vascular evaluation (T/F)

Peripheral Arterial Disease (PAD)

• Atherosclerosis, where lesions cause arterial blockages like stenosis and occlusion can result in PAD
• Critical arteries that supply the brain, vital organs, and limbs can be affected by it
• It frequently affects lower extremities, with smoking, high blood pressure, diabetes, age, and hypercholesterolemia as associated factors

Symptoms of PAD

• Intermittent claudication includes "claudico" refers to limping, pain with walking, and relief by rest
• Critical Limb Ischemia includes pain at rest, ulcers, or gangrene

PAD Prevalence

• Asymptomatic PAD is indicated by an ABI less than 0.9 and affects over 50% representing 4-6 million people
• Claudication, characterized by muscle pain, ache, cramps, and fatigue, affects 30%-35%, or 2-4 million people
• Critical Limb Ischemia, manifested by pain at rest, ulceration, or gangrene, affects less than 10%, approximately 400,000-1 million individuals
• In a primary care setting with shared age and risk factors, about one in three patients have PAD
• PAD prevalence increases with age

Risk Factors for PAD

• The major risk factors include smoking, diabetes, hypertension, hypercholesterolemia, hyperhomocysteinemia, and C-Reactive Protein
• Atherosclerosis is a major cause of death in the U.S

Intermittent Claudication Diagnosis

• The differential diagnosis includes pseudoclaudication, degenerative joint disease, and diabetic peripheral neuropathy

Natural History of Claudication

• 70%-80% experience Stable Claudication, 10%-20% experience Worsening Claudication and 1-2% experience Critical Limb Ischemia
• Non-fatal Cardiovascular (CV) events occur in 20% of patients
• Mortality rate is 15%-30%, with 75% due to CV causes

Natural History of Critical Limb Ischemia (CLI)

• 50% of patients are alive with both limbs, 25% require amputation, and 25% die after 1 year
• CLI results in rest pain, ulceration and gangrene

CLI Impact

• In the US, 67% of CLI patients undergo major amputation as the primary therapy
• Annually, there are about 200,000 major amputations performed
• Fewer than 50% have any vascular evaluation prior to amputation, and less than 50% of all amputees will regain mobility
• Greater than 50% of amputees die within one year

Peripheral Vascular Disease (PVD)

• 15-20% of patients with diabetes mellitus (DM) have PVD after 10 years
• 45% of patients with DM have PVD after 20 years

Ischemia Overview

• Ischemia happens when Demand exceeds Supply
• Absolute amount of flow is present with Absolute Ischemia
• Relative Ischemia includes a discrepancy between available flow and needed flow for the present clinical situation

Common Symptoms of PAD

• You might feel pain in the buttocks, thigh, calf, or arch
• You might feel pain at night

History and Physical Exam

• Look at the presence of hair growth and if the foot is warm or cold
• Check skin color, palpate pulses, and examine the status of the nail plates

Significant vascular disease

• Significant vascular disease may be present in 20% of patients with normal clinical exams
• Ischemia becomes more likely with toe or heel ulcers, unknown or pressure-related etiology, diminished pulses, shiny atrophic skin, infection, and dependent rubor or elevation pallor

Hx that might be relevant:

• History of CABG (Coronary Artery Bypass Grafting)
• History of CEA (Carotid Endarterectomy)
• History of tobacco use
• History of MI (Myocardial Infarction)
• History of CVA (Cerebrovascular Accident)
• History of Angina

Factors to note when taking History:

• Thigh, buttocks, or calf pain upon walking
• History of previous ulcerations and their healing time

Non-Invasive Vascular Testing

• Consider it when a patient shows Chronic non-healing ulcer/wound
• Consider it when assessing healing of proposed foot surgery, or the patient is pre-operatively
• Consider it when a patient shows ulcers of the digits, or boney prominences
• Consider it when a patient has symptoms of claudication

Noninvasive Modalities

• Ankle Brachial Index (ABI)
• Toe Brachial Index (TBI)
• Toe Pressure
• Segmental Pressures
• Doppler waveforms
• Photoplethysmography
• Pulse Volume Recordings

Ankle Brachial Index (ABI)

• Ankle Brachial Index: ratio of ankle / arm systolic blood pressure
• Normal value is 0.9 to 1.2
• Medial calcification can cause false elevation in DM
• It is a good screening test for non-diabetic patients

Toe Brachial Index (TBI)

• Toe Brachial Index: ratio of hallux / arm systolic pressure
• A TBI above > 0.6 means low risk
• A TBI below < 0.2 means severe risk
• Digital vessels less affected by calcification in DM

Ischemia

• Grade 0: ABI > 0.80, Ankle SP > 100 mm Hg, TP/TcPO2 > 60 mm Hg
• Grade 1: ABI 0.60-0.79, Ankle SP 70-99 mm Hg, TP/TcPO2 40-59 mm Hg
• Grade 2: ABI 0.40-0.59, Ankle SP 50-69 mm Hg, TP/TcPO2 30-39 mm Hg
• Grade 3: ABI < 0.40, Ankle SP < 50 mm Hg, TP/TcPO2 < 30 mm Hg

Medial Calcinosis

• Features involve tunica media changes
• Possibly neuropathy and elevated pressures can be involved
• It also includes considerations by Goebel and Fuessel, Edmonds

Doppler Waveform Interpretation

• Types include triphasic, biphasic, and monophasic
• Normal flow appears as narrow peak, followed by one or two smaller peaks
• Faster flow shows a higher audible pitch, with waveform resembling teepee
• Slower flow shows a lower pitch, with waveform resembling an igloo
• Waves flatten as flow deteriorates

Ischemic Patterns

• Distal, popliteal, 'trifurcation,' tibial, pedal are characteristics of Diabetic ischemic patterns
• Axial, aorta, iliac, superficial femoral are characterisitics of Nondiabetic ischemic patterns

Timing of Vascular Assessment: Acute Presentation

• Prioritize addressing limb-threatening infection
• Do not delay necessary debridement
• Prompt bypass integral to limb salvage

Timing of Vascular Assessment: Routine Outpatient Management

• Initial evaluation.
• Treating non-healing wound.
• Follow progression of known disease

5 Minute Hyperemia Test

• It can differentiate between organic occlusive disease versus vasospastic disease
• Look for color return
  • Immediate color return
  • Wait 5-8 seconds
  • Less than 10 seconds

Case (GS) Background

• GS is a 47 y/o HM with DM who presented 3 days post trauma in which he hurt his left 5th toe wile walking on the beach
• He had an ulceration to the 5th is discolored
• Pain and discoloration is progressively increasing

Case (GS) Relevant history

• Has DM II x 15 yrs
• Hx of HTN
• Takes Glipizide and Captopril
• No known drug allergies

Case (GS) ROS

• BG average 150-160
• No GI symptoms
• No visual disturbance/blurred vision
• Has numbness to feet
• No LE cramping

Case (GS) Diagnostics

• Lower Extremity: -DP/PT faintly palpable
  • Densely neuropathic -Derm: 0.5 x 0.7 cm ulcer to the 4th web space medial to the 5th toe with purulent exudate and erythema encompassing the toe to the MP

Case (GS) Lab Testing

• Albumin - 3.2, PT - 12.5, PTT - 32.3, and ESR - 58

Case (GS) Treatment

• Admitted to the hospital and within 4 days his toe turned black due to dry gangrene
• Fem - DP bypass and partial 5th ray amputation.