This document discusses peripheral vascular disease and its management. It covers topics such as thrombosis, varicose veins, deep vein thrombosis, peripheral artery disease, aneurysms, Raynaud's phenomenon, Buerger's disease, venous disease, blood clots, lymphedema, risk factors, symptoms, diagnostic tests including Doppler ultrasound, ankle-brachial index, angiography and treatments including medications, surgery, and lifestyle changes like exercise and smoking cessation.

1. A. Thangamani ramalingam
PT, MSc(psy),PGDRM,
ACspss MIAP

2.  Management of vascular disease[8 Hours]:
thrombosis, phlebitis and phlebothrombosis,
 burger’s disease, varicose veins, DVT, venous
ulcers, lymphoedema & its PT management

3.  Atherosclerosis and
Peripheral Artery Disease
 Aneurysm
 Raynaud's Phenomenon
(Raynaud's Disease or
Raynaud's Syndrome)
 Buerger's Disease(TAO)
 Peripheral Venous
Disease and Varicose
Veins
 Blood Clots in
Veins/venous
thromboembolisms (VTE)
 Blood Clotting Disorders
 Lymphedema

4.  Decreases-
thrombosis,
ischemia
&infarction
 Increases-
hemorrhage, edema
&hyperemia
Causes:
 Traumatic
 Compressive
 Occlusive
 Tumours (growths)
or malformations
 Vessel spasms

5.  not engaging in physical exercise
 poor eating habits
 smoking
 drug use
 over age 50
 overweight
 abnormal cholesterol level
 history of cerebrovascular disease or stroke
 heart disease
 diabetes
 family history of high cholesterol, high blood
pressure, or PVD
 high blood pressure
 kidney disease on hemodialysis
 extreme injuries
 blood vessel
inflammation
 infection.

6.  Pain
 Decreased or no pulse
 Abnormal color
changes in the
fingertips(palor)
 Ulcers or wounds that
do not heal/gangrene
 Hand problems when
in cold temperatures
or locations
 Numbness or tingling
of the fingertips
 Swelling
 Reduced hair growth
 Severe burning of
extremities
 Heavy limbs
 Cramps
 Claudication

8. Test Method interpretation
Doppler ultrasound
sound waves for
imaging
blood flow
ankle-brachial index
(ABI)
ultrasound and blood
pressure cuff around
your ankle and arm,
measured before and
during exercise
comparison of blood
pressure readings in
leg and arm - lower
pressure in leg
indicates a blockage
angiography
injected dye in a
catheter that’s guided
through the artery
to diagnose the
clogged artery
magnetic resonance
angiography (MRA)
magnetic field
imaging
to diagnose blockage
computerized
tomography
angiography (CTA)
X-ray imaging to diagnose blockage

9. Medications
 cilostazol or pentoxifylline
to increase blood flow and
relieve symptoms of
claudication
 clopidogrel or daily aspirin
to reduce blood clotting
 atorvastatin, simvastatin,
or other statins to lower
high cholesterol
 angiotensin-converting
enzyme (ACE) inhibitors to
lower high blood pressure
 diabetes medication to
control blood sugar
 Surgery
 Phlebotomy
 Amputation

10. Phlebo thrombosis occurs when
a blood clot in a vein, forms
independently from the presence
of inflammation of the vein
(phlebitis). Thrombophlebitis is
phlebitis (vein inflammation)
related to a thrombus (blood
clot). These are conditions usually
of the superficial venous system
and generally mild and
uncomplicated as opposed
to deep vein thromboses which
can be life-threatening
 Phlebitis refers to
inflammation of a vein
 Thrombophlebitis refers to
the formation of a blood
clot associated with
phlebitis.
 Thrombophlebitis can be
superficial (skin level) or
deep (in deeper veins).
 First described by the
Scottish surgeon John
Hunter in 1784.
 Treatment usually consists
of NSAIDs
 Pain
 Swelling
 Redness
 Tenderness
 Hard and cord like
veins

11.  Increased temp
 Tender/swollen calf
 Red/shiny skin
 Homan’s test positive
 Engorged veins/edema
 Cord like veins
 Pain along the course of the vein

13. Risk of DVT may begin
during,in24-48hrs or late as
3 months of surgery

14.  Homans' sign is a sign of deep vein
thrombosis (DVT). A positive sign is present
when there is pain in the calf or popliteal
region with examiner's abrupt dorsiflexion of
the patient's foot at the ankle while the knee is
flexed to 90 degrees.

