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Disease
Booklet to accompany PALS tutorial
James Giles, Mary-Jo McLaughlin, Daniel Newbery & Madhurima Rai
Peer-Assisted Learning Scheme (PALS) Vascular Group 2008-2009
Contents
Varicose Veins 9
1. Peripheral Arterial Disease
Peripheral Arterial Disease (PAD) encompasses disorders that obstruct arterial blood flow.
Peripheral Arterial Disease affecting the legs is of overwhelming importance and is the focus of
this booklet.
Epidemiology
• Prevalence is 6.9% among 25-74 year olds (22% of these are symptomatic)
• The male to female ratio (of patients requiring surgical intervention) is 5:1
• The most common cause of arterial obstruction (and therefore PAD) is atherosclerosis.
• Smoking
• Hypertension
• Diabetes Mellitus
• Hyperlipidaemia
• Hyperhomocysteinaemia
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Other Signs
• Lower limbs are cold and pale
• Skin may be dry with a lack of hair on toes and dorsum
• Pulses may be diminished or absent
• There may be peripheral cyanosis in the toes (associated with ulceration and gangrene)
Differential Diagnosis
Spinal canal claudication
Osteoarthritis of the hip/knee (knee pain often at rest)
Peripheral neuropathy (may be associated with tingling and numbness)
Entrapment of the popliteal artery (pulses usually normal and patients tend to be
younger)
Venous claudication (‘bursting’ pain on walking +/-history of previous DVT)
Beurger’s disease (young males who are heavy smokers)
Compartment syndrome (swelling of muscles within a fascial compartment resulting in
tissue ischaemia, often following trauma)
Causes
1. Embolic Disease
• Common due to cardiac thrombus and cardiac arrhythmias
• Rheumatic fever is an uncommon cause
• Embolisation may also secondary to thrombus on atherosclerotic plaques or aneurysms
2. Thrombotic Disease
• Acute thrombus may form on a chronic atherosclerotic stenosis
• Thrombus may also form in normal vessels if a hypercoagulable state exists
• Prosthetic or venous grafts may be targets for thrombosis
• Popliteal aneurysms may thrombose ( and also embolise distally)
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Investigations for Lower Limb Ischaemia (acute and chronic)
Blood Tests 1. FBC (Anaemia and infection)
2. U&Es (renal disease)
3. Lipids (dyslipidaemia)
4. Blood glucose (to exclude diabetes)
5. ESR/CRP (to exclude arteritis)
Arteries that are heavily calcified and therefore incompressible will produce falsely elevated
results.
Angiograms
Angiograms can be preformed via percutaneous arterial catheterisation. However, these are
rarely used diagnostically. Doppler ultrasound and duplex imaging are less invasive and can
give accurate anatomical assessment of the degree of disease.
Management
a. Mild Disease
Aim – To prevent progression of the disease
• Manage risk factors
• Lifestyle adaptations (exercise, smoking, diet)
• Avoid injury
• Medication: Anti-platelet (aspirin)
Statin (if required)
Hypertensive drugs
Peripheral Vasodilators (Naftidrofuryl, Cilostazol)
b. Moderate Disease
Aim - conservation
• Percutaneous balloon angioplasty
• Fibrinolytics (TPA; used only for acute or acute-on-chronic ischaemia)
• Surgery
c. Severe Disease
Aim – minimise impact on patient’s quality of life
• IV drugs e.g. vasodilators
• Percutaneous balloon angioplasty
• Surgery
• Amputation
• Palliation
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2. Deep Vein Thrombosis (DVT)
Definition
Deep vein thrombosis is a condition in which a blood clot forms in a vein which is deep inside
the body. The clot may interfere with blood flow or break off and cause an embolus, which
may travel through the vascular system. Venous emboli always go to the lungs unless there is a
patent foramen ovale or ventriculo-septal defect (VSD), causing a paradoxical embolus from the
venous to arterial system.
Epidemiology
• There is a 1 in 20 lifetime of developing a DVT
• Male : Female = 1.2 : 1
• Most common in people over 40 years, but can occur in any age group.
