determining a vascular cause for leg pain and referrals

Peripheral Overview

Peripheral Overview

Learning Objectives

1. Understand epidemiology and presentation of common vascular causes of lower limb pain

2. Review basic anatomy and diagnostics

3. Discuss referrals and treatment

Peripheral Overview

Peripheral Overview

Differential for leg pain

1. Vascular•Peripheral Vascular Disease – acute/chronic•Chronic venous disease•DVT

2. Neurospinal•Spinal stenosis

•Disc disease

3. Neuropathic•Diabetic •Chronic EtOH

4. Musculoskeletal•OA of hip or knee•Chronic compartment syndrome

Peripheral Overview

Differential for leg pain

1. Vascular•Peripheral Vascular Disease – acute/chronic•Varicose veins•Chronic venous insufficiency•DVT

2. Neurospinal•Spinal stenosis•Disc disease

3. Neuropathic•Diabetic •Chronic EtOH

4. Musculoskeletal•OA of hip or knee

•Chronic compartment syndrome

1. Vascular•Peripheral Vascular Disease – acute/chronic•Chronic venous disease•DVT

Peripheral Overview

Peripheral Overview

Risk factors

ARTERIAL DISEASE•Advancing age

•Hypertension•Hyperlipidaemia•Family history

•Diabetes

•Smoking

VENOUS DISEASE•Advancing age

•Increased BMI•Pregnancy•Family history

•Standing occupation

•Smoking

•Trauma•Previous DVT

Peripheral Overview

Clinical presentation of PAD~15%

Classic (Typical) Claudication

~33%Atypical Leg Pain(functionally limited)

50%Asymptomatic

1%-2%Critical Limb Ischemia

Peripheral Overview

Claudication vs Pseudoclaudication

Claudication Pseudoclaudication

Characteristic of discomfort

Cramping, tightness, aching, fatigue

Same as claudication plus tingling, burning,

numbness

Location of discomfort

Buttock, hip, thigh, calf, foot

Same as claudication

Exercise-induced Yes Variable

Distance Consistent Variable

Occurs with standing No Yes

Action for relief Stand Sit, change position

Time to relief <5 minutes ≤30 minutes

Peripheral Overview

30% Buttock & Thigh Claudication±Impotence – Leriche’s Syndrome Thigh Claudication

60% Upper 2/3 Calf Claudication

Lower 1/3 Calf Claudication

Peripheral Overview

Symptoms in PAD

• Chronic– Claudication– Restpain

– ulcers / tissue loss

• Acute – 6 P’ s– Pain– Pallor– Poikilothermia– Pulselessness– Paraesthesia– Paralysis

Peripheral Overview

Pathology of PAD

Chronic Causes• Atherosclerosis

• Vasculitis

• Takayasu’s disease

• Buerger’s disease

• Trauma

• Raynaud’s disease

• Fibromuscular dysplasia

Acute Causes• Embolism

• Thrombosis

• Dissection

• Trauma

• Vasculitis

Peripheral Overview

Clinical presentation of venous disease

Varicose veins Oedema Skin changes Ulcers

Peripheral Overview

Symptoms of chronic venous disease

• Limb discomfort – tired, heavy legs, aching

• Oedema

• Discolouration

• Erythema

• Muscle cramps

• Itching

• Tingling/numbness

• Spontaneous bleeding

Peripheral Overview

CEAP Classifications

Clinical Classification of Venous Insufficiency

•Class 0 No visible or palpable signs of venous disease

•Class 1 Telangiectasias or reticular veins

•Class 2 Varicose veins

•Class 3 Oedema

•Class 4 Skin changes– a Including pigmentation or venous eczema– b With lipodermatosclerosis

•Class 5 Healed ulceration•Class 6 Active ulceration

Peripheral Overview

Telangiectasia/reticular veins

Peripheral Overview

Varicose veins

Peripheral Overview

Oedema

Peripheral Overview

Skin changes

Peripheral Overview

Diagnostic Test - ABI

Ankle Brachial Index (ABI):

Blood pressures measured in both ankle & arm – Blood pressure is compared– Pressures should be equal

