Peripheral Overview
Peripheral Overview
Peripheral Overview
Learning Objectives
1. Understand epidemiology and presentation of common vascular causes of lower limb pain
2. Review basic anatomy and diagnostics
3. Discuss referrals and treatment
Peripheral Overview
Peripheral Overview
Differential for leg pain
1. Vascular•Peripheral Vascular Disease – acute/chronic•Chronic venous disease•DVT
2. Neurospinal•Spinal stenosis
•Disc disease
3. Neuropathic•Diabetic •Chronic EtOH
4. Musculoskeletal•OA of hip or knee•Chronic compartment syndrome
Peripheral Overview
Differential for leg pain
1. Vascular•Peripheral Vascular Disease – acute/chronic•Varicose veins•Chronic venous insufficiency•DVT
2. Neurospinal•Spinal stenosis•Disc disease
3. Neuropathic•Diabetic •Chronic EtOH
4. Musculoskeletal•OA of hip or knee
•Chronic compartment syndrome
1. Vascular•Peripheral Vascular Disease – acute/chronic•Chronic venous disease•DVT
Peripheral Overview
Peripheral Overview
Risk factors
ARTERIAL DISEASE•Advancing age
•Hypertension•Hyperlipidaemia•Family history
•Diabetes
•Smoking
VENOUS DISEASE•Advancing age
•Increased BMI•Pregnancy•Family history
•Standing occupation
•Smoking
•Trauma•Previous DVT
Peripheral Overview
Risk factors
ARTERIAL DISEASE•Advancing age
•Hypertension•Hyperlipidaemia•Family history
•Diabetes
•Smoking
VENOUS DISEASE•Advancing age
•Increased BMI•Pregnancy•Family history
•Standing occupation
•Smoking
•Trauma•Previous DVT
Peripheral Overview
Clinical presentation of PAD~15%
Classic (Typical) Claudication
~33%Atypical Leg Pain(functionally limited)
50%Asymptomatic
1%-2%Critical Limb Ischemia
Peripheral Overview
Claudication vs Pseudoclaudication
Claudication Pseudoclaudication
Characteristic of discomfort
Cramping, tightness, aching, fatigue
Same as claudication plus tingling, burning,
numbness
Location of discomfort
Buttock, hip, thigh, calf, foot
Same as claudication
Exercise-induced Yes Variable
Distance Consistent Variable
Occurs with standing No Yes
Action for relief Stand Sit, change position
Time to relief <5 minutes ≤30 minutes
Peripheral Overview
30% Buttock & Thigh Claudication±Impotence – Leriche’s Syndrome Thigh Claudication
60% Upper 2/3 Calf Claudication
Lower 1/3 Calf Claudication
Peripheral Overview
Symptoms in PAD
• Chronic– Claudication– Restpain
– ulcers / tissue loss
• Acute – 6 P’ s– Pain– Pallor– Poikilothermia– Pulselessness– Paraesthesia– Paralysis
Peripheral Overview
Pathology of PAD
Chronic Causes• Atherosclerosis
• Vasculitis
• Takayasu’s disease
• Buerger’s disease
• Trauma
• Raynaud’s disease
• Fibromuscular dysplasia
Acute Causes• Embolism
• Thrombosis
• Dissection
• Trauma
• Vasculitis
Peripheral Overview
Clinical presentation of venous disease
Varicose veins Oedema Skin changes Ulcers
Peripheral Overview
Symptoms of chronic venous disease
• Limb discomfort – tired, heavy legs, aching
• Oedema
• Discolouration
• Erythema
• Muscle cramps
• Itching
• Tingling/numbness
• Spontaneous bleeding
Peripheral Overview
CEAP Classifications
Clinical Classification of Venous Insufficiency
•Class 0 No visible or palpable signs of venous disease
•Class 1 Telangiectasias or reticular veins
•Class 2 Varicose veins
•Class 3 Oedema
•Class 4 Skin changes– a Including pigmentation or venous eczema– b With lipodermatosclerosis
•Class 5 Healed ulceration•Class 6 Active ulceration
Peripheral Overview
Telangiectasia/reticular veins
Peripheral Overview
Varicose veins
Peripheral Overview
Oedema
Peripheral Overview
Skin changes
Peripheral Overview
Skin changes
Peripheral Overview
Diagnostic Test - ABI
Ankle Brachial Index (ABI):
Blood pressures measured in both ankle & arm – Blood pressure is compared– Pressures should be equal
ABI Classification Severity of PVD
>1.3 Non-compressible / CA++
≥0.9 Normal
0.70-0.89 Mild
0.50-0.69 Moderate
<0.5 Severe
÷ Ankle pressure Arm pressure
Peripheral Overview
Diagnostic Test- Ultrasound
Ultrasound/Duplex Ultrasound:• Detects blood flowing through the
vessel
• Can detect if flow is severely blocked
• Speed and direction of blood flow
• Assess valve competence
• Readily available in many offices
Peripheral Overview
Treatment Options - PAD
• Lifestyle change– Exercise regularly– Smoking cessation– Diet -Low-fat to reduce cholesterol
