Peripheral Vascular Disease

Peripheral Vascular Disease

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Peripheral vascular disease (PVD) is a nearly pandemic condition that has the potential to cause loss of limb or even loss of life. PVD manifests as insufficient tissue perfusion initiated by existing atherosclerosis acutely compounded by either emboli or thrombi. Many people live daily with significant degrees of PVD; however, in settings such as acute limb ischemia, this latent disease can suddenly become life-threatening and necessitate emergency intervention to minimize morbidity and mortality. [1, 2]

For patient education information, see Peripheral Vascular Disease.

PVD, also known as arteriosclerosis obliterans, is primarily the result of atherosclerosis. The atheroma consists of a core of cholesterol joined to proteins with a fibrous intravascular covering. The atherosclerotic process may gradually progress to complete occlusion of medium-sized and large arteries. The disease typically is segmental, with significant variation from patient to patient.

Vascular disease may manifest acutely when thrombi, emboli, or acute trauma compromises perfusion. Thromboses are often of an atheromatous nature and occur in the lower extremities more frequently than in the upper extremities. Multiple factors predispose patients to thrombosis. These factors include sepsis, hypotension, low cardiac output (see the Cardiac Output calculator), aneurysms, aortic dissection, bypass grafts, and underlying atherosclerotic narrowing of the arterial lumen.

Emboli, the most common cause of sudden ischemia, usually are of cardiac origin (80%); they also can originate from proximal atheroma, tumor, or foreign objects. Emboli tend to lodge at artery bifurcations or in areas where vessels abruptly narrow. The femoral artery bifurcation is the most common site (43%), followed by the iliac arteries (18%), the aorta (15%), and the popliteal arteries (15%).

The site of occlusion, the presence of collateral circulation, and the nature of the occlusion (thrombus or embolus) determine the severity of the acute manifestation. Emboli tend to carry higher morbidity because the extremity has not had time to develop collateral circulation. Whether caused by embolus or thrombus, occlusion results in both proximal and distal thrombus formation as a consequence of flow stagnation.

Female sex appears to have an effect on outcomes after lower-extremity interventions for peripheral arterial disease (PAD). In a retrospective study (2004-2009) evaluating data from 12,379 patients (41% women) in 16 centers participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium PVI registry who underwent these procedures, female sex was associated with a higher rate of vascular complications, transfusions, and embolism, but no differences wer eseen for inpatient mortality, myocardial infarction (MI), or stroke or transient ischemic attack. [3] Despite the higher complication rates in women, the investigators reported similar overall procedural success rates between the sexes.

In another retrospective study that evaluated data over 6 years from 23,870 index transfemoral vascular access procedures from cross-matching the Eastern Danish Heart Registry with the Danish Vascular Registry, Dencker et al noted a low risk of major vascular complications (0.54%) with femoral access following coronary angiography and percutaneous coronary intervention (PCI). [4] Risk factors for such complications included left-side access, the presence of PAD, and female sex. [4]

Thukkani AK, Kinlay S. Endovascular intervention for peripheral artery disease. Circ Res. 2015 Apr 24. 116(9):1599-613. [Medline].

Suzuki J, Shimamura M, Suda H, et al. Current therapies and investigational drugs for peripheral arterial disease. Hypertens Res. 2016 Apr. 39(4):183-91. [Medline].

Jackson EA, Munir K, Schreiber T, et al. Impact of sex on morbidity and mortality rates after lower extremity interventions for peripheral arterial disease: observations from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. J Am Coll Cardiol. 2014 Jun 17. 63(23):2525-30. [Medline].

Dencker D, Pedersen F, Engstrom T, et al. Major femoral vascular access complications after coronary diagnostic and interventional procedures: A Danish register study. Int J Cardiol. 2016 Jan 1. 202:604-8. [Medline].

Hussein AA, Uno K, Wolski K, et al. Peripheral arterial disease and progression of coronary atherosclerosis. J Am Coll Cardiol. 2011 Mar 8. 57(10):1220-5. [Medline].

Nakata S, Yokoi Y, Matsumoto R, et al. Long-term cardiovascular outcomes following ischemic heart disease in patients with and without peripheral vascular disease. Osaka City Med J. 2008 Jun. 54(1):21-30. [Medline].

