Peripheral vascular disease (PVD), also known as peripheral artery disease (PAD), is a common cause of limb ischemia characterized by atherosclerotic narrowing of the arteries in the lower extremities. It can present acutely with critical limb ischemia manifested as severe pain, pallor, pulselessness, coldness and potential paralysis, or chronically with intermittent claudication pain on exertion that resolves with rest. PVD risk factors include smoking, diabetes, hypertension, hyperlipidemia and age over 70. Treatment involves risk factor modification, exercise rehabilitation, medical management with antiplatelets and cilostazol, as well as endovascular or surgical revascularization for severe symptoms or limb threatening ischemia. Acute

1. Peripheral Vascular
Disease
Acute & Chronic Limb Ischemia
Lipi Shukla

2. What is PVD?
Definition:
• Also known as PAD or PAOD.
• Occlusive disease of the arteries of
the lower extremity.
• Most common cause:
o Atherothrombosis
o Others: arteritis, aneurysm +
embolism.
• Has both ACUTE and CHRONIC Px
Pathophysiology:
• Arterial narrowing  Decreased
blood flow = Pain
• Pain results from an imbalance
between supply and demand of
blood flow that fails to satisfy
ongoing metabolic requirements.

3. The Facts:
1. The prevalence: >55 years is 10%–25%
2. 70%–80% of affected individuals are asymptomatic
3. Pt’s with PVD alone have the same relative risk of death from
cardiovascular causes as those CAD or CVD
1. PVD pt’s = 4X more likely to die within 10 years than pt’s without
the disease.
2. The ankle–brachial pressure index (ABPI) is a simple, non-invasive
bedside tool for diagnosing PAD — an ABPI <0.9 = diagnostic for PAD
1. Patients with PAD require medical management to prevent future
coronary and cerebral vascular events.
1. Prognosis at 1 yr in patient’s with Critical Limb Ischemia (rest pain):
• Alive with two limbs — 50%
• Amputation — 25%
• Cardiovascular mortality 25%

4. Risk Factors:
Typical Patient:
• Smoker (2.5-3x)
• Diabetic (3-4x)
• Hypertension
• Hx of Hypercholesterolemia/AF/IHD/CVA
• Age ≥ 70 years.
• Age 50 - 69 years with a history of smoking or diabetes.
• Age 40 - 49 with diabetes and at least one other risk factor for
atherosclerosis.
• Leg symptoms suggestive of claudication with exertion or
ischemic pain at rest.
• Abnormal lower extremity pulse examination.
• Known atherosclerosis at other sites (eg, coronary, carotid, or
renal artery disease).

5. Chronic PVD History:
3. Critical Stenosis = >60%, impending acute ischemic limb:
- rest pain
- ischemic ulceration
- gangrene
2. Other Symptom/Signs:
• A burning or aching pain in the feet (especially at night)
• Cold skin/feet
• Increased occurrence of infection
• Non-healing Ulcers
• Asymptomatic
1. INTERMITTENT CLAUDICATION
• Derived from the Latin word ‘to limp’
• “Reproducible pain on exercise which is relieved by rest”
• Pain can also be reproduced by elevating the leg
• “my legs get sore at night and feel better when I hang them over
the edge of the bed”

6. Thigh Claudication
60% Upper 2/3 Calf Claudication
Lower 1/3 Calf Claudication
Foot Claudication
30% Buttock & Hip Claudication
±Impotence – Leriche’s Syndrome

7. DDx of Leg Pain
1. Vascular
a) DVT (as for risk factors)
b) PVD (claudication)
2. Neurospinal
a) Disc Disease
b) Spinal Stenosis (Pseudoclaudication)
3. Neuropathic
a) Diabetes
b) Chronic EtOH abuse
4. Musculoskeletal
a) OA (variation with weather + time of day)
b) Chronic compartment syndrome

