Reference: Braddom; De Lisa

1. Lower Limb Peripheral Vascular Disease
Lower limb peripheral vascular disease includes
arterial,venous, and lymphatic disorders.
Types Of Peripheral Vascular Disease
Arterial
- Atherosclerotic peripheral arterial
disease
Thromboangiitis obliterans, also called
Buerger’s disease
- Vasospastic disease (Raynaud’s
phenomenon, livedo reticularis,
acrocyanosis)
Venous
- Chronic venous insufficiency
- Superficial thrombophlebitis
Venous thromboembolism, includes
deep venous thrombosis and pulmonary
embolism
Lymphatic
- Primary lymphedema
- Secondary lymphedema
Arterial Disease of the Lower
Limb
Anatomy (Lower Limb)
Abdominal Aorta> 2 common Iliac Arteries
th
(Level of 4 lumbar vertebra) > Internal and
external Iliac Arteries
External Iliac artery (pass under inguinal
ligament) > common femoral artery (thigh)
>superficial and deep femoral arteries
Superficial artery > popliteal artery (level of
knee) > anterior and posterior tibial artery
(divides below the knee)
Anterior tibial artery > dorsalis pedis artery
1
ARTERIAL DISEASES
Atherosclerotic Peripheral Arterial
Disease (PAD)
Epidemiology and Risk Factors
- Cause partial or incomplete obstruction
of the arteries of the legs
- Major cause of morbidity and mortality
worldwide
- Commonly seen because of other
vascular d/o like stroke
- Common in America
- Men=Female
- Blacks (common)
- Smoker (higher risk)
- Diabetes (major risk factor)
Lower Limb Peripheral Vascular Diseases| Mica Pusing

2. (paleness of the skin), paresthesia,
paralysis
present for less than 2 weeks
requires emergent vascular surgery>
must be done to prevent irreversible
tissue loss
- embolectomy, thrombolysis,
st
amputation(30% in the 1 month of
presentation)
Critical Limb Ischemia
- ischemia> more than 2 weeks
- causes rest pain, ischemic ulcer and
gangrene
- begins once toe pressure falls to less
that 30 to 50 mm Hg
- rest pain : toe pressure falls 30mmHg
- higher pressure is needed to heal
wound than needed to maintain intact
skin
- 40mmHg: asymptomatic, intact skin,
develop nonhealing ischemic ulcer after
minor trauma
Evaluation
-
Clinical Presentation
-
asymptomatic, intermittent claudication
(IC), critical limb ischemia (CLI), and
acute limb ischemia, with the most
common being asymptomatic
Clinical Presentation of PAD
-Asymptomatic (most common)
-Intermittent claudication: Reproducible paon
in the lower limb with exertion that resolves
quickly with rest
-Acute limb ischemia: a sudden decrease in
limb perfusion that threatens loss of the limb
-Critical limb ischemia: chronic ischemia that
causes either rest pain or wounds.
Asymptomatic
- complete occlusion was found in 1/3 of
pt.
- lack of symptoms is due to low physical
ax
- functional impairment is present
- functional decline is related to anklebrachial index (ABI)
Intermittent Claudation(IC)
- leg pain with exertion that is relieves
with rest
- claudation produces ischemia in the
affected muscle > pain
- pain can be felt in : buttock, hip, thigh,
calf, or foot
- limits the pt. ability to walk
- decreased walking speed and distance
- decreased leg function
Acute Limb Ischemia
- can be caused by embolism, thrombosis
or dissection
- limb threatening medical emergency
- pt. present with pain,
poikilothermia(disruption of normal
hypothalamic thermoregulatory
function), pulselessness, pallor
2
-
functional history should be taken to include
mobility, activities of daily living, and
independent activities of daily living.
- The presence of risk factors for PAD must
be noted
- physical examination: lower limb pulses
(evaluated) including the dorsalis pedis,
posterior tibial, popliteal, and femoral.
- legs and feet: changesof skin temperature,
color, and evidence of poor vascular flow.
- Dreased blood flow> atrophy thin shinny
skin, decreased hair growth, nails are
thickand brittle; foot >red or purple; pallor
when elevated
Vascular Testing for Peripheral Arterial
Disease
Ankle–Brachial Index.
- compares the brachial systolic pressure with
the ankle systolic pressure
- 95% sensitive in detecting PAD
- Obtained in pt. 70, patients aged 50 to 69
who have cardiovascular risk factors
Toe Pressures
- obtained by placing asmall cuff on the first
or second toe.
- For pt, with elevated ABI
- .7 : abnormal
Segmental Limb Systolic Pressure Measurement
- taken in the thigh, calf, and ankle
- Occlusive disease is noted by a significant
decrease in systolic pressure
Lower Limb Peripheral Vascular Diseases| Mica Pusing

