Clinical examination peripheral vascular disease

CLINICAL EXAMINATION OF PERIPHERAL

VASCULAR DISEASES

What is PVD?

Definition:

• Also known as PAD or

PAOD.

• Occlusive disease of the

arteries of the extremity.

charac. by a reduction in

blood flow and hence 02

through the peripheral

vessels

when the need of the

tissues for 02

exceeds the

supply, areas of ischemia

and necrosis will develop

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.

Factors that can contribute to the development

of peripheral vascular disorders :

atherosclerotic changes

thrombus formation

embolization

coagulability of blood

hypertension

inflammatory process/infection

CAUSES OF ISCHEAMIA

LARGE ARTERY OCCLUSION

-Atherosclerosis

-Embolism.

SMALL ARTERY OCCLUSION

-Buerger`s disease

-Raynaud`s disease

-embolism

-scleroderma

-physical agents –Trauma,radiation,electric

burns,pressure necrosis

ATHEROSCLEROSIS

AGE- above 50yrs

Vessels involved– medium sized & large vessels

aorta,femoral,carotids.

Nature of vessel- Thickned

Pathology – Deposition of atheromatous plaque in

the intima.

Risk factors – smoking, diabetes,hypertensive,

obesity,hypercholesterolaemia.

TAO (BUERGER`S DISEASE)

Age -20-40 yrs

Sex – Exclusively males

Vessel involved –Small & medium sized arteries.

Nature of vessel –Not thickned.

Pathology – Diffusion inflammatory reaction

involving all coats of vessels results

obliterans.

Risk factors – Smoking, hypercoagulable,

autonomic hyperactivity,

low socioeconomic.

RAYNAUD`S DISEASE

(PRIMARY RAYNAUD`S PHENOMENON)

-Occur in young females.

-Upper limbs more involved than lower limbs.

- Its episodic digital ischeamia on exposure to

cold

- Peripheral pulses are normal.

- Recurrent attacks.

Atherosclerosis

Thromboangitis Obliterans

CLINICAL EXAMINATION

HISTORY

1. AGE & SEX

Atherosclerosis – Older AGE M~ F

BURGER`S Disease - Mostly men age 20-40yrs

RAYNAUD`S DISEASE – Young women

Diabetic arteriopathy - middle age

2. LIMBS AFFECTED

Lower limbs –Buergers`s disease

- Atherosclerotic

-gangrene

Upper limbs- Raynaud`s disease

Superficial gangrene of fingers

-Raynauds disease

- cervical rib

-scalenus anticus syndrome

3.BILATERAL & UNILATERAL

BILATERAL –BURGER`S

-Raynaud`s disease.

Atherosclerotic – intially UL later B/L.

UNILATRAL – Embolus.

Diabetic gangrenous – U/L or B/L.

4.MODE OF ONSET

Spontaneously & gradually

-Atherosclerosis gangrene

- Raynaud`s disease

-Buerger`s disease

Suddenly

- embolic gangrene

Traumatic & infection

- Diabetic

5.PAIN

-site

-charcter

-radiation

TYPES

-Intermittent claudication.

claudication distance

Grades I,II,II (boyd`s classification)

- Rest pain

5.EFFECTS OF HEAT & COLD

Raynaud`s phenomenon

Raynaud`s disease

-local syncope

- local asphyxia

- local recovery ----- local gangrene

6. PARAESTHESIA

- Numbness.

- pins and needles sensation.

7.HISTORY OF SUPERFICAIL PHLEBITIS:

8.INVOLVMENT OF OTHER ARTERIES

-Transient attack, fainting .(stroke)

- chest pain (coronary arteries)

- abdominal pain (mesentric arteries)

- blurred vision (retinal areteries)

HISTORY IMPOTENCE

B/L internal iliac artey occlusion.

PAST HISTORY

cardiac attacks, embolic, frost bite.

PERSONAL HISTORY\: Smoking.

FAMILY HISTORY:

PHYSICAL EXAMINATION

LOCAL EXAMINATION

1.INSPECTION

Change in colour

Pallor

– sudden occlusion of arteries

- spasm of arteries in raynaud`s.

