peripheral vascular disease


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Related to peripheral vascular disease: Raynaud's disease, Peripheral neuropathy

Peripheral Vascular Disease

 

Definition

Peripheral vascular disease is a narrowing of blood vessels that restricts blood flow. It mostly occurs in the legs, but is sometimes seen in the arms.

Description

Peripheral vascular disease includes a group of diseases in which blood vessels become restricted or blocked. Typically, the patient has peripheral vascular disease from atherosclerosis. Atherosclerosis is a disease in which fatty plaques form in the inside walls of blood vessels. Other processes, such as blood clots, further restrict blood flow in the blood vessels. Both veins and arteries may be affected, but the disease is usually arterial. All the symptoms and consequences of peripheral vascular disease are related to restricted blood flow. Peripheral vascular disease is a progressive disease that can lead to gangrene of the affected area. Peripheral vascular disease may also occur suddenly if an embolism occurs or when a blot clot rapidly develops in a blood vessel already restricted by an atherosclerotic plaque, and the blood flow is quickly cut off.

Causes and symptoms

There are many causes of peripheral vascular disease. One major risk factor is smoking cigarettes. Other diseases predispose patients to develop peripheral vascular disease. These include diabetes, Buerger's disease, hypertension, and Raynaud's disease. The main symptom is pain in the affected area. Early symptoms include an achy, tired sensation in the affected muscles. Since this disease is seen mainly in the legs, these sensations usually occur when walking. The symptoms may disappear when resting. As the disease becomes worse, symptoms occur even during light exertion and, eventually, occur all the time, even at rest. In the severe stages of the disease the leg and foot may be cold to the touch and will feel numb. The skin may become dry and scaly. If the leg is even slightly injured, ulcers may form because, without a good blood supply, proper healing can not take place. At the most severe stage of the disease, when the blood flow is greatly restricted, gangrene can develop in those areas lacking blood supply. In some cases, peripheral vascular disease occurs suddenly. This happens when an embolism rapidly blocks blood flow to a blood vessel. The patient will experience a sharp pain. followed by a loss of sensation in the affected area. The limb will become cold and numb, and loose color or turn bluish.

Diagnosis

Peripheral vascular disease can be diagnosed by comparing blood pressures taken above and below the point of pain. The area below the pain (downstream from the obstruction) will have a much lower or undetectable blood pressure reading. Doppler ultrasonography and angiography can also be used to diagnose and define this disease.

Treatment

If the person is a smoker, they should stop smoking immediately. Exercise is essential to treating this disease. The patient should walk until pain appears, rest until the pain disappears, and then resume walking. The amount of walking a patient can do should increase gradually as the symptoms improve. Ideally, the patient should walk 30-60 minutes per day. Infections in the affected area should be treated promptly. Surgery may be required to attempt to treat clogged blood vessels. Limbs with gangrene must be amputated to prevent the death of the patient.

Prognosis

The prognosis depends on the underlying disease and the stage at which peripheral vascular disease is discovered. Removal of risk factors, such as smoking, should be done immediately. In many cases, peripheral vascular disease can be treated successfully but coexisting cardiovascular problems may ultimately prove to be fatal.

Resources

Books

Alexander, R. W., R. C. Schlant, and V. Fuster, editors. The Heart. 9th ed. New York: McGraw-Hill, 1998.

Key terms

Embolism — The blockage of a blood vessel by air, blood clot, or other foreign body.
Plaque — A deposit, usually of fatty material, on the inside wall of a blood vessel.

peripheral

 [pĕ-rif´er-al]
pertaining to or situated at or near the periphery.
peripheral vascular disease (PVD) any disorder affecting blood flow through the veins and arteries distal to the heart. Disruption of circulation in the peripheral veins can be caused by venous stasis, hypercoagulability, or injury to the vein wall secondary to immobility, orthopedic surgery, aging, and dehydration. Arterial insufficiency in the peripheral vessels is most often due to atherosclerosis, blood clots, trauma, spasms of smooth muscles in the arterial walls, and congenital structural defects in the arteries.