Aetiology
Think of Virchow’s Triad to remember the causes of thromboses:
Stasis of Blood
1. Stasis of Blood:
• Increasing age
• Immobilisation longer than three days i.e. hospital admission
• Major surgery in the past four weeks
• Long plane or car journey in the previous four weeks
2. Hypercoaguability:
• Medical conditions e.g cancer, myocardial infarction (MI)
• Haematological disorders e.g. protein C or S deficiency, Factor V Leidin,
polycythaemia rubra vera, inherited coagulation disorders, systemic lupus
erythematosus (SLE)
• Pregnancy and the post-partum period
• Oestrogens and the combined oral contraceptive pill (COCP)
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Pathology
DVT of the leg usually occur in the deep veins of the calf around the valve, and a minority of
cases are in the ileo-femoral area due to direct trauma (e.g. surgery or a catheter).
• 80% dissolve completely without therapy.
• 20% propagate proximally. Propagation usually occurs before embolisation, whilst the
thrombus is still forming and so is not fixed.
Differential Diagnosis
• Cellulitis
• Ruptured Baker’s Cyst - also known as a popliteal cyst, a benign swelling found behind
the knee joint.
• Compartment syndrome
Investigations
General Investigations:
• FBC
• U&Es
• Lipids
• Clotting
• Coagulation screen
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Clinical Scoring System – Wells Score
The Wells Score is a clinical probability scoring system carried out before specific tests:
• Negative D-Dimer with low to moderate Wells score rules out DVT.
• Increased D-Dimer levels plus moderate or high Wells score means further tests are
needed.
<3 ≥3
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Compression Duplex Ultrasound
Compressing the leg usually leads to venous flow. If there is an occluding thrombus, no venous
flow will occur, and Doppler signals will be absent.
Plethysmography
Plethysmography is used to measure changes in blood flow or volume in different parts of the
body. Limb plethysmography is a technique where blood pressure cuffs are wrapped around the
arms and legs and any difference in blood pressure us noted. There should be a less than 20
mmHg difference in the pressure between the arms and the legs.
Management
Aims
• Prevent pulmonary emobolism and gangrene
• Reduce morbidity
• Prevent and minimise the rest of developing the postphlebitic syndrome
Treatment
• Anticoagulation - LMWH for 5 days, and Warfarin, aim for INR 2.5
• Thromboembolism deterrent stockings (TED stockings)
• Thrombolyic therapy for DVT (rarely used)
• Surgery for DVT (rarely used)
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3. Varicose Veins
Definition
Varicose veins are excessively dilated, tortuous superficial leg veins, with resultant pooling of
blood. These develop due to increased pressure secondary to valvular insufficiency.
Aetiology
1. Valvular insufficiency in perforating veins:
Perforating veins link the high pressure deep venous system with the low
pressure superficial veins. If valves in these veins are incompetent, high
pressures are transmitted to the superficial veins.
Women are 2-8 times more likely to suffer from varicose veins. This female disposition is
thought to be a result of cyclical hormonal changes (oestrogen & prostaglandins). These
changes lead to muscular and connective tissue dilatation, affecting the lower limb venous
system. In pregnancy, direct compression of the IVC by the fetus can lead to increased pressure
and reflux.
Complications
• Phlebitis, caused by chronic inflammation of the vein
• Leg ulcers cause by venous insufficiency
• Rupture of the varicosity
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Investigations
Not all patients will undergo investigation. In some centres diagnosis is made and surgery
performed on clinical grounds.
Duplex ultrasound allows accurate mapping of veins and venous blood flow in the leg prior to
surgery.
Management
This depends on the severity of symptoms and patient choice.
Conservative
The patient puts up with the discomfort, alleviating the symptoms by resting. Compression
stockings provide some relief.
Medical
Injection of a sclerosing substance into the varicosities causing endothelial damage, sclerosis
and degradation of the vein. This is only effective in mild cases. Sclerotherapy is done while
the patient is standing – an elastic band is wrapped around the legs after the procedure.
Surgical
Vein-Stripping
The surgeon makes a cut at the bottom (ankle end) and the top (groin end) of the varicose vein.
A thin, plastic tube-like instrument is placed into the vein and tied around it. When the tube is
pulled out, it pulls the vein from out under the skin. Small surgical cuts can also be made over
individual veins to remove them.
References:
Front cover picture: http://jama.ama-assn.org/content/vol291/issue7/images/medium/jmn40022f1.jpg
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