Peripheral Vascular Disease (PVD), often called Peripheral Artery Disease (PAD), is a common circulatory problem wherein narrowed arteries reduce blood flow to the limbs. It primarily affects the legs, though other arteries can also be involved.
Causes of Peripheral Vascular Disease
- Atherosclerosis: The leading cause, characterized by plaque buildup in the arteries.
- Diabetes: Chronic diabetes increases the risk of PVD due to associated microvascular and macrovascular changes.
- Smoking: Contributes to arterial narrowing and plaque formation.
- Hypertension: High blood pressure can damage artery walls.
- Hyperlipidemia: High levels of fats in the blood contribute to plaque formation.
- Age: Risk increases with age, especially over 50 years.
- Family History: Genetic predisposition plays a role.
- Obesity: Increases the risk of atherosclerosis.
Diagnosis of Peripheral Vascular Disease
- History
- Symptoms: Patients often report claudication (pain in the limbs during exercise, relieved by rest), numbness, weakness, or coldness in the legs.
- Risk Factors: Inquire about diabetes, smoking, hypertension, and family history.
- Physical Examination
- Pulse Examination: Diminished or absent pulses in the lower extremities.
- Skin Changes: Coolness, pallor, atrophic skin changes, hair loss, and ulcers.
- Capillary Refill Time: Prolonged in affected limbs.
- Auscultation for Bruits: Over the arteries for sounds indicative of turbulent blood flow.
- Investigations
- Ankle-Brachial Pressure Index (ABPI): Compares blood pressure in the ankle with that in the arm, with ABPI < 0.9 indicating PVD.
- 0.9 – 1.3 is normal
- 0.6 – 0.9 indicates mild peripheral arterial disease
- 0.3 – 0.6 indicates moderate to severe peripheral arterial disease
- Less than 0.3 indicates severe disease to critical ischaemic
- Doppler Ultrasound: To assess blood flow and locate blockages.
- CT Angiography/MRI Angiography: For detailed imaging of the blood vessels.
- Blood Tests: To evaluate for diabetes, cholesterol levels, and kidney function.
- Angiography: Invasive but provides detailed images of arterial flow.
- Ankle-Brachial Pressure Index (ABPI): Compares blood pressure in the ankle with that in the arm, with ABPI < 0.9 indicating PVD.
Differential Diagnosis (DDx)
- Deep Vein Thrombosis (DVT): Presents with leg swelling, pain, and redness.
- Chronic Venous Insufficiency: Characterized by leg swelling, varicosities, and skin changes.
- Neuropathy (especially in Diabetics): Numbness and tingling without vascular insufficiency.
- Spinal Stenosis: Back pain radiating to the legs, worsening with walking.
- Restless Legs Syndrome: Discomfort or sensations in the legs, with an urge to move them.
Management of Peripheral Vascular Disease
- Lifestyle Modifications
- Smoking Cessation: Critical for slowing disease progression.
- Exercise: Walking programs to improve leg circulation.
- Diet: Low-fat, high-fiber diet; control of blood sugar and lipids.
- Pharmacological Treatment
- Antiplatelet Agents: Such as aspirin or clopidogrel to reduce clotting risk.
- Anticoagulants: Aspirin + Rivaroxiban in eTG
- Cholesterol-lowering Drugs: Statins to reduce plaque formation.
- Antihypertensive Drugs: To manage blood pressure.
- Surgical Interventions
- Angioplasty and Stenting: To open narrowed arteries.
- Bypass Surgery: Creating a new route around narrowed or blocked arteries.
- Atherectomy: Removal of plaques from the arterial wall.
- Regular Monitoring and Follow-Up
- Regular Follow-Up: For risk factor management and monitoring of disease progression.
- Foot Care: Education about foot care to prevent ulcers and infections.
Conclusion
The management of PVD involves a comprehensive approach, including risk factor modification, pharmacotherapy, possible surgical interventions, and close monitoring. Multidisciplinary care involving primary care physicians, cardiologists, and vascular surgeons is often necessary for optimal management and to prevent complications such as limb ischemia and amputation.