15.  Pratt's sign is an indication of femoral deep
vein thrombosis. It is seen as the presence of
dilated pretibial veins in the affected leg,
which remain dilated on raising the leg.
 The sign was described
by American surgeon Gerald H. Pratt of St.
Vincent's Hospital in 1949

16.  Wells score or criteria: (Possible score -2 to 9)
 Active cancer (treatment within last 6 months or
palliative) +1 point
 Calf swelling >3 cm compared to other calf (measured
10 cm below tibial tuberosity) +1 point
 Collateral superficial veins (non-varicose) +1 point
 Pitting edema (confined to symptomatic leg) +1 point
 Previous documented DVT +1 point.
 Swelling of entire leg +1 point
 Localized pain along distribution of deep venous system +1 point
 Paralysis, paresis, or recent cast immobilization of lower
extremities +1 point
 Recently bedridden > 3 days, or major surgery requiring regional
or general anesthetic in past 4 weeks +1 point
 Alternative diagnosis at least as likely -2 points

17. Interpretation:
 Score of 2 or higher — deep vein
thrombosis is likely. Consider imaging the
leg veins.
 Score of less than 2 — deep vein
thrombosis is unlikely. Consider blood test
such as d-dimer test to further rule out
deep vein thrombosis.

18.  Night pain
 Venous ulceration
 edema

19.  Duplex ultra sound
 Venography
 Impedance plethysmography
 MRI
 D-dimer blood test

20.  Heparin
 Warfarin
 Aspirin
 Dextran
 Compression devices

21. Medicines don’t usually work
well to treat the disease.
surgery may be effective
stop using all tobacco products
 recurring progressive
inflammation and
thrombosis (clotting)
of small and medium
arteries and veins of
the hands and feet.
 Pain
 Claudication at
rest/walking
 ischemic ulcers or
gangrene
 Cold hands or feet
 Skin changes

22.  With the patient
supine, note the
colour of the feet
soles. They should be
pink. Then elevate
both legs to 45
degrees for more than
1 minute. Observe
the soles. If there is
marked pallor
(whiteness), ischemia
should be suspected.
 Capillary refill test
 Rubor of dependency:
Sit the patient upright
and observe the feet.
In normal patients,
the feet quickly turn
pink. If, more slowly,
they turn red like a
cooked lobster,
suspect ischemia.

23.  Elevate leg to approximately 60 for 1‐2
minutes • Allow gravity to drain distal veins •
Quickly lower leg over edge of table/bed to
dependent position (leg hanging
perpendicular to floor) • Observe superficial
veins and record amount of time required for
them to refill and return to baseline
appearance • Normal 5‐15 seconds • > 20
seconds indicative of moderate to sever
arterial insufficiency • If refill < 5 seconds
suspect venous insufficiency

24.  The ankle pressure should be equal to or
slightly higher than the arm pressure in the
absence of arterial occlusive disease

25.  Buerger exercises is a system
of exercises for arterial
insufficiency of lower limbs,
consisting of legs elevation,
followed by dependency of the
legs, and finally horizontal
position of legs for rest.
Published in 1924 by Leo
Buerger (1879-1943), New York
physician.
 Buerger exercises augmented
by active exercises of the feet.
These exercises consist in
flexion, extension, and
circumduction of the ankles
and are done during the phase
of dependency of the legs, as
suggested in 1931 by Arthur W.
Allen (1887-1958).
 Buerger-Allen exercise - Specific
exercises intended to improve
circulation to the feet and legs. The
lower extremities are elevated to a
45 to 90 degree angle and supported
in this position until the skin blanches
(appears dead white). The feet and
legs are then lowered below the level
of the rest of the body until redness
appears (care should be taken that
there is no pressure against the back
of the knees); finally, the legs are
placed flat on the bed for a few
minutes. The length of time for each
position varies with the patient's
tolerance and the speed with which
color change occurs. Usually the
exercises are prescribed so that the
legs are elevated for 2 to 3 minutes,
down 5 to 10 minutes, and then flat
on the bed for 10 minutes.

26.  Valvular
insufficiency/valvular
incompetence
 visible, bulging, palpable
(can be felt by touching),
long, and dilated (greater
than 4 millimeters in
diameter).
 retrograde flow or venous
reflux
 leg swelling, stasis
dermatitis/venous eczema,
skin
thickening(lipodermatosclero
sis) and ulceration
 Cramps
 telangiectasia/spider veins
 sclerotherapy, elastic
stockings, leg elevation and
exercise.
 ultrasound-guided foam
sclerotherapy,
radiofrequency ablation and
endovenous laser treatment.
 Cryotherapy