3. Segmental Plethysmography (Pulse Volume
Recordings)
- recordings are obtained at the thigh, calf,
and ankle.
Occlusive lesions are detected by a change
in waveform from one level to the next.
Doppler Velocity Waveform Analysis
- performed to localize the lesion
Transcutaneous Partial Pressure of Oxygen
- test to predict wound healing
- usedto select amputation level
- TcPo2 less than 30 mm Hg : poor wound
healing
- TcPo2 above 40mm Hg : adequate skin
perfusion for healing
Angiography
- gold standard imaging test for PAD
- used to visualize the arterial anatomy and
the extent of PAD before revascularization
procedures.
Magnetic Resonance Angiography
- safer
- sensitivity and specificity are greater than
90% for evaluating PAD
Multidetector Computed Tomography Angiography.
- Faster and safer as compared to MRA
Management
Patients with PAD are more likely to have coronary
artery disease and cerebral artery disease than
patients without PAD.
goals of tx:
- reduce ischemic symptoms,
- increase walking ability
improve function, prevent and heal wounds
- prevent limb loss
- reduce morbidity and mortality
management
- education
- risk factor modification
- pharmacotherapy,
- exercise
- vascular interventions
Risk Factor Modification
Includes:
smoking cessation,
- - weight reduction
control of hyperlipidemia, hypertension,
and diabetes
smoking cessation:
3
-
can reduce their risk of amputation and
cardiovascular events even if it does not
improve claudication symptoms
Pain Management
- diabetic neuropathy: impair sensation
enough that the pt cannot feel ischemic pain
- ischemic pain relieved by reperfusion
- opiates for pain control
- pt that develop rest pain at night when they
lie down and find that keeping the foot in a
dependent position provides relief
Wounds
- ischemic wounds are best treated with
reperfusion of the limb
- tissue might not have sufficient blood supply
to repair itself after the trauma of
debridement.
- Dry gangrene can be allowed to
autoamputate as long as there is no evidence
of infection and there is adequate perfusion
to support healing of the underlying tissue
- Dependent rubor : fade with elevation and is
not associated with induration or increased
warmth.
erythema of cellulitis is often associated
with induration, increased warmth, swelling,
and does not fully resolve with elevation of
the limb.
Exercise
- improve walking time and walking distance
in PAD patients
Foot Protection
- Footwear should have enough length,
breadth, and depth to prevent pressure on
any bony prominences, deformities, or
calluses
Surgical Intervention
- Open surgical bypass is used in more diffuse
lesions.
- surgical interventions include limb salvage
and amputation
Arteriosclerosis Obliterans
-
-
disease commonly present because of
symptoms of intermittent claudication
or critical leg ischemia
intermittent claudication: active
Pts describe claudication as numbness,
weakness, giving way, aching, cramping,
or pain
Lower Limb Peripheral Vascular Diseases| Mica Pusing

4. -
-
inactive: rest pain, ulceration,
dependent rubor, or gangrene may be
the presenting findings
symptoms occur distal to the level of
stenosis
-
Angioplasty
- indicated for focal stenosis or short
Tx
Risk factor modification
major risk factors for peripheral arterial
occlusive disease:
- age
- diabetes mellitus
current smoking status(2x risk)
alterations in lipid metabolism
Hypertension
elevated plasma homocysteine levels
- elevated fibrinogen levels
Antiplatelet Therapy
-
decrease the rate of atherosclerotic
disease progression, decrease the
incidence of thrombotic events in the
limbs, and decrease the rate of adverse
coronary and cerebral vascular ischemic
events
Rehabilitation
General Self-Care Measures
- instructed to monitor their extremities
carefully for redness or skin breakdown
- Extremes of temperature should be
avoided
- Wash feet with mild soap and warm
water
- Rubbing when drying the foot is
avoided since it can injure the skin
- Skin bet toes should be dried to avoid
maceration
- Prevent the cracking of skin
- Proper foot wear
- Decrease activity
Exercise
- Elicit maximum walking time
- Should receive structured claudication ex
rehab program for at least 3 sessions weekly
over a period of 12 weeks
4
instruct to walk until claudication
occurs, rest until it subsides, and
continue repeating the cycle for 1 hour
each day.
-
-
segmental occlusions in which the
adjacent vessels are relatively free of
disease
localized stenosis of the common iliac
artery (less than 5 cm in length) is the
most favorable situation for angioplasty
decrease effectiveness in distal vessel
surgical revascularization
-
-
considered in patients with rest pain,
impending tissue loss, or significant
limitation of lifestyle
Pedal bypass grafting for critical limb
ischemia is a durable procedure with
acceptable graft patency and a very
good limb salvage rate
Intermittent Pneumatic Compression
- Skin blood flow, as reflected by TcPO
- External compression briefly raises
tissue pressure, emptying the
underlying veins and transiently
reducing venous pressure without
occluding arterial blood flow
Epidural Spinal Cord Stimulation (SCS)
- may decrease ischemic limb pain and
enhance perfusion
- result from vasodilation, possibly
through an effect on resting
sympathetic tone
Acute Arterial Occlusion
-
-
-
three causes:
o thrombosis
o aortic dissection
o emboli
thrombosis
o insitu occurs at the site of the
vascular abnormality,
Dissection
o Aotic dissection associated to
hypertention arthrosclerosis,
Lower Limb Peripheral Vascular Diseases| Mica Pusing

