Peripheral Vascular

Diseases

Subarna Thapa Chhetri

MPT, Cardiopulmonary sciences

Dhulikhel hospital
Peripheral vascular disease (PVD)

• Peripheral vascular disease is a circulation disorder that causes

narrowing of blood vessels to part of the body other then the brain and
heart
PVD

• Arterial disease

• Vascular disease
• Peripheral Arterial disease

• Functional PAD

• Organic PAD

• Peripheral Vascular disease

1. Superficial vein disorder

• Thrombophlebitis

• Varicose vein

• SVT

2. Deep vein thrombosis

 Characteristics of arterial and venous disorder
characteristics Arterial disease Venous disease

pulse Often absent or diminish Usually present

pain Sharp stabbing worsen with Aching cramping with prolong

activity standing
Leg down relieve pain elevation

skin Cool or cold , hairless, dry, Warm, though, thickened,

shiny, pigmented area
Pallor on elevation and rubor on
dangling
edema infrequent Frequent at the end of the day

ulcers Severely painful, pale, gray Moderately painful, pink base

base, found on heel toes found on medial aspect of the
dorsum of toot ankle
• Arterial insufficiency:

• Decrease flow of blood to the tissue- decrease peripheral perfusion-ischemia

• Pulse usually diminished or absent

• Sharp, stabbing pain particularly with activity

• Interference with nutrients and O2 to the tissue-ischemic ulcers and changes in the skin

• Venous insufficiency

• Reduce blood return to heart

• Leads venous congestion and stasis

• Pulse are present

• Lead to edema, skin changes and stasis ulcers

• Functional PAD :

• Don’t involve defects in blood vessels

• Often have the symptoms related to spasm( may come and go): (Raynaud
disease)

• Organic PVD:

• Are caused by structural changes(Inflammation and tissue damage

• Arteriosclerosis obliterans

• Thromboangitis obliterans(burger's disease)

• Aneurysm

• Arterial thrombosis
• PVD can be categorized using the Fontaine or Rutherford
classification system.

• Each system grades PVD from no symptoms to major tissue loss

• It can be used at diagnosis and to evaluate the progression or

improvement of symptoms.
 There are several classification systems and the two most used are
the following:
Fontaine Classification
Rutherford Classification
Assessment of PVD

1. Venous filling time

2. Rubor of dependency
 Venous filling time

• The extremity is elevated and then

lower into the dependent position

• The time it takes for the vein on the

top of the foot to refill is recorded.

• Normal filling time is 15 seconds

• Greater then 15 second indicates

arterial disease while lee then 15
second indicates venous disease
Rubber of
dependency • A noninvasive test that examined the lower limb for
the presence of ischemia

• Following elevation of the limb

• Lowering of the limb should return the skin of the

limb to pink color

• If the color is dark and takes more than 30 seconds to

appear, the test is positive for arterial insufficiency
Test to rule out PAD

Arterial Disorder:

a. Doppler US

b. ABI (ankle brachial Index)

c. Pole test/Buerger’s test

d. Claudication test

e. Air plethysmography
Test to rule out PVD
Venous disorder:

a. Superficial vein test,:

a. Percussion test,

b. trendle berg test:

a. Superficial vein

b. perforating vein

b. Deep vein Test:

a. Cudd test

b. Homans Test
ABI (ankle
brachial
Index)
 • With the patient lying down, a Doppler signal is
Pole test: recorded in the foot.

• When the leg is elevated, the Doppler signal

becomes attenuated depending on the vertical
height above the heart.

• The desired arterial perfusion pressure is 60mmHg

at a height of 77cm.

• If a pulsatile Doppler signal can be recorded at this

height, then the perfusion pressure is >60mmHg.

• If the desired pressure is not recorded at this Hight

can consider there is arterial incuficiency
 Modified Allen’s test
• Ask the patient to clench his fist tightly and compress the radial and ulnar arteries at the wrist
with the thumbs. Wait for 10 second and ask the patient to open his hand pallor can be seen in
the palm

• Now release pressure on the radial artery and watch for blood flow.

• Repeat the test for ulnar artery

• If there is occlusion of either artery

colour changes occur in the fingers slowly

Claudication test

• Claudication is muscle pain that happens when you’re active and stops when
you rest.

• It’s usually described as cramping, aching, tingling or numbness.

