| Peripheral vascular disease (PVD) is a condition in which the arteries or veins carrying blood to or from the arms or legs become narrowed or clogged. The feet and legs may be more affected than the hands and arms. The most common symptom is leg cramps or pain that becomes worse with walking or other activity, and better with rest (intermittent claudication). Other symptoms may include leg numbness, tingling, or weakness. The feet may be cold or discolored, with loss of hair. However, up to 75% of those with PVD have no symptoms.
Disruption of circulation in the peripheral veins can be caused by failure of blood to move with sufficient speed through the veins (venostasis), or from overly active blood clotting (hypercoagulability). It can be a result of immobility or prolonged inactivity, trauma or serious injury, orthopedic surgery, aging, or dehydration. The most common cause of narrowing of the peripheral arteries is atherosclerosis, which used to be called "hardening of the arteries." Atherosclerosis develops gradually as cholesterol and scar tissue build up, forming a substance called plaque that clogs the blood vessels. Other causes of narrowed arteries include trauma, spasm of the smooth muscles in artery walls, and structural defects in the arteries that are present at birth. Individuals with diabetes are 8 times more likely to develop PVD than the general population (Martin).Risk: The leading cause of peripheral vascular disease (PVD) is atherosclerosis (Levy). Risk factors for both PVD and atherosclerosis include smoking, diabetes, obesity, sedentary lifestyle, high blood pressure, high cholesterol, and family history of heart or vascular disease. Prevalence increases with age, such that over 70 years of age, 20% will have PVD (Regensteiner).
Thirty to forty percent of those with PVD are smokers (Regensteiner). Overall, PVD is slightly more common in men than women. Incidence and Prevalence: Peripheral vascular disease (PVD) affects about 12% of individuals (Regensteiner), or about 8 to 12 million in the US (Levy; Martin). |
Source: Medical Disability Advisor
| History: The most common symptom of peripheral vascular disease of the lower extremities that individuals report is leg pain, particularly when walking or exercising, which disappears after a few minutes rest (intermittent claudication). Other symptoms of peripheral vascular disease of the lower extremities include numbness and tingling in the legs, feet, or toes; coldness in the lower legs and feet; loss of hair on the feet or legs; discoloration or cold feeling in the legs and feet; and ulcers or sores on the legs and feet that do not heal properly. Physical exam: Abnormal or reduced pulse in the feet (pedal pulses), murmur (bruit) over the large artery in the groin (femoral artery) or in arteries in the lower abdomen (iliac arteries), prolonged venous filling time, discolored or shiny (atrophic) skin with hair loss, reduced blood pressure in the lower extremities, and unilaterally cool limbs are associated with peripheral vascular disease. Observations of the effect of hanging the affected leg over the side of the bed on an individual's pain (the Buerger test) and warm knees are predictive of the extent of vascular disease. Tests: Doppler ultrasound may identify reduced blood flow to a specific area and locate any obstruction to venous flow. Plethysmography helps view areas of decreased circulation around the affected area. Phlebography involves injection of dye visualized on x-ray (radiopaque) into the veins, which shows areas of decreased or diverted blood flow. Arteriography involves injection of radiopaque contrast dye into the artery, to look at the diameter of the arteries, areas of plaque or blood clots, and diversion of blood to alternate vessels. Treadmill walking can quantify the amount of effort expended before pain occurs, and can be useful to monitor response to treatment. |
Source: Medical Disability Advisor
| In some cases, PVD can be successfully controlled by certain lifestyle changes, such as exercise programs and dieting to lose weight and lower blood cholesterol. The single most important thing an individual can do to slow PVD is to stop smoking. When lifestyle changes alone are not enough to control the symptoms of PVD, there are a number of treatment options, including: opening up the blockage in the vessel by inserting a very small balloon attached to a thin tube (catheter) into the vessel through a small nick in the skin (angioplasty); administration of clot-dissolving drugs through a catheter directly into the clot (thrombolytic therapy); a vein graft from another part of the body or a graft made from artificial material to create a detour around the blocked artery (bypass grafts); and insertion of a balloon catheter into the affected artery above the clot, which when inflated and pulled back brings the clot with it (thrombectomy). In the future, we may see some increased use of tubes (stents) inserted into the vessel in order to keep it open, similar to those used in the coronary arteries. Medications that thin the blood (anticoagulants) or affect platelets involved in blood clotting (such as aspirin) may be helpful. Statins are showing promise in reducing the incidence of PVD by 38% (Aronow). |
Source: Medical Disability Advisor
| Overall, with treatment (thrombolytic therapy, angioplasty, bypass grafts, or thrombectomy), the prognosis is reasonably favorable; without treatment limb loss may be imminent. The prognosis does vary somewhat depending on the specific type and cause of disease and the stage at which it is first diagnosed. Treatment to bypass an obstructed vessel is generally not very helpful if atherosclerosis also affects smaller arteries beyond the site of blockage. As atherosclerosis underlying PVD is typically a progressive condition, it tends to recur and PVD tends to worsen following treatment unless there are significant lifestyle changes, including stopping smoking. |
Source: Medical Disability Advisor
| Rehabilitation of peripheral vascular disease focuses on increasing the exercise capacity of the individual. However, individuals with this disease have a lowered aerobic capacity when exercising the arms or legs. Because of this, aerobic activity for these individuals cannot be maintained for long periods of time. Short periods and intervals of intense exercise for 10 to 20 seconds, followed by lower levels of activity, are usually achievable goals set in the rehabilitation program. Physical therapists instruct individuals in the progression of intermittent activities such as walking, stationery biking, or pool activities.