5. connective tissue disorders,
trauma
-
Emboli
o Large enough to occlude large
arteries typically cardiac source
o Arterial embolus unusual cause
paradoxic embolus(DVT>pass
foramen ovale)
o Multiple ad recurrent
Other Arterial Diseases
UPPER EXTREMITY ISCHEMIA
- Coldness and color changes: presenting
sx
Thromboangiitis Obliterans
(Buerger’s Disease)
-
nonatherosclerotic PAD affecting young
male smokers
- inflammatory disease that affects smalland
medium-sized arteries of the upper and
lower distal extremities
- considered to be a form of vasculitis
- M>F
- Higher risk for smokers
- high risk for amputation as compared to
PAD
Clinical Presentation, Evaluation, and
Diagnosis of Thromboangiitis Obliterans
- legs are more involved than the arms,
however, three or four limbs involved when
assessed with angiography
- Allen test to assess for asymptomatic
involvement of the upper extremities; (+)
indicates small artery disease in the upper
limbs but is not specific to TAO
Management of Thromboangiitis Obliterans
- Smoking cessation is key to disease
management
Vasospastic Disease (Raynaud’s
Phenomenon, Livedo
Reticularis,Acrocyanosis)
Raynaud’s Phenomenon
-
pain, and numbness in the fingers and
sometimes the toes
- triggered by cold temperatures, emotional
stress, vibration, or anything that activates the sympathetic nervous system
- Secondary Raynaud’s phenomenon is
associated with other disorders, such as
connective tissue diseases such as
scleroderma and lupus
- Patients should be instructed to keep the
whole body warm, avoid sudden decreases
in temperature, stop smoking, avoid
caffeine, avoid sympathomimetic drugs, and
reduce stress
Livedo Reticularis
-
seen on the arms and legs and occasionally
the trunk
- common in young women
- trigeer: cold
Acrocyanosis
-
causes the hands and feet to be bluish and
cold but is not painful
common in young women
aggravated by cold exposure
episodic
Venous Disorders of the Lower
Limb
Peripheral venous disorders include the following
conditions:
1. Chronic venous insufficiency (CVI) and venous
leg ulcers
2. Superficial thrombophlebitis
3. Deep venous thrombosis (DVT)
4. VTE, which is a collective term for DVT with
pulmonary embolism (PE)
Chronic Venous Insufficiency
Epidemiology of Chronic Venous Insufficiency
-
2x common in women but severity is higher
in men
-
Predisposing factor:
o
o
o
more common in young women and those
with a family history of the disorder
affect both hand and feet but affect hand
more often
occurs when the normal vascular response
becomes exaggerated causes color changes,
o
o
Pathogenesis
5
Lower Limb Peripheral Vascular Diseases| Mica Pusing
prolonged standing,
obesity,
positive family history,
multiparity,
advanced age,
historyof leg injury, surgery, heart
failure, paralysis, and DVT