• Most cases are caused by circulatory problems like peripheral artery disease, but it
can also be caused spine conditions
Venous disorder:

a. Superficial vein test,:

a. Percussion test,

b. trendle berg test:

a. Superficial vein

b. perforating vein

b. Deep vein Test:

a. Cuff test

b. Homans Test
 Percussion(Schwartz ) test

• With lower extremity in dependent position, the greater saphenous

vein is palpated distal to the knee with one hand while it is tapped 6
inch proximal to the knee with other hand.

• If a wave of fluid is detected under the distal palpation site , it

indicates the possibility of valvular incompetency
Brodie –Trendelenburg test • Test measure the time required to refill the veins
in the dorsum of the foot.

• The LE elevated to allow venous blood to empty

• A torniquet on the thigh prevent backflow.

• After1 min the individual stands.

• If veins fully distend with in 5 second before the

torniquet is released, : valvular incompetence in
the deep vein is suspected.

• If distension occurs within 5 seconds after the

tourniquet is released : incompetence of
Venous disorder: Deep vein Test:

a. Homans Test

b. Cuff test
Homans’s Sign:

• Common test to rule out deep vein thrombosis

• Support the patient's thigh with one hand and his/her foot with other

• Bend his//her leg slightly at the knee

• Then firmly and abruptly dorsiflex the ankle

• Resulting deep calf pain indicates +ve homen’s sign

 Moses’ Sign

• Tenderness/pain over calf muscles on

squeezing the lower calf muscles against
tibia indicates DVT

• Not done now a days due to fear of

embolism
Cuff test/Lowernberg’s test
• Cuff from the sphygmomanometer is
imposed on the leg

• If at pressure of 80-100 mmHg a pain arise

in the calf muscle, then this test considered
to be positive for thrombophlebitis of
profound veins
Principle of exercises in vascular condition
Principle of exercises in vascular condition
Acute molecular effects of exercise on blood vessels.

• During exercise, increased arterial blood flow leads to an elevation of:

• blood pressure (greater hydrostatic pressure),

• luminal shear stress,

• arterial wall stress.

• The consequence is a vasodilation predominantly in the resistance

arteries (mainly due to a greater release of nitric oxide (NO) and
prostacyclin (PGI2) from the endothelial cells and dilation of the
smooth muscle cells).
• In addition, during exercise, changes in neural, metabolic, and humoral factors
take place in both the micro- and macrovascular circulation.

• All these changes contribute to acute adaptations in arterial function, diameter,

and wall thickness.

• NO: nitric oxide, PGI2: prostacyclin I2, NPY: neuropeptide Y, GABA: Gamma-
aminobutyric acid, ATP/AMP: Adenosine triphosphate/Adenosine
monophosphate; [Ca2+]: intracellular calcium
• Acute bouts of exercise also enhance proangiogenic stimuli, such as the vascular
endothelial growth factor (VEGF), which in turn signals capillary development.
• Repeated hemodynamic stimuli due to regular exercise training can lead to better
compliance and regulation of blood pressure in conduit arteries as well as in the
small vessels.

• In addition, the vascular adaptations lead to a better capacity for oxygen delivery
and diffusion from the capillaries to the skeletal muscle cells and possibly contribute
to improvements in exercise capacity.

• Regular exercise can prevent and/or reverse age-re lated endothelial dysfunction in
both the macro- and microvascular circulation by increasing Nitric oxide (NO)
bioavailability, and mitochondrial health, and lowering systemic inflammation.

•
• Exercise stimulates angiogenesis, the formation of capillary
networks, and arteriogenesis, the growth of preexistent collateral
arterioles.

• Early reports showed a greater arteriolar and capillary density in

trained individuals compared to untrained aged-matched controls
Recommendation

• The World Health Organization recommends at least 75 min per week of vigorous
physical activity or 150 min of moderate intensity physical activity

• However, these effects depend on frequency, intensity, volume, and modality of

the training,
• It is best to repeat 2-4 times a day

• Each cycle for 3-6 times

Buerger allien exercise

• Buerger allien exercises is a system of exercises for arterial

insufficiency of lower limb

• Consisting of 45-degree leg elevation(2 min) followed by 90-degree

dependency of leg (2min)and finally 180-degree horizontal position of
leg for rest (5 Min)
Mechanism

