Peripheral Vascular Disease - Medical Disability Guidelines

Medical Codes

	ICD-9-CM:
	443.82 -	Peripheral Vascular Disease, Other; Erythromelalgia
	443.89 -	Peripheral Vascular Disease, Other, Other; Acrocyanosis; simple [Schultzes type]; vasomotor [Nothnagels type]; Erythrocyanosis; Erythromelalgia
	443.9 -	Peripheral Vascular Disease, Unspecified

Related Terms

Claudication
Intermittent Claudication
Peripheral Arterial Disease
Peripheral Arterial Insufficiency
Peripheral Arteriosclerosis
Peripheral Atherosclerosis

Overview

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. While technically "vascular disease" would indicate disease in arteries or veins, this "PVD" term is usually used to discuss arterial disease. Deep vein thrombosis may provide additional information.

The feet and legs are 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. However, about 40% of those known by screening tests to have PVD have no symptoms (Roger).

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. Atherosclerosis in the lower limb arteries is the same disease as atherosclerosis in the arteries is to the heart, brain, and kidney, for example. Thus, the risk factors (genetics, smoking, hypertension, hypercholesterolemia, and diabetes) are the same regardless of what body part is being discussed. Individuals with diabetes are 2 to 4 times more likely to develop PVD than the general population (Selvin; Roger).

Other causes of narrowed lower limb arteries include trauma, vasculitis diseases, prior radiation therapy, and structural defects in the arteries that are present at birth.

Incidence and Prevalence: Peripheral vascular disease (PVD) affects about 4.3% of the population or about 5 to 8 million adults in the US (Selvin; Roger).

Source: Medical Disability Advisor

Diagnosis

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.

Tests: The best screening test is ankle/brachial blood pressure ratio. Brachial artery blood pressure is measured in both upper limbs (stethoscope at the elbow). A difference of > 10 mm Hg in blood pressure in the arms usually indicates peripheral vascular disease in the arm with the lower blood pressure. The blood pressure in the arm with the higher pressure is compared to the blood pressure measured at the ankle with a Doppler. Normal is 0.9 to 1.2. The lower the ratio (ankle/brachial index [0.4 to 0.9]) the more severe the peripheral arterial disease usually is. Those with rest pain or tissue loss usually have an index below 0.4

Doppler ultrasound in an imaging department or a vascular lab may identify reduced blood flow to a specific area and locate an obstruction to venous flow. Arteriography involves injection of radiopaque contrast dye into the involved 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 in monitoring the response to treatment.

Since spinal stenosis can cause similar leg pain with exercise (claudication), tests may be done on the lumbar spine. Since peripheral neuropathy can cause lower limb symptoms, and since individuals with diabetes are predisposed to both peripheral arterial disease and peripheral neuropathy, EMG and nerve conduction testing may also be performed to evaluate peripheral neuropathy.

Individuals with atherosclerosis in limb arteries usually have the same disease in other arteries, and thus tests of the adequacy of arterial circulation to the heart and brain may be done before surgical treatment.

Source: Medical Disability Advisor

Treatment

In some cases, PVD can be successfully controlled by certain lifestyle changes, such as exercise programs, dieting to lose weight, and taking medications to lower blood cholesterol and blood pressure. The single most important thing an individual can do to slow PVD is to stop smoking.

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 effects of PVD over time (Aronow).

When lifestyle changes and medications 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.

Source: Medical Disability Advisor

Prognosis

Overall, with treatment (thrombolytic therapy, angioplasty, bypass grafts, or thrombectomy), the immediate prognosis is reasonably favorable for improving blood flow and prevented amputation of the limb. 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. 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 smoking cessation.

More severe cases may end in amputation of the effected lower limb. Amputation for atherosclerotic arterial disease in an upper limb is rare.

Individuals with atherosclerosis in limb arteries usually have the same disease in other arteries, and thus they have an increased mortality rate from events such as heart attack or stroke.

Source: Medical Disability Advisor

Differential Diagnosis

Buerger's disease
Cauda equina syndrome
Lumbar radiculopathy
Peripheral neuropathy (paralysis)
Raynaud's disease
Spinal stenosis
Vasculitis

Source: Medical Disability Advisor

Specialists

Cardiologist, Cardiovascular Physician
Physiatrist (Physical Medicine and Rehabilitation Specialist)
Radiologist
Vascular Surgeon

Source: Medical Disability Advisor

Rehabilitation

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 cannot be maintained for long periods of time. The rehabilitation program usually begins with short periods, and intervals of intense exercise for 10 to 20 seconds, followed by lower levels of activity. Physical therapists instruct individuals in the gradual daily increase of intermittent activities such as walking, stationery biking, or pool activities. This therapy is essentially "cardiac rehabilitation."

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.