6. o
-
-
-
persistent ambulatory venous hypertension
in the superficial and deep venous systems
in the lower limbs
Normal functioning of the venous blood
flow system depends on competent valves,
calf muscle pump mechanism, and normal
venous anatomy
Incompetence in any valves disrupts the
unidirectional flow of blood from the
superficial to the deep systems and toward
the heart, resulting in ambulatory venous
hypertension
Clinical Features
-
-
-
-
Initial complaints can be purely cosmetic
Chief clinical manifestation: dilated leg
veins, edema, leg pain, skin pigmentation,
subcutaneous fibrosis, dermatitis, and
ulceration
Patients can describe heaviness and aching
in the legs with prolonged standing. The
pain is usually localized to the calf or along
the varicose veins and is relieved by walking
or lying down with the leg elevated.
deep venous system obstruction can
experience venous claudication, a mild
aching sensation at rest that becomes an
intense cramping-type sensation in the calf
with ambulation
cutaneous manifestation:
o brownish pigmentation
(perimalleolar area)
o reddish purple hue (from venous
engorgement and obstruction)
Diagnostic Evaluation
-
Duplex ultrasound scanning has become the
test of choice for evaluation (allows
identification of any underlying
unrecognized acute or subacute DVT, as
well as the site and type of pathology
causing the CVI
Management
-
-
-
limb elevation is used for edema control,
patients should be instructed to elevate the
limb above heart level.
Periodic elevation of the leg 20 cm above
heart level during the day has been shown to
relieve edema by effectively lowering the
hydrostatic pressure to nearly zero
Compression stockings
6
reduce superficial venous volume
and venous hypertension, assist calf
muscle pump, and help prevent
transcapillary leakage of fluid into
the interstitial tissue
- Contraindications for compression therapy
include arterial insufficiency with ABI of
less than 0.6, ankle pressure less than 60 mm
Hg, active skin disease, or allergy to any of
the stocking components
- Physiologically, intravenous pressure in the
leg vein reflects the weight of the blood
column between the site of measurement
and the right atrium
- In the supine position: leg vein pressure: bet.
10-20 mmHg > total occlude at pressure of
:20-25mmHg
- Thromboembolic stockings exert a pressure
between 14 and 20 mm Hg.
- During standing, intravenous pressure in the
lower leg veins: around 60 mm Hg,
depending on the height of the individual.
- An external pressure of 35 to 40 mm Hg has
been shown to narrow the veins in the
standing position, and 60 mm Hg will totally
occlude the veins in the standing position.
- For mild disease and those with underlying
arterial disease, compression stockings with
20 to 30 mm
Venous Ulceration
-
disabling complication of CVI
most often large, irregular in shape, and
have a flat wound edge with a shallow moist
ruddy or beefy granulation base
- risk is highest when the ambulatory venous
pressure is 80mm Hg or greater
- Compression therapy is the mainstay of
treatment and is aimed at lessening the
impact of the underlying venous
insufficiency
Superficial Thrombophlebitis
-
-
treated with elevation, superficial heat, and ambulation with 30 to 40 mm Hg
compression stockings.
Nonsteroidal anti-inflammatory drugs are
useful in reducing pain and limiting local
inflammation
Venous Thromboembolism
Epidemiology
-
primarily a disease of old age
incidence increases with age
Lower Limb Peripheral Vascular Diseases| Mica Pusing

7. -
Male to female ratio = 1.2:1
Higher in women in childbearing yrs
Higher incidence in African American and
whites
-
-
Pathogenesis
-
Primary or idiopathic DVT occurs in the
absence of recognized thrombotic risk
factors
- secondary DVT occurs in the presence of
known risk factors
- Virchow’s Triad
o venous stasis
o vessel wall injury
o variation in coagulability of the
blood (important contributor in
pathogenesis of DVT)
- Thrombi usually begin to form at low flow
sites (deep veins of the calf, soleus sinuses,
behind the cusps of venous valves, and at
the entrance of tributary veins)
Risk factos associated with virchows triad
stasis
Hypercoagulable
Endothelial
state
injury
Age(>60)
Estrogenic
PostOp state
medication
Immobility Pregnancy
Cenous acess
Paralysis
Cancer
Trauma, burns
HR/
Family HX
Spinal cord
Myocardial
injury
infarction
Anesthesia Sepsis
Sepsis
in past
surgery
Obesity
Inherited
vasculitis
hypercoagulable state
Long
Factor v leiden
Prior DVT
distance
mutation
travel
-
-
Surgery of hip and knee, venous
catheterization, and burns can cause vessel
wall damage that initiates thrombus
formation
Venous thrombi consist of deposit of fibrin,
red cells, platelets and leukocytes
Most clinically significant PE originates
from DVT of the proximal lower limb
(popliteal, femoral, or iliac veins)
Clinical Features of Venous
Thromboembolism
7
-
-
Classic signs of edema, erythema, warmth,
tenderness, and positive Homan’s sign are
nonspecific and might not be always present
Patients can present with unilateral edema
and tenderness confined to the calf muscle
or along the distribution of the deep veins of
medial thigh without any other signs.
A 3-cm or greater difference in calf
circumference 10 cm below the tibial
tuberosity is associated with a high
likelihood of having DVT
Patients with obstructive iliofemoral
thrombosis can present with a markedly
swollen, cyanosed leg or with a white, cold
leg if there is associated arterial spasm
Diagnostic Evaluation of Venous
Thromboembolism
Duplex Ultrasound for Deep Venous Thrombosis
- choice for detection of DVT
Magnetic Resonance Venography
100% sensitivity in diagnosis
- of DVT proximal to the inguinal ligament
- safe to use in pregnant women
- concern: in pt with renal insufficiency
D-Dimer Assay
- Elevated levels of d-dimer occur with acute
thrombosis, but this does not discriminate
between physiologic (e.g., postoperative or
posttrauma) or pathologic (e.g., deep vein)
thrombi
Diagnostic Testing for Pulmonary Embolism
Ventilation Perfusion Scintigraphy
A normal study can effectively rule out
clinically important PE.
Spiral Computed Tomography.
- It is minimally invasive compared with
pulmonary angiography but allows
visualization of pulmonary vessels,
parenchyma, pleura, and mediastinum.
Pulmonary Angiography
- costly, invasive, technically demanding, and
has significant radiation exposure.
Treatment of Acute Venous
Thromboembolism
-
goals of treatment:
o prevent PE
o recurrent VTE,
o postphlebitis syndrome
Lower Limb Peripheral Vascular Diseases| Mica Pusing

