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Peripheral Vascular Occlusive Disease

Diagnosis/Definition

Peripheral arterial occlusive disease includes two main categories:

Patients with claudication or cramping of muscle groups with activity that is alleviated by rest; and

Those who have threatened extremities, as evidenced by rest pain, non-healing ulcers or tissue gangrene

Younger patients without history of cardiac disease or hyperlipidema may be more appropriately referred to orthopedics for evaluation of compartment syndrome.

Claudication: cramp-like pain in major muscle groups, with the calf muscles generally being affected first, that starts during activity and is alleviated by rest. This pattern is consistent and repeatable with the same activity, and is always relieved by rest. Generally, pulses will be absent distally, though they may be present at rest and only disappear with activity

Threatened limb: patients will usually have evidence of “rest pain”, which is constant pain in the distal most part of the extremity, that is generally worsened by elevation and may be improved with dependency. They may also have tissue gangrene or non-healing ulcers

Diabetic patients are unique in that they may develop severe ischemia or ulceration that is painless, due to neuropathy

Mild to moderate claudication is defined as symptoms arising with walking greater than three blocks

Initial Diagnosis and Management

Diagnosis is generally made on a clinical basis, with history and physical exam

All patients should try to reduce risk factors and have co-morbid conditions managed. Tobacco use should be stopped, patients with hyperlipidemia should have this controlled, and patients with diabetes should have their disease optimally managed

Management of concomitant cardiac and pulmonary disease, which is often associated with peripheral vascular disease, should be emphasized. Obese patients should be encouraged to lose weight

Key to management is risk factor reduction, exercise to tolerance with invasive intervention, as necessary.

Ankle brachial indices (ABIs), segmental pressures and treadmill testing are all parts of the initial vascular work-up, done in the Vascular Lab

Ongoing Management and Objectives

Risk factor reduction through education, graded exercise and medical management of co-morbid conditions

Patients with evidence of severe ischemia may be candidates for endovascular intervention, arterial bypass, or endarterectomy

The Vascular Surgery Service should coordinate all arteriographic studies and interventions

Indications for Specialty Care Referral

All patients with any degree of claudication should be referred to the Vascular Surgery Service for initial evaluation

Patients with non-healing ulcers, rest pain of the distal extremity, or tissue gangrene due to ischemia should be referred expeditiously to Vascular Surgery or Limb Preservation

All patients with a threatened limb should be referred to the Vascular Surgery or Limb Preservation

Criteria for Return to Primary Care

The Vascular Surgery Service should follow patients with severe claudication or a threatened limb on a regular basis. It is critical that these patients still be followed by their primary care manager to assist in risk factor reduction and management of co-morbidities

Patients who undergo a vascular procedure involving arterial reconstruction should be followed lifelong in the Vascular Surgery Service to monitor their vascular grafts for both graft failure and disease progression. These patients should also be followed by their primary care manager

Individuals with very mild to moderate claudication, should be followed primarily by their primary care manager with only an annual follow up by the Vascular Surgery Service