Peripheral vascular disease (PVD) is caused by a buildup of plaque in the arteries that reduces blood flow. It most commonly affects arteries in the legs. PVD is usually caused by atherosclerosis and is associated with risk factors like smoking, diabetes, and hypertension. Symptoms include leg pain when walking or at rest. Diagnosis involves tests like the ankle-brachial index. Treatment focuses on risk factor modification through exercise, medication, and lifestyle changes. More severe cases may require procedures like angioplasty, stents, or surgery to improve blood flow.

1. PERIPHERAL
VASCULAR DISEASE
Presented by dr.nawin kumar

2. Pathophysiology
• Form of atherosclerosis
• Progressive disease
May occur suddenly if an embolism occurs or when a blood clot
rapidly develops in a blood vessel restricted by an atherosclerotic
plaque, and the blood flow is quickly cut off.

3. • PVD is a generic term that encompasses vascular
insufficiencies such as arteriosclerosis, arterial
stenosis, Raynaud’s phenomenon.
• Peripheral arteriosclerosis is common in the elderly
and is often associated with hypertension and
hyperlipidemia.
PVD is frequently observed in patients with CAD, diabetes, and a
long-term history of smoking.

4. Two types of PVD
• Functional
Doesn’t have an organic cause.
Doesn’t involve defects in blood vessels’ structure, usually short-
term effects and come and go.
Ex: Raynaud’s disease.
• Organic
Caused by structural changes in the blood vessels, such as
inflammation.
Ex: Peripheral artery disease, caused by fatty buildups in arteries.

5. How Common is PVD?
• Affects about 1 in 20 people over the age of 50,
or 8 million people in the US.
• PVD is only diagnosed in 50% of the population.
• Symptomatic PVD carries at least a 30% risk of
death within 5 years and almost 50% within 10
years, primarily due to MI (60%) or stroke (12%).

6. Symptoms of PVD
• Leg or hip pain during walking (intermittent
claudication).
• The pain stops when you rest.
• Numbness, tingling or weakness in the legs.
• Burning or aching pain in feet or toes when
resting.
• Sore on leg or foot that won’t heal.
• Cold legs or feet.
• Color change in skin of legs or feet.
• Loss of hair on legs.

7. The 5 P’s
• Peripheral signs of PVD are the classic 5 P’s
Pulselessness
Paralysis
Paraesthesia
Pain
Pallor

8. • Paralysis and paraesthesia suggest limb-
threatening ischemia and mandate prompt
evaluation and consultation.
• Advanced PVD may manifest as mottling in a
“fishnet pattern”, pulselessness, numbness, or
cyanosis. Paralysis may follow, and the
extremity may become cold; gangrene
eventaully may be seen. Poorly healing injuries
or ulcers in the extremities help provide
evidence of preexisting PVD.

9. Who is at risk for PVD?
• Over the age of 50
• Smokers
• Diabetics
• Overweight (especially with syndrome X or
hyperinsulinism)
• Male sex
• Sedentary people
• People who have hypertension or high cholesterol
• Family history of heart or vascular disease

10. Pain Scale
• A subjective grading scale for PVD pain is as follows:
Grade 1: Definite discomfort or pain, but only of initial or modest
levels (established, but minimal).
Grade 2: Moderate discomfort or pain from which the patient’s
attention can be diverted, for example by conversation.
Grade 3: Intense pain (short of Grade 4) from which the patient’s
attention cannot be diverted.
Grade 4: Excruciating and unbearable pain.

11. How is PVD Diagnosed?
• Ankle-Brachial Index Test (ABI)
The blood pressure in your arms and ankles is checked using a
regular blood pressure cuff and a special ultrasound stethoscope
called a Doppler.
The pressure in your ankle is compared to the pressure in your
arm to determine how well your blood is flowing.
The index is determined by dividing ankle systolic BP by arm
systolic BP.

12. ABI
• Measurements are usually taken at rest and after
standardized treadmill exercise (i.e.. For 5 min. at
2mph, 12%).
• A normal resting ABI is 1 or 1.1.
• An index of 0.9 or less indicates the presence of
obstructive disease.
• 0.5 or less suggests multiple-level arterial disease.
• An ABI of less than 0.26 indicates severe, limb-
threatening arterial compromise.

13. Duplex Ultrasonography and
Doppler Color-Flow Imaging
• Technical advances in ultrasonography have
allowed reproducible measurements of blood
vessels and blood flow as well as standardization
of criteria for assessment of PVD.
• Doppler color-flow imaging are useful in localizing
diseased segments, and spectral imaging can
assess lesion severity.

14. Magnetic Resonance Imaging
and Angiography
• Useful in evaluating arterial dissection and
characterizing vessel-wall morphology (including
hematoma or thrombus).
• Computed Tomography (CT) Angiography

15. Treatment for PVD
• Severe lower extremity PVD is treated initially with
cardiovascular disease risk factor modification:
Exercise training
Medication
Diet
Stop Smoking
Interventional Radiology
Surgery
Gene-Based Therapy

16. Exercise
• Research has shown that regular exercise is the
most consistently effective treatment for PVD.
• Patients who have taken part in a regular
exercise program for at least 3 months have
seen substantial increases in the distances they
are able to walk without experiencing painful
symptoms.

17. Exercise Prescription
• Training Intensity
Initial
• Set by result of peak treadmill.
• Starting exercise work load brings on
claudication pain.
Subsequent
• Speed or grade increased if patient walks >
10 minutes.
• Grade increased first if speed > 2 mph.
• Speed increased first if < 2 mph.