8. Physical Examination:
Examination: What do to:
Inspection
Expose the skin
and look for:
• Thick Shiny Skin
• Hair Loss
• Brittle Nails
• Colour Changes (pallor)
• Ulcers
• Muscle Wasting
Palpation • Temperature (cool, bilateral/unilateral)
• Pulses: ?Regular, ?AAA
• Capillary Refill
• Sensation/Movement
Auscultation • Femoral Bruits
Ankle Brachial
Index (ABI)
= Systolic BP in ankle
Systolic BP in brachial artery
Buerger’s Test • Elevate the leg to 45° - and look for pallor
• Place the leg in a dependent position 90°& look
for a red flushed foot before returning to normal
• Pallor at <20° = severe PAD.

9. Pictures:

10. What does the ABI mean?
ABI Clinical Correlation
>0.9 Normal Limb
0.5-0.9 Intermittent Claudication
<0.4 Rest Pain
<0.15 Gangrene
CAUTION:
Patient’s with Diabetes + Renal Failure:
They have calcified arterial walls which can falsely elevate their ABI.

11. Investigations:
NON INVASIVE:
Duplex Ultrasound
 normal is triphasic  biphasic  monophasic  absent
BLOOD TESTS:
1. FBE/EUC/Homocysteine Levels
2. Coagulation Studies
3. Fasting Lipids and Fasting Glucose
4. HBA1C
WHEN TO IMAGE:
1. To image = to intervene
2. Pt’s with disabling symptoms where revascularisation is considered
3. To accurately depict anatomy of stenosis and plan for PCI or Surgery
4. Sometimes in pt’s with discrepancy in hx and clinical findings

12. ANGIOGRAPHY:
Non-invasive:
• CT Angiogram
• MR Angiogram
Invasive:
• Digital Subtraction Angiography
 Gold Standard
 Intervention at the same time

14. Tardus et parvus = small amplitude + slow rising pulse

15. CT Angiography Digital Subtraction Angiography
Value of angiography
Localizes the obstruction
Visualize the arterial tree & distal
run-off
Can diagnose an embolus:
Sharp cutoff, reversed meniscus or clot
silhouette

16. Treatment:
1. RISK FACTOR MODIFICATION:
a) Smoking Cessation
b) Rigorous BSL control
c) BP reduction
d) Lipid Lowering Therapy
3. MEDICAL MANAGEMENT:
a) Antiplatelet therapy e.g.
Aspirin/Clopidogrel
b) Phosphodiesterase Inhibitor e.g.
Cilostazol
c) Foot Care
2. EXERCISE:
a) Claudication exercise
rehabilitation program
b) 45-60mins 3x weekly for 12 weeks
c) 6 months later +6.5mins walking
time (before pain)

17. PCI/Surgery:
Indications/Considerations:
•Poor response to exercise rehabilitation + pharmacologic therapy.
•Significantly disabled by claudication, poor QOL
•The patient is able to benefit from an improvement in claudication
•The individual’s anticipated natural hx and prognosis
•Morphology of the lesion (low risk + high probabilty of operation
success)
PCI:
•Angioplasty and Stenting
•Should be offered first to patients with significant comorbidities who are
not expected to live more than 1-2 years
Bypass Surgery:
•Reverse the saphenous vein for femoro-popliteal bypass
•Synthetic prosthesis for aorto-iliac or ilio-femoral bypass
•Others = iliac endarterectomy & thrombolysis
•Current Cochrane review = not enough evidence for Bypass>PCI
Amputation: Last Resort

18. Some Bypass Options:

19. Mr. X presents with an acutely
painful leg:
You have had a busy day in the ED and the next
patient to see is:
Mr. X – a 60 yr old gentleman with a very painful leg.
He tells you that he woke up this morning with an
excruciating pain in his left leg and has never felt
this pain before.
? Embolism (AF/Recent Infarct/Anuerysm)
? Thrombosis of native vessel or graft
?Trauma
MUST RULE OUT ACUTE LIMB ISCHEMIA

