Vascular Occlusive Disease, Peripheral (PVOD)

• • Predominantly disease of lower extremities

  • In arms, subclavian and axillary mostly affected, radial and ulnar if diabetic

  • In legs, femoropopliteal disease more common than aortoiliac disease

  • Indicator for early death (from myocardial infarction [MI] and strokes) and imminent limb loss

  • Single arterial segment obstruction limits walking to half to 1 block on average prior to onset of claudication pain

  • Also known as peripheral artery insufficiency

Epidemiology

• • Affects 20% of population > age 70

  • Indicates atherosclerotic disease; high risk of death from MI or stroke

  • 20% die of nonatherosclerotic causes

Symptoms and Signs

• • Intermittent claudication

  • -Pain, fatigue, cramping in leg muscles (most often calf) with walking; relieved by 2-5 min rest

    -Is reproducible and does not occur at rest

    -Thigh pain if occlusion proximal to profunda femoral, gluteal pain if proximal to hypogastric arteries

    -Leriche syndrome: Aortoiliac disease— claudication of hip, thigh, buttock, atrophy of leg muscles, impotence, and diminished femoral pulses

    -Sensation usually intact except in cases of peripheral neuropathy (diabetes)

  • Ischemic rest pain

  • -Severe, burning pain in forefoot aggravated by leg elevation, improved with leg in dependent position

    -Grave symptom caused by ischemic neuritis and tissue necrosis

    -Indicates advanced arterial insufficiency

    -Without treatment, results in gangrene and amputation

    -Often preceded by claudication

  • Nonhealing wounds ulcers

  • -Trivial trauma may cause wounds in pts with PVOD

    -Commonly located on toes, or distal foot

    -Usually painful with eventual gangrene

  • Erectile dysfunction

  • -Due to obstructed blood flow through hypogastric and/or terminal aorta

    -Less common than other causes of erectile dysfunction

  • Diminished pulses, bruits (may be present at stenosis), pallor, reactive hyperemia, rubor, decreased temperature in foot, ulceration, tissue necrosis of toes, muscle atrophy, loss of hair on foot, thickening of toenails (slow keratin turnover), skin atrophy

Laboratory Findings

• • Noninvasive vascular tests: ABIs (ankle to brachial index)

  • ABI < 1.0 indicates occlusive disease, rest pain typically ABI < 0.4

  • Calcified vessels may not be compressed and suspected when ABI > 1.2 and does not correlate to clinical status (diabetics often elevated ABI, measure toe-brachial index (TBI)

  • Segmental limb pressures: Measure pressure and pulsatile wave forms from thigh to foot to identify location of occlusive disease

  • Exercise ABI done within 1 min of exercise may help diagnose occlusive disease

Imaging Findings

• • Color duplex: Can identify arterial lesions but is operator dependent

  • Arteriography: Provides anatomic information for location of disease (complications of arteriography: hematoma, pseuodaneurysm, contrast allergy, contrast nephropathy)

  • Magnetic resonance angiography (MRA): Can delineate arteries without contrast, but overestimates disease

• • Intermittent claudication

  • Ischemic rest pain

  • Decreased pulses

  • Nonhealing ulcers/wounds

  • Necrosis and atrophy

  • Low ABI

Rule Out

• • Osteoarthritis

  • Neurospinal compression (spinal stenosis)

  • Venous claudication

  • Vasculitis

  • Aortic ...