Peripheral Vascular Disease: What you need to know. Mr Dan Higman MBBS MS FRCS Consultant Vascular Surgeon

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1 Peripheral Vascular Disease: What you need to know Mr Dan Higman MBBS MS FRCS Consultant Vascular Surgeon

2 What you need to know about peripheral vascular disease History of peripheral vascular disease How to examine the leg, and what else to look for Diagnosing aetiology of leg ulcers Principles of management of PVD

3 Two Clinical Syndromes Intermittent Claudication - More difficult to diagnose Easier to treat Critical Ischaemia - Easier to diagnose More difficult to treat

4 Why is it Intermittent Claudication? Because the pain is a claudication-like pain occurs during walking causes the patient to stop is worse on hills is relieved by resting for 2-3 minutes occurs in a muscle occurs at a fixed distance never occurs at rest

5 Other points in the claudicant history Effects on lifestyle Risk factors smoking, DM, HT, lipids Other sites of atheroma: IHD, stroke Other significant co-morbidities

6 Claudicants clinically. May have palpable foot pulses May have a normal resting ABPI May have warm feet May have normal capillary refill BUT Will have abnormal exercise ABPI Will have abnormal duplex

7 Measuring the ABPI

8 Ankle-Brachial Pressure Index Normal >1.0 Mild claudicants may have ABPI>1.0 at rest On exercise (treadmill), patients with PVD have fall in ABPI Explanation: Limb vasodilation on exercise NOT accompanied by increased flow (stenosis) therefore ankle pressure drops

9 PVD: on examination Expose lower limbs Inspection: pallor, hair loss, skin and nail condition Palpation: capillary refill, temperature Peripheral pulses: Femoral, popliteal, DP, PT PULSES CAN ONLY BE NORMAL, REDUCED, OR ABSENT

10 Expose lower limbs

11 Look for Pallor

12 Capillary Refill < 2 sec

13 Compare temperature

14 Peripheral Pulses - Popliteal

15 Peripheral pulses dorsalis pedis

16 Peripheral pulses posterior tibial

17 PVD: on examination Buergers test: Elevation until foot goes pale (Buergers angle) Then place foot dependant Foot becomes hyperaemic Explanation: Foot with PVD becomes ischaemic on elevation, it vasodilates and then becomes hyperaemic on dependancy.

18 Buergers test Buergers angle

19 PVD Patient other areas to check Carotid bruit AAA: palpate epigastrium Renal artery bruit Cardiac examination

20 Other leg pains in my clinic Arthritis in hip / knee / ankle Cramp Sciatica Spinal claudication Muscular pain (e.g. polymyalgia) Peripheral oedema

21 Critical Ischaemia Rest pain OR Tissue loss DUE TO Arterial Insufficiency

22 Rest Pain Occurs in the forefoot o Is made worse by elevation Is relieved by dependency Occurs in bed at night Tissue loss includes Digital gangrene Arterial ulceration, which may be painful on elevation

23 Critical ischaemia: tissue loss

24 Diagnosing venous ulceration Gaiter area of the lower leg Typically medial Surrounding skin shows: pigmentation (haemosiderin) thickening on palpation (lipodermatosclerosis) eczema Pain less on elevation ABPI normal (caution in diabetes)

25 Secondary venous change

26 Venous ulceration

27 Diagnosing Trophic Ulceration pressure area / neuropathy / callus

28 Diagnosing arterial ulceration Gaiter area or onto the foot Typically lateral Surrounding skin is atrophic and shiny Pain is worse on elevation Foot pulses absent ABPI low (caution in diabetes)

29 Arterial Ulceration

30 Treating claudication Manage risk factors (smoking, diabetes, hypertension, lipids) Antiplatelet therapy Exercise In disabling claudication, (having done above) Angioplasty? Fem-pop bypass?

31 Managing critical ischaemia (arterial ulceration or gangrene) Manage risk factors: smoking cessation diabetic control treat hypertension treat hyperlipidaemia statins Revascularise the limb

32 Principles of bypass surgery Bypass needs inflow, conduit and outflow Inflow: generally femoral artery Conduit: use vein whenever possible Outflow: any vessel down to foot vessels

33 Poor inflow due to blocked iliac arteries

34 Arterial bypass surgery using saphenous vein

35 Summary PVD causes 2 clinical syndromes: intermittent claudication and critical ischaemia (rest pain, ulceration or digital gangrene) All PVD patients need risk factor management

36 Summary 2 Arterial ulceration must be distinguished from venous ulceration Some patients have elements of both Patients with critical ischaemia (rest pain, ulceration or gangrene) require revascularisation to prevent limb loss.

37 Summary 3 Arterial ulceration is treated by revascularisation (angioplasty or bypass) Venous ulceration is treated by compression Mixed ulceration is treated by revascularisation followed by compression

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