• During elevation the gravity causes an emptying of vein so increase the inflow of
right atrium and promote cardiac output

• At leg dependency gravity will increase the inflow of arteries in addition to the
angle movement will force the muscle to contact and reinforce the distal
circulation

• The last step promote leg perfusion

 References
1. Physical rehabilitation –Susan B O sullican (6th edition)
2. Cardiopulmonary physical therapuy- scot inwin (4th edition)
3. A concise textbook of surgery- S Das (8th edition)
4. R.D.B art of clinical presentation in surgery(3rdedition)
Principle of exercises in vascular condition
Medical treatment
 Preventative pharmacologic treatments include antiplatelet therapy
with aspirin alone 75-325mg orally daily or clopidogrel alone 75 mg orally
daily to reduce MI, stroke and vascular death in patients with symptomatic
or asymptomatic PAD.
 Dual antiplatelet therapy (aspirin, clopidogrel) may be used to reduce
limb-related events post revascularization.
 A statin is indicated for all patients with PAD.
 Claudication symptoms can be treated with cilostazol 100 mg orally twice
daily in the absence of heart failure
 Acute PAD
 Immediate angiography to confirm location of occlusion and collateral flow
is essential.
 Embolectomy, thrombolysis, and bypass surgery are options for treatment.
 Of the patients, 20% to 30% with acute arterial occlusion require
amputation within the first 30 days.

Winterbottom A et al. 2016

Chronic PAD
 Supervised claudication rehabilitation is superior to unsupervised
training:
 Begin at 15 min/session increasing to 45-50 minutes/session of treadmill
or track walking at least 3 times per week for minimum of 12 weeks.
 Initial workload is set to speeds that is near maximal claudication within
3 to 5 minutes followed by rest periods as needed.
 The patient should resume walking when claudication subsides.
 It is expected to markedly improve walking ability, with results of increased
speed, duration, distance, and decreased claudication symptoms.
 If there are cardiac signs, exercise should stop.
 Home-based exercise with behavioral change techniques is also an effective
alternative for patients unwilling or unable to attend the 3 times a week
supervised exercise session.
Mcdermott MM et al. 2018
 Individuals with professional and lifestyle limitations caused by PAD that are
not responding to conservative treatments can be considered for
endovascular interventions (e.g., percutaneous transluminal angioplasty
[PTA]). PTA with or without stent insertion is the primary nonsurgical
method for dilating vascular occlusions.
 Surgery options include
• Thromboendarterectomy
• Revascularization
• Last amputation
Gerhard-Herman MD et al, 2016
2017 Medicare Coverage Database for supervised exercise therapy
(SET)
 Up to 36 sessions lasting 30-60mins over a 12-week period in a hospital
outpatient or physicians office.
 The therapies are to be provided by qualified personnel trained in PAD
exercise therapy.
 These auxiliary personnel are directly supervised by a physician,
physician assistant or nurse practitioner/clinical nurse specialist who
are trained in both basic/advanced life support techniques.
Jensen TS et al. 2017
Venous Insufficiency:
 Chronic venous disorders (CVDs): this term includes the full
spectrum of morphologic and functional abnormalities of the
venous system.
Eklaf B et al. 2009

 Chronic venous disease: Any morphological and functional

abnormalities of the venous system of long duration manifested
either by symptoms and/or signs indicating the need for
investigation and/or care.
Eklaf B et al. 2009
 Chronic venous insufficiency: A term reserved for advanced CVD, which
is applied to functional abnormalities of the venous system producing
edema, skin changes, or venous ulcers.
Eklaf B et al. 2009

 Post-thrombotic syndrome(PTS): Chronic venous symptoms and/or

signs secondary to deep vein thrombosis and its sequelae.
Eklaf B et al. 2009

 PTS is the most common sequelae of DVT, occurring in approximately

40% of patients presenting with a DVT.
Metz AK et al, 2018
Primary prevention of PTS includes the following:
[Link] to prevent DVT in high-risk hospitalized patients.
[Link] risk of recurrent DVT by appropriate anticoagulation after acute DVT.
[Link] elastic compression stockings (ECS) with ankle pressure gradient of 30 to
40 mm Hg for at least 2 years if patients have symptomatic, proximal DVT and
symptoms of PTS.
[Link] of acute DVT followed by standard anticoagulant therapy.
Kahn SR et al, 2016
 Rehabilitation Management And
Treatments
 Lifestyle modifications (weight loss, diet, exercise, leg elevation, ECS) are
recommended.
 Compression therapy is the mainstay of management. However, a 2016
meta-analysis which consisted of 6 RCTs with 1465 patients with acute DVT
was unable to draw a conclusion as to whether or not compression
therapy prevented PTS.
Jin YW et al. 2016