FREQUENCY OF REHABILITATION VISITS
	Nonsurgical or Surgical ^†
	Specialist	Peripheral Vascular Disease
	Cardiac Rehabilitation Specialist	Up to 8 visits over 4 weeks

	Nonsurgical or Surgical ^‡
	Specialist	Peripheral Vascular Disease
	Cardiac Rehabilitation Specialist	2-3 visits/week for 12-18 weeks, or 36 total visits ^§

^† Without known co-morbid cardiac disease.
^‡ With known co-morbid coronary artery disease.
^§ For those who have had a heart attack within the last year, Medicare covers up to 36 sessions (http://www.caring.com/medicare_information/medicare-coverage-of-cardiac-rehabilitation).

Source: Medical Disability Advisor

Comorbid Conditions

Cerebrovascular disease
Chronic obstructive pulmonary disease (COPD)
Coronary artery disease
Diabetes mellitus
Hypothyroidism
Obesity
Spinal Stenosis
Vasculitis

Source: Medical Disability Advisor

Complications

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 arteries can break off and travel “downstream” in the artery, causing an acute embolus with infarction of toe(s) or part of the foot.

Individuals with PVD are at a greater risk of heart attack (myocardial infarction) or stroke (cerebrovascular accident) ("About PAD").

Source: Medical Disability Advisor

Factors Influencing Duration

Individual response to treatment and the extent of vascular involvement affect the duration of disability. Duration depends on specific diagnosis and treatment.

Source: Medical Disability Advisor

Ability to Work (Return to Work Considerations)

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.

Risk: Risk of working with this condition is probably reflected by the degree of abnormality on testing including Arterial Brachial Index. For more information, refer to "Disease and Injury Causation," page 245, and to "Work Ability and Return to Work," pages 280-281.

Capacity: Stress testing to verify walking limit is the best controlled method to verify ability. Refer to "Work Ability and Return to Work," page 281.

Tolerance: Patients may report a hesitation to work with symptoms, but this may be addressed through objective stress tests results. Refer to "Work Ability and Return to Work," page 281.

Source: Medical Disability Advisor

Failure to Recover

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 continue to complain of claudication with activity?
Does individual continue to have leg numbness, tingling, or weakness? Are the lower legs and feet cold or discolored with loss of hair?
Does individual have sores that do not heal properly?
Does individual have diabetes, obesity, sedentary lifestyle, high blood pressure, high cholesterol, and family history of heart or vascular disease? Does individual smoke?
On exam, were reduced pedal pulses, a bruit over the femoral artery or iliac arteries, prolonged venous filling time, and unilaterally cool limbs evident?
What is the current ankle/brachial index?
Were Doppler ultrasound, plethysmography, phlebography, arteriography or treadmill walking performed?
Have conditions with similar symptoms been ruled out (especially spinal stenosis by lumbar MRI and peripheral neuropathy by EMG/nerve conduction testing)?
Is atherosclerosis in a different body part present, undiagnosed, but impairing function (coronary artery disease, cerebrovascular disease, abdominal aorta causing mesenteric ischemia)?

Regarding treatment:

Has individual addressed correctable lifestyle activities such as diet, weight loss, lowering blood cholesterol, lowering blood pressure, and cessation of smoking?
Is individual on anticoagulant medication?
If the disease has been managed medically, is angioplasty necessary? Is a bypass graft indicated?

Regarding prognosis:

Is individual active in physical therapy?
Can individual's employer accommodate any necessary restrictions?
Does individual have any conditions that may affect ability to recover?
Have any complications occurred such as leg ulcers, thrombophlebitis, or gangrene and amputation?

Source: Medical Disability Advisor

References

Cited

"About Peripheral Artery Disease (PAD)." American Heart Association. 13 Sep. 2012. American Heart Association, Inc. 1 Feb. 2013 <http://www.heart.org/HEARTORG/Conditions/More/PeripheralArteryDisease/About-Peripheral-Artery-Disease-PAD_UCM_301301_Article.jsp>.

Alonso-Coello, P. "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 141 (2012): E669S-E690S.

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.

Hirsch, A. T. , et al. "ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic)." Circulation 113 (11) (2006): e463-e654.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Navas-Acien, A. , et al. "Lead, cadmium, smoking, and increased risk of peripheral arterial disease." Circulation 109 (25) (2004): 196-201.

Norgren, L. , et al. " Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)." Journal of Vascular Surgery 45 Supp S (2007): s5.

Novo, S. "Classification, epidemiology, risk factors, and natural history of peripheral arterial disease." Diabetes, Obesity & Metabolism 4 Suppl 2 (2002): s1-s6.

Roger, V. L. , et al. "Heart disease and stroke statistics--2012 update: a report from the American Heart Association." Circulation 125 (1) (2012): e2-e220.

Selvin, E. , and T. P. Erlinger. "Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999-2000." Circulation 110 (6) (2004): 738-743.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

Source: Medical Disability Advisor