Diminished or interrupted flow of blood through peripheral arteries can eventually lead to ischemic necrosis and gangrene. Sluggish venous flow leads to increased pressure within the vessels, causing varicose veins and sometimes thrombophlebitis. When blood is not moved out of the veins of the lower limbs, it accumulates there and serves as an excellent medium for bacterial growth and contributes to the formation of leg ulcers. Treatment is aimed at improving blood flow by removing or mitigating the cause of impaired circulation.
Assessment of Arterial Circulation. Arterial insufficiency is characterized by two types of pain. The first is a cramping pain in the muscles brought on by exercise and relieved by rest (intermittent claudication). The pain is most often felt in the calves of the legs, but it may also affect the thighs and buttocks. A second type of pain is characteristic of advanced chronic occlusive arterial disease. It occurs when the patient is at rest, usually at night while lying down. The sensation is described as burning and tingling, with numbness of the toes.

Assessment includes noting the color and temperature of the skin in the affected areas and any signs of trophic changes. Epidermoid tissues that are chronically malnourished because of poor blood supply appear shiny, smooth, and thin, with little or no hair on the surface. The nails are thick, with deposits of cornlike material under them. With time, a decreased blood supply produces ischemic changes that cause the skin to assume a purple-black color that is characteristic of cyanosis and gangrene. Additional assessment data include the rate, rhythm, and force of the peripheral pulses.
Assessment of Venous Circulation. Assessment of venous circulation focuses on changes in the hydration status (edema) and pigmentation of the skin. Chronic edema can lead to ulceration. Venous insufficiency also produces a darkened color, dryness, and scaling of the skin in the affected areas. Venography, a radiologic test in which the vein is injected with a radiopaque dye prior to filming, can also demonstrate engorged and tortuous veins.
Patient Teaching. In order to prevent or mitigate the effects of arterial insufficiency or venous stasis, patients must be taught techniques of self-care. Exercises such as the buerger-allen exercises are often prescribed. Additionally, patients need to know how to take care of their feet and legs (see foot care), the reasons for avoiding smoking and keeping warm, and the importance of taking prescribed medications.

peripheral vascular disease

n.
Any of various diseases, including peripheral artery disease, that occur in blood vessels outside the heart and the brain.

peripheral vascular disease (PVD)

any abnormal condition that affects the blood vessels and lymphatic vessels, except those that supply the heart. Different kinds and degrees of PVD are characterized by a variety of signs and symptoms, such as numbness, pain, pallor, elevated blood pressure, and impaired arterial pulsations. Causative factors include obesity, cigarette smoking, stress, sedentary occupations, and numerous metabolic disorders. PVD in association with bacterial endocarditis may involve emboli in terminal arterioles and produce gangrenous infarctions of distal parts of the body, such as the tip of the nose, the pinna of the ear, the fingers, and the toes. Large emboli may occlude peripheral vessels and cause atherosclerotic occlusive disease. Treatment of severe cases may require amputation of gangrenous body parts. Less severe peripheral vascular problems may be treated by eliminating causative factors, especially cigarette smoking, and by administering various drugs, such as salicylates and anticoagulants. Some kinds of peripheral vascular disease are atherosclerosis and arteriosclerosis.

peripheral vascular disease

Atherosclerosis of extremities Vascular disease Any vasculopathy, generally of the major peripheral arterial branches of the aorta with ASHD, which supply the legs and feet, with resulting ↓ in blood flow Diagnosis Angiography Management Angioplasty, peripheral bypass operation, amputation

pe·ri·pher·al vas·cu·lar dis·ease

(PVD) (pĕr-if'ĕr-ăl vas'kyū-lăr di-zēz')
Noncardiac-centered disease of blood vessels, often in extremities. Spider veins are one sign of the presence of such disease.

peripheral vascular disease

Disease of the major blood vessels supplying the limbs, especially diseases such as ATHEROSCLEROSIS, diabetic large vessel disease, Raynaud's disease and THROMBOANGIITIS OBLITERANS, that result in narrowing of vessels and restriction of blood supply. Advanced peripheral vascular disease tends to lead to GANGRENE and is difficult to treat. Avoidance of smoking is one of the most important measures. Arterial reconstructive surgery to bypass affected vessels or ENDARTERECTOMY may help.