18. Exercise Prescription
• Duration
Initial
• 35 minutes (intermittent walking)
Subsequent
• Add 5 minutes every session until 50
minutes (intermittent walking) is possible

19. Exercise Prescription
• Frequency
3-5 times per week.
• Specificity of Activity
Treadmill walking is the recommended exercise.

20. Stop Smoking
• On average, smokers are diagnosed with PVD as
much as 10 years earlier than non-smokers.
• Stopping smoking now is the single most
important thing you can do to halt the
progression of PVD or prevent it in the future.

21. Medications
• Drugs that lower cholesterol or control high blood
pressure.
• Decrease blood viscosity.
Trental, Persantine, or Coumadin
• Antiplatlet agents: their primary long-term
benefit is reduction in cardiovascular events and
mortality.
ASA doses of 75 to 325mg QD have shown protective benefits.
Ticlid and Plavix also have shown promise in disease prevention
and in therapy after vascular intervention.

22. Interventional Radiology
Treatments
• Angioplasty
• Stents
• Thrombolytic Therapy
• Stent-Grafts

23. Gene-Based Therapy
• The field of molecular genetics has provided new
understanding of vascular physiology and
pathology and has opened exciting frontiers in the
treatment of PVD.
• Direct gene transfer by intramuscular injection of
DNA encoded with vascular growth factors has
resulted in growth of new vessels and collateral
circulation in chronically occluded lower extremity
arterial vessels.

24. Surgical Treatments for PVD
• Thrombectomy
• Bypass Grafts

26. Aneurysms
• Most common lethal peripheral vascular
abnormality.
An artery whose diameter is 1.5 times the normal.
• Aortic aneurysms are caused by weakening of the
artery walls due to atherosclerosis. The weakened
walls balloon out, forming an aneurysm.
• When blood pumps from the heart through the
aorta, it places pressure on the aneurysm walls.
Over time, the aneurysm can get bigger and bigger,
until eventually it may rupture.

27. Aortoiliac Occlusive Disease
• Typically involves the distal abdominal aorta as
well as the common and external iliac arteries.
• Aortobifemoral bypass with a prosthetic graft has
been the traditional treatment of choice for
aortoiliac occlusive disease since the 1960’s.
• The operative morbidity and mortality are in the
2% range, and long-term patency exceeds 90%.

28. Superficial Femoral Occlusive
Disease
• Presents with symptoms of claudication of the
calf and sole of the foot.
Usually improves as collateral circulation develops.
• Best treatment initially is antiplatelet therapy in
combination with a vigorous exercise program.

29. Tibial Artery Disease
• Distal atherosclerotic disease involving the
tibioperoneal trunk and the tibial vessels is the
most difficult to treat and leads to the greatest
morbidity and tissue loss.
• ABI is typically less than 0.4 before rest pain
develops, and any value less than 0.3 almost
always results in ischemic tissue loss.

30. Upper Extremity Disease
• Atherosclerotic disease involving the arms is
almost always limited to the larger proximal
vessels and rarely involves the brachial, radial, or
ulnar arteries.
• Although these patients have no symptoms, they
can have a large discrepancy in BP between the
left and right arms.
Always prudent to measure BP in both arms.

31. Thrombosis
• A thrombus, or blood clot, within a blood vessel.
• Normally, a blood clot forms to prevent bleeding
but a thrombus is an abnormal blood clot in the
vessel when it is not even punctured.
• The clotting process may be encouraged by the
buildup of fatty acids on the vessel walls.
• Thrombosis in the vein may cause pain and
swelling.

32. Deep Venous Thrombosis
• A blood clot in a deep vein.
• May form on the valves within the vein, and may
subsequently increase in size to totally occlude
the vein.
• Sometimes parts of the clot may break off and
travel in the bloodstream to the lungs and cause
serious health problems (pulmonary embolism).
• DVT is perhaps the most dangerous problem.
• Patients with DVT have a 30 to 40% risk of
recurrence later in life.

33. Phlebitis
• Inflammation of the leg veins.
• Two types:
Inflammation of the veins on the surface of the leg (more
common).
Inflammation of the deep veins of the leg.
• Phlebitis is caused by an infection or injury.
• Can cause a blood clot to form and this clot can
then embolize and result in pulmonary embolism.
This is the worst thing that can happen if you
have phlebitis.

34. Pulmonary Embolism
• An embolus is a clot or any other piece of
material that is carried around in the blood.
• Pulmonary embolism is where the embolus gets
stuck in a vessel going to the lungs.
• The only way a clot can go to a vessel in the lungs
is if it passes through the heart and is pumped out
of the pulmonary artery.
• So, the closer the clot is to the heart, the more
likely to get a pulmonary embolism.

35. Varicose Veins
• Caused because either the blood flow is too slow
making the vein pile up with blood or the valve in the
vein is not working well so the blood falls down due to
gravity and piles up in the veins of the legs.
• Sclerotherapy: Irritant chemical is injected into the
veins, causing them to scar and seal off. This
“detours” the blood to nearby healthier veins.
• Stripping: Procedure used to remove larger varicose
veins. Parts of the vein can be removed or tied off, or
the entire vein can be removed.

36. • Surgery continues to play an important role in the
management of peripheral vascular disease.
• Revascularization procedures provide excellent
outcomes for many patients at risk for loss of a
limb or seriously impaired quality of life.
• Although endovascular techniques are now being
used for managing many vascular problems, the
traditional surgical approaches still offer well-
documented benefits.