discussion
55F, presented to ED with
C/C - left thigh/calf pain , sudden onset , worsening on the evening of the DOA
Hx of mechanical fall after slipping in the bathroom 2/7 prior to attendance in ED, reduced
mobility
Non smoker
Normally fit and well
No anticoagulants/no previous medications

27. ..cont
Clinical examination -
- Pelvis/ L hip : no gross deformity, pain on movements
- Femoral pulse +, Popliteal/PT/DPA -
- Pale
- Reduced power
- Sensation intact
- Beurger’s test : positive
XR pelvis/Lt hip - unremarkable
ECG sinus rhythm

28. cont..
- ABPI < 0.5
- Handheld doppler : biphasic signals femoral +, no signals Popliteal/Peroneal
trunk/PT/DPA -
- CTA lower limbs - moderate to severe disease of the SFA, occlusion at popliteal artery,
no evidences of DVT
- Underwent femoral endarterectomy + Fogarty catheter embolectomy
- ECHO : no sources of emboli
- Antiplatelet therapy + NOAC
- For follow up in Vascular OP clinic

29. Any questions ???
Thank you……...