27.  patient in the supine position
 leg is flexed at the hip and raised
 A tourniquet is applied around the upper thigh to compress the
superficial veins
 The leg is then lowered by asking the patient to stand.
 Normally the superficial saphenous vein will fill from below
within 30–35 seconds as blood from the capillary beds reaches the
veins; if the superficial veins fill more rapidly with the tourniquet
in place there is valvular incompetence below the level of the
tourniquet in the "deep" or "communicating" veins. After 20
seconds, if there has been no rapid filling, the tourniquet is
released. If there is sudden filling at this point, it indicates that
the deep and communicating veins are competent but the
superficial veins are incompetent
 The test can be repeated with the tourniquet at different levels
 above the knee - to assess the mid-thigh perforators
 below the knee - to assess incompetence between the short
saphenous vein and the popliteal vein

28.  commonly used as sclerosants are
polidocanol, sodium tetradecyl sulphate
(STS), Sclerodex , Hypertonic Saline, Glycerin
and Chromated Glycerin.
 Flavonoids drug therapy.

29.  An ulcer is a shallow destruction of the
skin tissues & mucous membrane
which may occur at any part of the
body. Various ulcers are the
complication of various veinous
problems
 Stasis and congestion both in veins &
lymphatics
 Slight trauma – break down of skin –
infected – ulcer – chronic inflammation
–pain & stiffness – less usage –
hypotonia of the muscle – decreased
venous pumping –stasis & congestion –
skin more prone for injuries(vicious
cycle)
 Massage/pain relief/FUP/UVR/Laser
 Bisguard bandage method
Infected
ulcer
Hyper
granulating
ulcer
Healing ulcer
Chronic ulcer
Indurated
chronic ulcer
Indolent
ulcer

30.  Primary
 Secondary

31.  1. Increased Hydro static Pressure of blood
 2. Decreased Osmotic Pressure of blood
 3. Increased Capillary permeability
 4. Lymphatic obstruction
 5. Slowed flow of blood and lymph

32.  Arterial end: 30.3(Hydro)-22.= 8.3 out
 Venule end: 22(Net COP)- 15.3= 6.7 in

33.  1+ - oedema barely there
 2+ - oedema Significantly present
 3+ - oedema is Very significant
 4+ - The limb is 1.5-2.0 times more than the
normal size

34. • Latent or subclinical condition wherein edema is not evident
despite impaired lymph transport.
• It may exist months or years before overt edemaoccurs .Grade0
• The edema pits in response to pressure and isreduced
significantly by elevation. There is no clinical evidence of
fibrosis.Grade 1
• Edema does not pit in response to pressure and is not reduced
by elevation. Moderate to severe fibrosis is evident on clinical
examination.Grade 2
• Lymphedema is irreversible and develops as a result of
repeated inflammatory insults. Fibrosis and sclerosis of the skin
and subcutaneous tissues is present.
• This stage of edema is known also as lymphostatic elephantiasis
Grade 3

41.  Quitting smoking
 Lowering cholesterol
 Lower blood pressure
 Lower blood glucose
 Physical activity

42.  The recommended parameters of physical exercise
are a 6 month program of 30-35 minutes walking
sessions at a frequency of 3-5 times a week at near-
maximal pain tolerant (Mahameed, AA, Bartholomew,
JR, Disease of Peripheral Vessels. In: Topol, EJ,
editor. Textbook of Cardiovascular Medicine. 3rd ed.
New York: Lippincott Williams &amp; Wilkins, 2007,
p.1531-1537).
 NICE recommends PAD patients to exercise at near-
maximal pain for a total of 2 hours per week for 3
months to improve quality of life (NICE National
Institute for Health and Care Excellence. Lower limb
peripheral arterial disease: diagnosis and
management,2012. https://www.nice.org.uk/guidanc
e/cg147/chapter/guidance#management-of-
intermittent-claudication)

43. • Gardner AW, Poehlman ET. Exercise rehabilitation programs for the
treatment of claudication pain. A meta-analysis. JAMA. 1995;274:975-80.
• Lauret GJ, Fakhry F, Fokkenrood HJ, Hunink MG, Teijink JA, Spronk
S. Modes of exercise training for intermittent claudication. Cochrane
Database Syst Rev. 2014;7:CD009638
 The duration and frequency of the exercise training
sessions and duration of the exercise training program are
important to achieve maximal benefit with training
sessions: >30 minutes per session provides greater benefit
than <30 minutes per session; >3 sessions per week is more
effective than <3 sessions per week, and program lengths
of >26 weeks are more effective than program lengths of
<26 weeks .
 Alternatives to treadmill exercise potentially consist of
various forms of lower extremity exercise alone or in
combination (brisk walking, bicycle ergometer, and
strength training). However, the outcomes of treadmill
exercise have so far been found to be superior to the
outcomes of several other lower extremity exercises,
namely cycling, stair climbing, and static and dynamic leg
exercises .