peripheral vascular disease

generic term denoting reduced arterial supply to, and compromised venous/lymphatic return from, the lower limbs and feet; see disease, peripheral vascular
peripheral vascular disease; peripheral arterial disease; PAD generic term denoting lower-limb macrovascular disease (e.g. arteriosclerosis, atherosclerosis, arterial stensois or blockage) or the symptoms of macrovascular disease (e.g. intermittent claudication, rest pain, dry gangrene); patients with PAD are likely to have similar vascular effects in brain, heart and kidney arteries (see Table 1, Table 2and Table 3)
Table 1: Risk factors for the development of peripheral arterial disease (PAD)
Risk factorFeature of the risk factor
Modifiable factors
SmokingCigarette smoking is the most powerful risk factor for the development of PAD. It is dose-dependent and the risk declines within 6 months of quitting. A non-smoker is 10 times less likely to develop PAD than a smoker
Blood lipid disordersPlasma cholesterol levels of >5.2 mmol/L
Increased plasma concentrations of low-density lipoprotein (LDL) cholesterol, low plasma concentrations of high-density lipoproteins (HDLs), and higher concentrations of plasma triglycerides all correlate with increased incidence of PAD
Familial hypercholesterolaemia (affecting 1:500 in UK)
Familial combined hyperlipidaemia (affecting 1:250 in UK)
Diabetes mellitus (DM)Type 2 DM increases risk of PAD by 1.5-4.0, due to the associated hypertension, hyperlipidaemia and altered vascular reactivity
HypertensionRaised systolic blood pressure (BP) increases the risk of PAD and atherosclerosis by 4 due to endothelial injury caused by increased intra-arterial shear stresses at the blood-endothelium interface (raised systolic pressures are more predictive than raised diastolic pressures)
ObesityCentral obesity is an independent risk for PAD, but also predisposes to other risk factors for PAD, such as type 2 DM, hypertension
HomocysteineHomocysteine is an amino acid that in high levels is associated with thromboembolism
Haemostatic variablesIncreased levels of clotting factors VII, VIIIC and fibrinogen are associated with increased risk of atherosclerosis
Sedentary lifestyleLow levels of regular activity are associated with increased risk of PAD (higher levels of activity are associated with higher levels of plasma HDL-cholesterol and reduced blood pressures and facilitate the development of the collateral circulation)
Dietary deficienciesLow levels of antioxidant vitamins (vitamins C and E) and polyunsaturated fatty acids facilitate the formation of oxidized LDLs and thus predispose to the risk of PAD
Type A behaviours (TABs)People who tend to aggression, ambitiousness, restlessness, time urgency and high anxiety tend to an increased incidence of PAD, possibly due to increased levels of circulating catecholamines
Non-modifiable or fixed factors
Age and sexAtherosclerosis is more common in males, and in postmenopausal women
Family historyAtherosclerosis shows familial patterns of incidence, possibly due to genetic factors and/or lifestyle choices and patterns
Early environmentFetal origins hypothesis: adverse conditions in utero or infancy predispose to the risk of cardiovascular disease in later life (e.g. statistically, small-birth-weight babies have a higher incidence in adult life of hypertension, type 2 DM, altered plasma lipids, altered bone densities, altered stress responses, less elastic arteries, thicker-walled ventricles and 'age' quicker)
Table 2: Fontaine classification of peripheral arterial disease (PAD)
StageCharacteristic symptoms
1Clinically symptom-free vascular occlusion
2Exercise-induced ischaemia causing intermittent claudication
No pain at rest
3Ischaemia at rest, causing rest pain
4Ulceration and ischaemic gangrene
Table 3: Clinical tests used in the diagnosis of peripheral arterial disease (PAD)
Test modalityDiagnostic indicators
Medical history• Evidence of atherosclerosis, such as ischaemic heart disease, cerebrovascular disease
• Risk of atherosclerosis, such as cigarette smoking, diabetes mellitus
Pulses in the lower limbPopliteal, posterior tibial, dorsalis pedis and peroneal pulses
• Pulse quality (bounding, full, normal, weak, absent)
• Rate (beats/minute)
• Regularity (regular, irregular, regularly irregular, irregularly irregular)
Presenting symptoms• Cold, numb feet
• Intermittent claudication
• Rest pain
• Painful ulceration
Ankle-brachial index (ABI)• 0.9-1.1 = normal
• 0.7-0.9 = PAD, some compromise of tissue viability
• 0.5-0.7 = severe PAD, compromised tissue viability
• <0.5 = threat of ischaemic gangrene/very poor tissue viability
• >1.2 = calcification of tunica media of leg/foot artery, compromised tissue viability
Segmental systolic pressureSerial measurement of systolic blood pressure along length of limb:
• A sudden decrease indicates the location of the vascular obstruction
Venous filling time
Note : this test is not valid if the patient has venous incompetence
The time it takes for veins to refill in a limb that has been drained of venous blood (with the patient supine, the leg is elevated to 45° for 1 minute, then the leg placed in a dependent position and the time taken for the dorsal foot veins to refill)
• <15 seconds = normal
• 20-30 seconds = moderate ischaemia
• >40 seconds = severe ischaemia
Buerger's testThe observation of the change in skin colour in response to limb elevation and dependency (with the patient supine, the leg is elevated to 45° for 1 minute, then the leg is placed in a dependent position and the time taken for normal skin colour to return is noted)
• <10 seconds = normal response
• Patchy persistent rubor indicates limb ischaemia
• Persistent pallor (>10 seconds) indicates limb ischaemia
• Persistent cyanosis indicates limb ischaemia
Buerger's angleThe colour response of the sole of the foot to limb elevation (with the patient supine, the leg is elevated and the angle of limb elevation is noted when the skin of medial longitudinal arch shows pallor)
• 60-70° = normal arterial supply to foot
• < 45° = compromised arterial supply to foot
• < 30° = severe compromised arterial supply to foot
Capillary refill time
Note: this test is not valid if the patient has signs of current Raynaud's disease
The time taken for normal skin tone of a horizontal limb to return after the nail bed or digital pulp has been compressed by thumb pressure
• <5 seconds = normal response
• >5 seconds = some ischaemia
• >15 seconds = marked ischaemia
Doppler sounds• Triphasic = normal
• Biphasic = normal/some loss of arterial elasticity
• Monophasic = loss of arterial elasticity/arterial stenosis
• Loud = high rate of blood flow
• Quiet = slow rate of blood flow
• No sound = no blood flow (proximal arterial occlusion)
Skin temperature
Note: this test is not valid if the patient has signs of current Raynaud's disease
• ~ 31°C = normal foot skin temperature
• <29°C = possible poor skin perfusion