Congestion& cyanosed

-severe ischemia & pre gangrenous stage

2.SIGNS OF ISCHEMIA

1.Thinning of skin

2.Diminished growth of hair,

3.Loss of subcutaneous fat,

4.Trophic changes in nails

5.Muscle wasting

6.Minor ulceration over pressure area

3.BUERGER`S POSTURAL TEST:

Bauerger angle (vascular angle)

-normal indiviual legs will be pink raised

above 90degree

-severe ischemia buerger angle less than 30

degree

4.CAPILLARY FILLING TIME

-severe ischaemic it take 20-30 sec.

5.VENOUS FILLING TIME

-Noramal 5 sec.

-In ischaemic limb veins collapsed.

IN GANGRENE

- Extent & color of gangrene.

-TYPE

dry (mummified) .

wet (putrefying).

-LINE OF DEMARCATION.

- SKIP LESIONS

PALPATION

1. Skin temperature.

2.capillary filling time.

3.venous filling time.

4.crossed leg test (fuchsig test):

oscillatory movements obsent popliteal block.

5.Cold and warm water test.

TEST FOR UPPER LIMBS:

-Elevated arm test.

-Allen`s test.

-Costoclavicular compressive manoeurve.

-Hyperabduction manoeurve

-GANGREANGENOUS AREA.

-CREPITUS.

-LIMB ABOVE GANGRENOUS AREA.

PALPATION OF BLOOD VESSELS.

LOWE LIMBS

-Dorsalis pedis

-posterior tibial

-anterior tibial

-popliteal

-femoral

UPPER LIMB

-radial & ulnar

-brachial

subclavian

common carotid.

Superficaial temporal.

Examination of arterial wall

-PIulse

-condition of wall

- thrombosis of vessel.

CERVICAL RIB

-Adson`s test.

NEUROLOGICAL EXAMINATION:

AUSCULTATION

systolic bruit. In occlusion

-Blood pressure of both arms.

-Ankle brachial pressure index.

-Heart for murmur etc.

Differential diagnosis of limb pain

– Arteritis

– Ischemic intermittent claudication

– Nerve root pain, sciatica, neurogenic

– pseudoclaudication (spinal stenosis)

– Peripheral nerve pain (eg, diabetic neuropathy)

– Phlebitic syndrome after deep venous

thrombosis

– Thromboangiitis obliterans (Buerger disease)

– Venous claudication

INVESTIGATION:

complte blood picture.

blood sugar.

blood lipid profile.

-Doppler ultrasound blood flow detector.

-Duplex scan.

-Plethysmography.

- Angiography

1.Modification factors

a)Smoking Cessation

b)Rigorous BSL con

c)BP reduction

d)Lipid Lowering Therapy

• 2EXERCISE:

a)Claudication exercise rehabilitation program

b)45-60mins 3x weekly for 12 weeks

c)6 months later +6.5mins walking time (before

pain)

3.MEDICAL MANAGEMENT:

a)Antiplatelet therapy e.g.

Aspirin/Clopidogrel

b)Phosphodiesterase Inhibitor e.g. Cilostazol

c)Foot Care

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

ACUTE ARTERIAL DISEASE

sudden occlusion of major peripheral artery.

due to:

-Arterial embolus

-Trauma

-Acute arterial thrombosis

FEATURES OF ACUTE LIMB

ISCHEAMIA

1.PAIN

2.PALLOR

3.PULSELESNESS

4.PERISHING COLD

(POIKILOTHERMIA)

5.PARASTHESIAS

6.PARALYSIS

INVESTIGATION

-Angiography

TREATMENT

- THRMOBOLYSIS

SURGICAL

-embolectomy

GANGRENE

• Gangrene implies death of macroscopic

portions of tissue; the term necrosis

may be used synonymously.

• It often affects the distal part of a limb

because of arterial obstruction (from

thrombosis, embolus or arteritis).

TYPES

- Dry gangrene

- Wet gangrene.

Signs of gangrene.

1.change of colour

pale,bluish purple and finally black.

2. loss of temperture.

3.loss of sensation.

4.loss of pulsation.

5.loss of function.

DRY GANGRENE

Wet gangrene

Causes of ischaemia

-Large vessel occlusion.

- Small vessel occlusion.

CAUSES OF GANGRENE.

cardiovascular

-traumatic .

-Infective.

-Diabetic

-Nervous diseases

-Physical gangrene . Frost bite

TREATMENT

- amputation.

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