• Medications– Blood pressure control– Antiplatelet therapy– Cholesterol-lowering agents – Vasodilators to dilate arteries
• Endovascular therapy
– Angioplasty
– Stenting
• Surgery– Surgical bypass– Endarterectomy– Amputation
Peripheral Overview
Treatment Options – Chronic venous disease
• Lifestyle change– Exercise regularly– Smoking cessation– Leg elevation
• Skin care– Emollients e.e fatty cream, vaseline– Barrier preparations e.g. vaseline,
zinc oxide– Topical coritcosteroids– COMPRESSION THERAPY
• Endovenous therapy
– Endovenous ablation – RFA, EVLT
– Ultrasound guided sclerotherapy
• Surgery– Debridement +/- skin grafting for
ulcers– Historically vein stripping and
avulsions
Peripheral Overview
COMPRESSION STOCKINGS
CLASS PRESSURE LEVEL OF SUPPORT
INDICATION CEAP
OTC <15 mmHg Minimal Asymptomatic, comfort only. 0, 1
I 15-20 mmHg Mild Minor varicosities, tired aching legs, minor swelling.
1, 2, 3
II 20-30 mmHg Moderate Moderate to severe varicosities, swelling, phlebitis, following ablation or DVT
3, 4, 5
III 30-40 mmHg Firm Lymphoedema N/A
Peripheral Overview
Referral guidelines – Intermittent claudication
Red flags
Urgent vascular assessment is required if:
•Critical limb ischaemia ie. rest pain and/or tissue loss with absent pulses
•Acute limb ischaemia
Assessment
•A typical history will usually make the diagnosis – cramp like pain brought on by walking exercise at fixed distance and relieved by rest•Risk factors – high risk of coronary and cerebrovascular events, 20% have diabetes, smoking•Assess impact on quality of life•Peripheral pulses
Peripheral Overview
Referral guidelines – Intermittent claudication
Investigations
•Blood tests – CFC, fasting lipids, glucose, renal function
•ABI if available
•Duplex scan
Suggested GP management
•Management of risk factors– smoking cessation advice– statins, even in patients with normal lipids– anti-platelet medication to reduce cardiovascular risk– aggressive control of blood sugars in diabetes– hypertension treatment – Beta blockers do not worsen PVD
•Targeted walking exercise – green prescription
Peripheral Overview
Referral guidelines – Intermittent claudication
When to refer
•If any red flags – acute referral
•Refer to outpatient if:– after 6 months of targeted exercise and risk factor reduction,
the pain is worse or there is no improvement– the patient’s quality of life is severely affected by symptoms– a young, otherwise healthy adult presents with symptoms of
claudication
Peripheral Overview
Referral guidelines – varicose veins and chronic venous insufficiency
Practice Point
•Evidence indicates that 80% of patients gain relief from vein ablation therapy. Offer options to everyone with symptomatic varicose veins even if public funding may not available, as patients may believe they need to tolerate their symptoms.
Assessment•Risk factors.•History of varicose vein complications – skin changes, thrombophlebitis, ulceration, bleeding.•Severity of symptoms and if controllable with compression – level of disability.•Determine patient’s wish for cosmetic treatment.
Peripheral Overview
Referral guidelines – varicose veins and chronic venous insufficiency
Investigations
•ABI if arterial disease suspected by absent pulses and compression stockings being prescribed – ABI>0.8
•Duplex ultrasound
Suggested GP management
•Lifestyle modification – weight management – smoking cessation– exercise to improve calf muscle pump– leg elevation
•Manage varicose eczema – soap substitutes, regular emollients, topical steroids.•Compression hosiery
Peripheral Overview
Referral guidelines – varicose veins and chronic venous insufficiency
Suggested GP management
•Thrombophlebitis – treat with anti-inflammatories, no role for antibiotics – if focal on duplex – rescan if getting worse– if extensive on duplex – anticoagulate with clexane if no
contraindications for 3 months
Peripheral Overview
Referral guidelines – varicose veins and chronic venous insufficiency
When to refer
•Complications of varicose veins:– recurrent cellulitis CCDHB patients– recurrent thrombophlebitis offered endovenous– healed/current ulcers treatment– recurrent bleeding
•Thrombophlebitis– If duplex demonstrates extensive STP and contraindication to
anticoagulation– If progression on duplex despite anticoagulation