Upper extremity exercises in conjunction with leg exercises serve as good rehabilitation to improve overall endurance. If comfortable for the individual, lower extremity exercise helps to establish collateral blood flow to the legs and heart. Buerger-Allen exercises may also be recommended to improve lower extremity circulation and reduce edema. Realistic goals should be set with regard to time, frequency, and distance of all exercises.
The rehabilitation program will vary in intensity and progression of the exercises depending on the extent of disease and the individual's overall health. |
Source: Medical Disability Advisor
| When venous blood flow is impeded, blood and bacteria may accumulate, leading to the formation of leg ulcers. Decreased venous flow results in increased venous pressure, promoting varicose veins that can become inflamed and clotted (thrombophlebitis). Interrupted blood flow to the peripheral arteries can lead to inadequate delivery of oxygen to the tissues and, consequently, to tissue death and gangrene, which may require leg amputation in 3% to 6% of cases. Clots in the veins or arteries can break off and travel to other vessels, causing stroke or blood clots in the lungs (pulmonary embolism). Individuals with PVD are at a greater risk of heart attack (myocardial infarction) or stroke (cerebrovascular accident) ("PAD Quick Facts"). |
Source: Medical Disability Advisor
| Work accommodations that may be required include postural and positional changes to accommodate the affected limbs and promote better circulation. If the individual performs a desk job, short routine walks should be scheduled to promote lower limb circulation. Strenuous physical activity or walking long distances may need to be limited in accordance with medical recommendations. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual complain of claudication with activity?
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Does individual have leg numbness, tingling, or weakness? Are the lower legs and feet cold or discolored with loss of hair?
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Does individual have sores that do not heal properly?
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Does individual have venostasis or hypercoagulability? Does individual have diabetes, obesity, sedentary lifestyle, high blood pressure, high cholesterol, and family history of heart or vascular disease? Does individual smoke?
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On exam, were reduced pedal pulses, a bruit over the femoral artery or iliac arteries, prolonged venous filling time, and unilaterally cool limbs evident?
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Were Doppler ultrasound, plethysmography, phlebography, arteriography or treadmill walking performed?
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Have conditions with similar symptoms been ruled out?
Regarding treatment:
- Has individual addressed correctable lifestyle activities such as diet, weight loss, lowering blood cholesterol, and cessation of smoking?
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Was an angioplasty necessary? Was thrombolytic therapy done? Was a bypass graft or thrombectomy performed?
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Is individual on anticoagulant medication?
Regarding prognosis:
- Is individual active in physical therapy?
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Can individual's employer accommodate any necessary restrictions?
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Does individual have any conditions that may affect ability to recover?
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Have any complications occurred such as leg ulcers, thrombophlebitis, or gangrene and amputation? Did individual have a pulmonary embolism?
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Source: Medical Disability Advisor
| Aronow, W. S., et al. "Effect of Simvastatin Versus Placebo on Treadmill Exercise Time Until the Onset of Intermittent Claudication in Older Patients with Peripheral Arterial Disease at Six Months and at One Year..." American Journal of Cardiology 92 6 (2003): 711-712. MD Consult. Elsevier, Inc. 18 Dec. 2004 <http://home.mdconsult.com/das/journal/view/43511520-4/N/14054753?sid=292016427&source=MI>.Levy, P. J. "Epidemiology and Pathophysiology of Peripheral Arterial Disease." Clinical Cornerstone 4 5 (2002): 1-15. MD Consult. Elsevier, Inc. 28 Dec. 2004 <http://home.mdconsult.com/das/journal/view/40017915-2/N/12708841?sid=292016427&source=MI>. Martin, R. P., and S. Lerakis. "Contrast for Vascular Imaging." Cardiology Clinics 22 2 (2004): 313-320. MD Consult. Elsevier, Inc. 28 Dec. 2004 <http://home.mdconsult.com>. "PAD Quick Facts." American Heart Association. American Heart Association, Inc. 28 Dec. 2004 <http://www.americanheart.org/presenter.jhtml;jsessionid=GD0MDEB4AE2TZWFZOAGSCZQ?identifier=3020248>. Regensteiner, J. G., and W. R. Hiatt. "Treatment of Peripheral Arterial Disease." Clinical Cornerstone 4 5 (2002): 26-40. MD Consult. Elsevier, Inc. 28 Dec. 2004 <http://home.mdconsult.com/das/journal/view/40017915-2/N/12708843?sid=292016427&source=MI>. |
Source: Medical Disability Advisor
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