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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 for thrombosis. These factors include sepsis,
hypotension, low cardiac output, 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%).
• Ischemic rest pain is more worrisome; it refers to pain in the extremity due
to a combination of PVD and inadequate perfusion.
o Ischemic rest pain often is exacerbated by poor cardiac output.
o The condition is often partially or fully relieved by placing the
extremity in a dependent position, so that perfusion is enhanced by
the effects of gravity.
• The Allen test may provide information on the radial and ulnar arteries.
• The skin may have an atrophic, shiny appearance and may demonstrate
trophic changes, including alopecia; dry, scaly, or erythematous skin;
chronic pigmentation changes; and brittle nails.
Lab Studies:
Imaging Studies:
• Plain films are of little use in the setting of PVD. Doppler ultrasound
studies are useful as primary noninvasive studies to determine flow status.
Upper extremities are evaluated over the axillary, brachial, ulnar, and
radial arteries. Lower extremities are evaluated over the femoral, popliteal,
dorsalis pedis, and posterior tibial arteries. Note the presence of Doppler
signal and the quality of the signal (ie, monophasic, biphasic, triphasic).
The presence of distal flow does not exclude emboli or thrombi because
collateral circulation may provide these findings.
Other Tests:
Procedures:
Prehospital Care: Prehospital care for PVD involves the basics: control ABCs,
obtain IV access, and administer oxygen. Generally, do not elevate the extremity.
Note and record distal pulses and skin condition. Perform and document a
neurological examination of the affected extremities.
Treatment for either thrombi or emboli in the setting of PVD is similar. Empirically
initiate a heparin infusion with the goal of increasing activated partial
thromboplastin time to 1.5 times normal levels. Acute leg pain correlated with a
cool distal extremity, diminished or absent distal pulses, and an ankle blood
pressure under 50 mm Hg should prompt consideration of emergent surgical
referral.
Patient Education:
Medical/Legal Pitfalls:
• Failure to recognize severe arterial insufficiency may put the patient at risk
for serious local ischemic complications. In addition, it is critical that the
patient be evaluated for acute cardiac conditions that might have led to
peripheral arterial ischemia. Potentially significant legal consequences
may ensue if these conditions are missed.