pe·ri·pher·al vas·cu·lar dis·ease

(PVD) (pĕr-if'ĕr-ăl vas'kyū-lăr di-zēz')
Noncardiac-centered disease of blood vessels.
References in periodicals archive ?
However, "the low sensitivity (15%) shows that measurement of differences is of little value as a screening test for peripheral vascular disease, and ankle-brachial pressure indices will still be necessary for diagnosis.
Our retrospective analysis supports the contention that peripheral vascular disease affects both sexes equally when similar risk factors are observed.
Mukherjee D, Lingam P, Chetcuti S, et al: Missed opportunities to treat atherosclerosis in patients undergoing peripheral vascular interventions: insights from the University of Michigan peripheral vascular disease quality improvement initiative (PVD-Q[I.
Norris said in an interview that the results suggest a need to pay closer attention to peripheral vascular disease and that his group has started follow-up studies.
Dialysis patients, who in many cases have diabetes and hypertension, may be at risk for peripheral vascular disease, but it often is under treated by physicians.
Early results indicate that this may be a non- invasive, earlier way to assess functional evidence for peripheral vascular disease.
will discuss the growing role of thrombectomy in treating peripheral vascular disease.
Joseph DeVivo, President and Chief Executive Officer of RITA Medical Systems, said, "AngioDynamics has established itself as a leader in developing, manufacturing and marketing innovative products for the diagnosis and treatment of peripheral vascular diseases, and has earned the respect of interventional radiologists and vascular surgeons for its commitment to its customers.

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