8. -
Anticoagulation is the mainstay of
treatment, and the treatment regimen is
similar to that for DVT and PE
Ambulation After DVT
- Adjunctive therapy with graduated belowknee stockings with 30 to 40 mm Hg
pressure at the ankle is indicated after
proximal DVT.
Lymphatic Disease in the Lower
Limbs
-
-
-
-
-
-
-
lymphatic vasculature is divided into
superficial and deep systems located in the
popliteal fossa and the inguinal region
superficial system : from the skin and
subcutaneous tissues
deep system: muscles and joints
lymph has no valve
lymph capillaries flows into the lymph
precollector then collectors
lymph angion
o a segment of a lymph collector
located between two valves
o Contain smooth muscle
o Contract around 10-12 time/min at
rest
Lymphangiomotoricity
o frequency and amplitude of these
contractions
o affected by : internal stretch,
temperature, hormones, external
stretch from manual lymph
drainage or muscle or joint pump
during exercise
Lymphedema
o caused by a defect in the lymphatic
system that leads to protein-rich
interstitial fluid overload.
primary lymphedema
o Hereditary and congenital types
o Less common
o Divided into three major types:
congenital, lymphedema praecox,
lymphedema tarda
Congenital lymphedema
o Onset in the first 1-2 years of life
o Bilateral
o Aplastic lymphatics
o Due to gene defect hat involves
lymphathogenesis
Lymphadema praecox
o Onset between 1-35 y/o
o Hypoplastic lymphatics
o Unilateral
8
-
-
Lymphadema tard
o Onset is after age of 35
o Week lymphatics unable to
compensate when stresses with
overload injury
Secondary lympedema
o Most common type
o Usually caused by canser
o Unilateral pain swelling
o Precaution
 Meticulous skin care
 Meticulous nail care
 Avoid anything that cause
swelling (needle sticks,
blood pressure cuff, tight
clothing, leaving the leg in
dependent position for
long period)
o Clinical presentation
 Pitting edema but
becomes nonpitting(tissue
become fibrotic)
 Pt. complains limb feels
heavy and stiff
o Complication
 Cellulitis
 Lymphangitis
 Lymphangiosarcoma
o Treatment goals
 Improve function of limb
 Prevent complication
 Improve quality of life
o The treatment phase involves
sessions 5 days/wk and includes
manual lymph drainage (MLD),
exercise, skin and nail care, and
compression. MLD consists of light
strokes to help stimulate lymph
production and transport
o The bandages should not be
removed and should be worn until
the next treatment session. Exercise
is performed twice a day for 15
minutes while wearing
compression bandages
o Once the patient has reached
maximum limb reduction, therapy
moves from the initial treatment
phase to the maintenance phase
o The maintenance phase is a lifelong
process of preventing
reaccumulation of lymphedema and
protecting the skin
Reference
Lower Limb Peripheral Vascular Diseases| Mica Pusing

9. Physical medicine and rehabilitation 4th edition by
Braddom
9
Lower Limb Peripheral Vascular Diseases| Mica Pusing