ABI Classification Severity of PVD

>1.3 Non-compressible / CA++

≥0.9 Normal

0.70-0.89 Mild

0.50-0.69 Moderate

<0.5 Severe

÷ Ankle pressure Arm pressure

Peripheral Overview

Diagnostic Test- Ultrasound

Ultrasound/Duplex Ultrasound:• Detects blood flowing through the

vessel

• Can detect if flow is severely blocked

• Speed and direction of blood flow

• Assess valve competence

• Readily available in many offices

Peripheral Overview

Treatment Options - PAD

• Lifestyle change– Exercise regularly– Smoking cessation– Diet -Low-fat to reduce cholesterol

• Medications– Blood pressure control– Antiplatelet therapy– Cholesterol-lowering agents – Vasodilators to dilate arteries

• Endovascular therapy

– Angioplasty

– Stenting

• Surgery– Surgical bypass– Endarterectomy– Amputation

Peripheral Overview

Treatment Options – Chronic venous disease

• Lifestyle change– Exercise regularly– Smoking cessation– Leg elevation

• Skin care– Emollients e.e fatty cream, vaseline– Barrier preparations e.g. vaseline,

zinc oxide– Topical coritcosteroids– COMPRESSION THERAPY

• Endovenous therapy

– Endovenous ablation – RFA, EVLT

– Ultrasound guided sclerotherapy

• Surgery– Debridement +/- skin grafting for

ulcers– Historically vein stripping and

avulsions

Peripheral Overview

COMPRESSION STOCKINGS

CLASS PRESSURE LEVEL OF SUPPORT

INDICATION CEAP

OTC <15 mmHg Minimal Asymptomatic, comfort only. 0, 1

I 15-20 mmHg Mild Minor varicosities, tired aching legs, minor swelling.

1, 2, 3

II 20-30 mmHg Moderate Moderate to severe varicosities, swelling, phlebitis, following ablation or DVT

3, 4, 5

III 30-40 mmHg Firm Lymphoedema N/A

Peripheral Overview

Referral guidelines – Intermittent claudication

Red flags

Urgent vascular assessment is required if:

•Critical limb ischaemia ie. rest pain and/or tissue loss with absent pulses

•Acute limb ischaemia

Assessment

•A typical history will usually make the diagnosis – cramp like pain brought on by walking exercise at fixed distance and relieved by rest•Risk factors – high risk of coronary and cerebrovascular events, 20% have diabetes, smoking•Assess impact on quality of life•Peripheral pulses

Peripheral Overview


Investigations

•Blood tests – CFC, fasting lipids, glucose, renal function

•ABI if available

•Duplex scan

Suggested GP management

•Management of risk factors– smoking cessation advice– statins, even in patients with normal lipids– anti-platelet medication to reduce cardiovascular risk– aggressive control of blood sugars in diabetes– hypertension treatment – Beta blockers do not worsen PVD

•Targeted walking exercise – green prescription

Peripheral Overview


When to refer

•If any red flags – acute referral

•Refer to outpatient if:– after 6 months of targeted exercise and risk factor reduction,

the pain is worse or there is no improvement– the patient’s quality of life is severely affected by symptoms– a young, otherwise healthy adult presents with symptoms of

claudication

Peripheral Overview

Referral guidelines – varicose veins and chronic venous insufficiency

Practice Point

•Evidence indicates that 80% of patients gain relief from vein ablation therapy. Offer options to everyone with symptomatic varicose veins even if public funding may not available, as patients may believe they need to tolerate their symptoms.

Assessment•Risk factors.•History of varicose vein complications – skin changes, thrombophlebitis, ulceration, bleeding.•Severity of symptoms and if controllable with compression – level of disability.•Determine patient’s wish for cosmetic treatment.

Peripheral Overview


Investigations

•ABI if arterial disease suspected by absent pulses and compression stockings being prescribed – ABI>0.8

•Duplex ultrasound


•Lifestyle modification – weight management – smoking cessation– exercise to improve calf muscle pump– leg elevation

•Manage varicose eczema – soap substitutes, regular emollients, topical steroids.•Compression hosiery

Peripheral Overview



•Thrombophlebitis – treat with anti-inflammatories, no role for antibiotics – if focal on duplex – rescan if getting worse– if extensive on duplex – anticoagulate with clexane if no

contraindications for 3 months

Peripheral Overview


When to refer

•Complications of varicose veins:– recurrent cellulitis CCDHB patients– recurrent thrombophlebitis offered endovenous– healed/current ulcers treatment– recurrent bleeding

•Thrombophlebitis– If duplex demonstrates extensive STP and contraindication to

anticoagulation– If progression on duplex despite anticoagulation

determining a vascular cause for leg pain and referrals

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