 Venoactive drugs are not recommended for PTS and diuretics are not
recommended for PTS-related edema.
Kahn SR et al. 2016
  Compression therapy
[Link] ECS with higher pressure at the ankle are the cornerstone of CVD
management.
[Link]-length stockings are as effective as thigh-length stockings, easier to
apply, more comfortable, have better compliance, and are cheaper.
[Link] with 30 to 40 mm Hg compression pressure are recommended for
C5-6 CVI; 20 to 30 mm Hg are recommended for symptomatic varicose veins
and mixed venous and arterial disease.
4. Unna boot (50-60 mm Hg pressure) is used for ambulatory patients
unable to tolerate graduated ECS.
5. Multilayer bandages (40 mm Hg pressure) are more effective in healing
ulcers.
6. Indications for intermittent pneumatic compression are non-
ambulatory patients, need for higher compression, patients not
responding to stockings/wraps, or patients with very large legs who
cannot tolerate stockings/wraps.
Lurie F et al. 2020
Patient & family education
 Education should focus on life-long use of ECS, leg elevation,
smoking cessation, exercise, avoiding trauma to the legs, weight
management, and nutrition.
WOCN Clinical Practice Guidelines, 2011
 Home-based exercises to improve calf-muscle pump function is
recommended.
 It has been suggested that stretching, leg strengthening/flexibility, and
walking for 45 to 60 minutes 3 times per week for 6 months improves
overall fitness, disease-specific QOL measures, and severity of PTS.
Kahn SR et al. 2011
 Electrical calf stimulation in PTS treatment has been shown to
reduce recurrent DVT rates, increase the speed of deep vein
recanalization, and improve clinical PTS outcomes.
Lobastov K et al. 2018
Imaging
DVT
[Link]: The gold standard for the diagnosis of lower limb DVT. This
test involves dye injected into a vein via catheter. It is used when
ultrasound or other tests are negative
[Link] US has almost as high positive and negative predictive values as
venography. It is the test of choice for patients with suspected DVT.

2010 VTE
Guideline
Rehabilitation Management And
Treatments
Pre-disease/prevention:
[Link] medical patients:
 Low Molecular Weight Heparin (LMWH) and Unfractionated
Heparin (UFH) [5000 units subcutaneously three times daily]
were found equally efficacious in preventing VTE, with similar
risks of bleeding.

R. Samuel Mayer et
2. Sequential compression devices (SCDs) have some effectiveness in
preventing VTE when used alone compared with no intervention but
had additional benefit when used in combination with anticoagulation.

R. Samuel Mayer et al.

2017
New onset/acute
[Link] enables VTE to be treated with less intensive monitoring than
intravenous unfractionated heparin (UFH).
[Link] for whom anticoagulation is contraindicated can be safely treated
with Inferior vena cava filters (IVCFs).
[Link] rest and compression hose: Traditionally physicians have recommended
bed rest and the removal of compression devices for several days after DVT, for
fear of propagation to PE.

R. Samuel Mayer et al.

 This approach is being challenged: according to a retrospective study in
Italy, DVT patients who were immobilized and did not receive
compression devices had a higher risk of developing PE subsequently.
 Evidence now shows that mobilization can now begin as early as 4
hours after diagnosis and management of lower extremity DVT.

R. Samuel Mayer et al.

2017
Subacute/chronic/stable stage
 Duration of treatment:
A systematic review of VTE management recommends consistently
overall treatment of 3 months of treatment over shorter or longer periods
(6-24 months) or extended therapy (no stop date) for known risk factors
and up to 6 months for unprovoked VTE.
Kearor et al. 2016

 Compression hose is not recommended for the prevention of post

thrombotic syndrome but is acceptable for the management of its
symptoms. Progressive ambulation is acceptable .
Kearor et al. 2016
Principle of exercises in vascular condition