Peripheral Vascular Disease

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Contents 1 More Specific Terms 2 Introduction 3 Etiology 4 Epidemiology 5 Pathology 6 Genetics 7 Clinical-manifestations 8 Diagnostic-procedures 9 Radiology 10 Complications 11 Differential-diagnosis 12 Management 13 More General Terms 14 Additional Terms 15 Internet Database 16 References

More Specific Terms

• acute arterial occlusion (severe limb ischemia)
• carotid artery stenosis
• intermittent claudication

Introduction

• Also see

• internal carotid artery disease
• intermittent claudication

Etiology

• risk factors presumptively the same as for coronary artery disease

Epidemiology

• 29% of patients who smoke or have diabetes [3] (40% of these same patients had coronary artery disease)
• 9% of patients with PVD have symptomatic claudication [3]
• 20% of patients > 70

Pathology

• patients appear to develop a metabolic myopathy & axonal polyneuropathy related to chronic lower extremity ischemia resulting in abnormal biomechanics prior to the onset of pain [13]

Genetics

• implicated genes

• CHRNA3 ( peripheral arterial occlusive disease type 2)

Clinical-manifestations

• signs of asymptomatic disease

• ankle to brachial index < 0.9 ( lower extremity disease)
• carotid bruit or diminished carotid pulse

• see carotid artery disease &/or intermittent claudication
• pain, paresthesias, pallor, paralysis, pulselessness [1]
• abnormalities in torque & power at the hip, knee, & ankle immediately upon walking (before onset of pain)
• systolic blood pressure difference of >= 15 mm Hg between arms may be associated with vascular disease [16]

Diagnostic-procedures

• echocardiogram: embolic source of ischemia

Radiology

• screening [10]

• ultrasound, ankle-brachial index
• contrast-enhanced MRI best 95% sensitivity, 97% specificity [14]

• intra-arterial contrast angiography identifies the vascular pathology

Complications

• 
  
• disease interaction(s) of peripheral vascular disease with overflow incontinence

Differential-diagnosis

• see intermittant claudication

Management

• acute arterial ischemia

• start heparin
• consult vascular surgery [1]

• diet & life-style modification (see CAD)

• exercise training & rehabilitation
• smoking cessation

• control blood pressure
• control diabetes mellitus
• pharmaceutical agents

• treat dyslipidemia (see CAD) [6]

• 80 mg of atorvastatin may improve pain-free walking time (without effect on ankle to brachial index) [5]
• 40 mg simvastatin diminished risk of major vascular events in patients with peripheral arterial disease (5-6%) [8]
• target LDL < 100 mg/dL [1]

• antiplatelet agents

• uncertain benefit [15]
• aspirin

• of no benefit (statistically) [11]
• preferred over clopidogrel [1]

• dipyridamole/aspirin ( Aggrenox)
• clopidogrel ( Plavix)
• no benefit of added warfarin [9]; potential harm [15]

• ACE inhibitor reduces risk of myocardial infarction & stroke in patients with peripheral arterial disease [4]
• cilostazol rather than pentoxifylline for symptoms

• contraindicated in heart failure
• questionable benefit

• Ginkgo biloba may be of benefit
  

• see secondary prevention in patients with cardiovascular disease
  

• angioplasty or surgery

• failure of medical therapy
• pain at rest
• poorly healing ulcers

More General Terms

• arterial/arteriolar/capillary disease

Additional Terms

• ankle-brachial index (ABI) or ankle-arm index (AAI)
• arterial ulcer
• coronary artery disease (CAD)
• internal carotid artery disease (carotid stenosis)
• peripheral vascular system
• secondary prevention in patients with cardiovascular disease
• vertebrobasilar disease