Chen CC, Hung KC, Hsieh IC, Wen MS. Association between peripheral vascular disease indexes and the numbers of vessels obstructed in patients with coronary artery disease. Am J Med Sci. 2012 Jan. 343(1):52-5. [Medline].

Jurado JA, Bashir R, Burket MW. Radiation-induced peripheral artery disease. Catheter Cardiovasc Interv. 2008 Oct 1. 72(4):563-8. [Medline].

Meller SM, Stilp E, Walker CN, Mena-Hurtado C. The link between vasculogenic erectile dysfunction, coronary artery disease, and peripheral artery disease: role of metabolic factors and endovascular therapy. J Invasive Cardiol. 2013 Jun. 25(6):313-9. [Medline].

McDermott MM, Liu K, Ferrucci L, et al. Circulating blood markers and functional impairment in peripheral arterial disease. J Am Geriatr Soc. 2008 Aug. 56(8):1504-10. [Medline]. [Full Text].

Craft LL, Guralnik JM, Ferrucci L, et al. Physical activity during daily life and circulating biomarker levels in patients with peripheral arterial disease. Am J Cardiol. 2008 Nov 1. 102(9):1263-8. [Medline]. [Full Text].

Napoli A, Anzidei M, Zaccagna F, Cavallo Marincola B, Zini C, Brachetti G. Peripheral arterial occlusive disease: diagnostic performance and effect on therapeutic management of 64-section CT angiography. Radiology. 2011 Dec. 261(3):976-86. [Medline].

Meyersohn NM, Walker TG, Oliveira GR. Advances in axial imaging of peripheral vascular disease. Curr Cardiol Rep. 2015 Oct. 17(10):87. [Medline].

Stacy MR, Sinusas AJ. Novel applications of radionuclide imaging in peripheral vascular disease. Cardiol Clin. 2016 Feb. 34(1):167-77. [Medline].

Criqui MH, Ninomiya JK, Wingard DL, Ji M, Fronek A. Progression of peripheral arterial disease predicts cardiovascular disease morbidity and mortality. J Am Coll Cardiol. 2008 Nov 18. 52(21):1736-42. [Medline]. [Full Text].

[Guideline] Alonso-Coello P, Bellmunt S, McGorrian C, et al. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb. 141(2 Suppl):e669S-90S. [Medline]. [Full Text].

Hackam DG, Wu F, Li P, et al. Statins and renovascular disease in the elderly: a population-based cohort study. Eur Heart J. 2011 Mar. 32(5):598-610. [Medline]. [Full Text].

Tu C, Das S, Baker AB, Zoldan J, Suggs LJ. Nanoscale strategies: treatment for peripheral vascular disease and critical limb ischemia. ACS Nano. 2015. 9(4):3436-52. [Medline].

[Guideline] Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017 Mar 21. 135(12):e726-e779. [Medline]. [Full Text].

Suzuki A, Kanai A. 8% Lidocaine pump spray relieves pain associated with peripheral blood flow disorders. Clin J Pain. 2009 Feb. 25(2):107-10. [Medline].

Abdullah O, Omran J, Enezate T, et al. Percutaneous angioplasty versus atherectomy for treatment of symptomatic infra-popliteal arterial disease. Cardiovasc Revasc Med. 2017 Sep 28. [Medline].

Roy TL, Chen HJ, Dueck AD, Wright GA. Magnetic resonance imaging characteristics of lesions relate to the difficulty of peripheral arterial endovascular procedures. J Vasc Surg. 2017 Dec 13. [Medline].

Everett Stephens, MD Assistant Clinical Professor, Department of Emergency Medicine, University of Louisville School of Medicine

Everett Stephens, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Department of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, National Association of EMS Physicians

Disclosure: Medical Director for: SironaHealth.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

David A Peak, MD Associate Residency Director of Harvard Affiliated Emergency Medicine Residency; Attending Physician, Massachusetts General Hospital; Assistant Professor, Harvard Medical School

David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, American Medical Association

Disclosure: Partner received salary from Pfizer for employment.

Peripheral Vascular Disease

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