20. What are the features of an
acute ischemic limb?
REMEMBER THE 6 P’S:
1. PAIN
1. PALLOR
1. PULSELESNESS
1. PERISHING COLD (POIKILOTHERMIA)
1. PARASTHESIAS
1. PARALYSIS
Fixed
mottling &
cyanosis

21. History & Exam Findings
Further Hx:
• Smokes 20cigs/day for 30 years
• 4 months of ‘leg cramps’ in BOTH legs
• 2-3 weeks of intermittent chest palpitations
• Has not seen a Dr. in the last month
Examination:
• Inspection:
o LLL: below the knee is pale/cool
• Palpation:
o Irregularly irregular pulse
o LLL Capillary return is sluggish
o No pulses palpable below L femoral artery
o All pulses palpable but appear reduced in R leg
o Normal Sensation + Movement bilaterally
Impression?
60yo male with a L Acute Ischemic limb on the background of heavy
smoking, untreated AF and symptomatic PVD.

22. What will you do now?
1. CALL THE VASCULAR REGISTRAR
2. ORDER INVESTIGATIONS
a) FBE
b) EUC
c) Coagulation Studies
d) Group and Hold
e) 12 Lead ECG
f) Chest XR
3. INITATE ACUTE MANAGEMENT:
a) Analgesia
b) Commence IV heparin
c) Call Radiology for Angiography if limb still viable
d) Discuss with registrar:
i) Thrombotic cause  ?cathetar induced thrombolysis
ii) Embolic cause  ?embolectomy
iii) All other measures not possible  Bypass/Amputation
Simple measures to improve
existing perfusion:
• Keep the foot dependant
• Avoid pressure over the heel
• Avoid extremes of temperature
(cold induces vasospasm)
• Maximum tissue oxygenation
(oxygen inhalation)
• Correct hypotension

23. Mr. X’s Complication
- Angiogram is done in radiology
- Shows acute thrombosis of L popliteal artery
- Cathetar induced urokinase and heparin infusion is started
…. 3-4 hours later
-Severe calf pain in the reperfused limb
-All pulses are present
-Leg is swollen, tense and +++ tender
REPERFUSION INJURY!
-Restored blood flow can lead to unwanted local + systemic effects
1) Washout =
oMetabolic Acidosis
oHyperkalemia
oARF (myoglobinuria)
oNon-cardiac APO
2) Compartment Syndrome =
oMay need fasciotomy

24. Learning Outcomes
1. Risk factors for PVD
2. Recognise signs and symptoms of chronic ischemia of the lower limbs
3. Differential diagnosis for leg pain
4. Examine a chronic ischemic limb
5. Understand medical/surgical of management of PVD
6. Recognise an acute ischemic limb
7. Know it is important to call the vascular registrar ASAP
8. Know what investigations to order in the ED
9. Be aware of the manifestations of reperfusion injury

25. Questions?

26. References:
Uptodate Articles:
- Clinical features, diagnosis & natural history of lower extremity PAD
- Treatment of chronic critical limb ischemia
- Indications for surgery in the patient with lower extremity claudication
• Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the
Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl S:S5
• McDaniel MD, Cronenwett JL. Basic data related to the natural history of
intermittent claudication. Ann Vasc Surg 1989; 3:273.
• Lane DA, Lip GYH. Treatment of hypertension in peripheral arterial disease.
Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD003075. DOI:
10.1002/14651858.CD003075.pub2
• Murabito JM, Evans JC, Nieto K, et al. Prevalence and clinical correlates of
peripheral arterial disease in the Framingham Offspring Study. Am Heart J 2002;
143:961
• Peripheral arterial disease: prognostic significance and prevention of
atherothrombotic complicationsPaul E Norman, John W Eikelboom and Graeme J
HankeyMJA 2004; 181 (3): 150-154
• http://www.imagingpathways.health.wa.gov.au/includes/dipmenu/limb_is/summar
y.html