Internet Database

OMIM: 612052

References

1. Medical Knowledge Self Assessment Program (MKSAP) 14, 15 American College of Physicians, Philadelphia 2006, 2009
2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 286-87
3. Journal Watch 21(21):168, 2001 Hirsch AT et al Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA 286:1317, 2001 PMID: [1]
4. Peripheral Arterial Disease Prescriber's Letter 10(2):9 2003 Detail-Document#: [2] (subscription needed) [3]
5. Journal Watch 24(3):22, 2004 Mohler ER III et al Cholesterol reduction with atorvastatin improves walking distance in patients with peripheral arterial disease. Circulation 108:1481, 2003 PMID: [4]
6. Statins and Peripheral Arterial Disease Prescriber's Letter 10(10):60 2003 Detail-Document#: [5] (subscription needed) [6]
7. Hirsch AT et al, ACC/AHA Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, abdominal aortic) J Am Coll Cardiol 2006, 47:1239 PMID: [7] Circulation 2006, 113:e463 <PubMed> PMID: [8] <Internet> [9]
8. Heart Protection Study Collaborative Group. Randomized trial of the effects of cholesterol-lowering with simvastatin on peripheral vascular and other major vascular outcomes in 20,536 people with peripheral arterial disease and other high-risk conditions. J Vasc Surg. 2007 Apr;45(4):645-654; discussion 653-4. PMID: [10]
9. Anand S et al and the Warfarin Antiplatelet Vasculare Evaluation Trial Investigators Oral anticoagulant and antiplatelet therapy and peripheral arterial disease. N Engl J Med 2007, 357:217 PMID: [11]
10. Collins R, Burch J, Cranny G, Aguiar-Ibez R, et al Duplex ultrasonography, magnetic resonance angiography, and computed tomography angiography for diagnosis and assessment of symptomatic, lower limb peripheral arterial disease: systematic review. BMJ. 2007 Jun 16;334(7606):1257. Epub 2007 Jun 4. Review. PMID: [12]
11. Berger JS et al Aspirin for the prevention of cardiovascular events in patients with peripheral artery disease: A meta-analysis of randomized trials. JAMA 2009 May 13; 301:1909. PMID: [13]
    - Dermott MM and Criqui MH. Aspirin and secondary prevention in peripheral artery disease: A perspective for the early 21st century. JAMA 2009 May 13; 301:1927. PMID: [14]
12. Fowkes FGR et al Aspirin for prevention of cardiovascular events in a general population screened for a low ankle brachial index: A randomized controlled trial. JAMA 2010 Mar 3; 303:841. PMID: [15]
    - Berger JS. Aspirin as preventive therapy in patients with asymptomatic vascular disease. JAMA 2010 Mar 3; 303:880. PMID: [16]
13. Koutakis P et al. Abnormal joint powers before and after the onset of claudication symptoms. J Vasc Surg 2010 Aug; 52:340. PMID: &dopt=Abstract
14. Menke J and Larsen J Meta-analysis: Accuracy of Contrast-Enhanced Magnetic Resonance Angiography for Assessing Steno-occlusions in Peripheral Arterial Disease Annals of Internal Medicine 2010, 153:325-334 <PubMed> PMID: [17] <Internet> [18]
15. Rooke TW et al 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline): A Report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines Circulation published online September 29, 2011 <PubMed> PMID: [19] <Internet> [20]
16. Clark CE et al Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis Lancet. 2012 Jan 27. [Epub ahead of print] <PubMed> PMID: [21] <Internet> [22]
    - McManus RJ and Mant J Do differences in blood pressure between arms matter? Lancet. 2012 Jan 27. [Epub ahead of print] <PubMed> PMID: [23] <Internet> [24]
17. National Guideline Clearinghouse Antithrombotic therapy for peripheral artery occlusive disease. American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). ngc-guideline: [25]
    - ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). ngc-guideline: [26]
    - Diagnosis and management of peripheral arterial disease. A national clinical guideline. Scottish Intercollegiate Guidelines Network ngc-guideline: [27]
    - ACR Appropriateness Criteria<TM> iliac artery occlusive disease American College of Radiology ngc-guideline: [28]
    - Screening for lower extremity peripheral artery disease (PAD) in primary care. University of Texas at Austin School of Nursing, Family Nurse Practitioner Program ngc-guideline: [29]

peripheral vascular disease; PVD; peripheral arterial disease; PAD