1. INTERNAL
MEDICINE:
Vascular Diseases
of the Extremities
nianderthalNOTES

2. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-Definition: stenosis or occlusion in the aorta or
arteries of the limbs
-atherosclerosis is the leading cause of PAD in
patients >40 years old
-other causes:
-thrombosis -embolism
-vasculitis -fibromuscular dysplasia
-entrapment -cystic adventitial disease
-trauma

3. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-the highest prevalence of atherosclerotic PAD
occurs in 60s-70s
-Risk Factors:
-cigarette smoking -hypercholesterolemia
-DM -hypertension
-hyperhomocysteinemia

4. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
Pathology:
-stenosis or occlusion are usually LOCALIZED TO
LARGE AND MEDIUM SIZED VESSELS
-include the ff:
1. Atherosclerotic plaques w/ calcium deposition
2. Thinning of the media
3. Patchy destruction of muscle & elastic fibers
4. Fragmentation of the internal elastic lamina
5. Thrombi composed of platelets and fibrin

5. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-Primary sites of involvement:
1. femoral and popliteal arteries
2. tibial and peroneal
3. abdominal aorta and iliac arteries
*atherosclerotic lesions occur preferentially at :
a.) arterial branch points
b.) sites of increased turbulence
c.) altered shear stress
d.) site of intimal injury

6. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-S/Sx:
-50% are asymptomatic
-MOST COMMON SYMTPOM: INTERMITTENT
CLAUDICATION
-Definition: pain, ache, cramp, numbness or
sense of fatigue in the muscles, occurs during
exercise and relieved by rest, common in lower than
upper extremities
-the site of claudication is DISTAL to the location
of the occlusive lesion e.g. calf claudication-
femoral/popliteal lesion

7. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-S/Sx:
-pts may complain of rest pain commonly at night when legs
are horizontal and improve when legs are on dependent
position
-absent/decreased pulses distal to obstruction
-bruits
-muscle atrophy ISCHEMIC NEUROPATHY:
-hairloss -numbness
-thickened nails -hyporeflexia
-smooth and shiny skin
SEVERE ISCHEMIA:
-decreased skin temperature
-pallor/cyanosis
-edema

8. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-Non-invasive Testing
*History and physical examination are often sufficient to
establish the diagnosis of PAD
1. Arterial Pressure
-placement of sphygmomanometric cuffs at the
ankles and use of a Doppler device to auscultate or record
blood flow from the dorsalis pedis and posterior tibial
arteries
-NORMAL arms and legs SBP are equal, but ANKLE
PRESSURE may be slightly HIGHER DUE TO PULSE-WAVE
AMPLIFICATION
-SBP in ankle is DECREASED IN STENOSIS

9. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-Non-invasive Testing
2. Ankle:Brachial Index
-NORMAL: > 1.0
-PAD: < 1.0
-Severe ischemia: < 0.5
3. Duplex Ultrasonography
-image and detect stenotic lesions in native
arteries and bypass grafts

10. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-Non-invasive Testing
4. Treadmill Testing / Stress test
-allows physician to assess functional limitation
objectively
-decline in ABI immediately after exercise
provides further support for the Dx of PAD
5. Magnetic Resonance Angiography, CT
angiography, contrast angiography
-not for routine testing but done prior to
revascularization

11. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-Non-invasive Testing
6. Other tests
-segmental pressure measurements
-pulse volume recordings
-doppler flow velocity waveform analysis
-transcutaneous oximetry

12. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-Prognosis:
-influenced primarily by coexistence of:
1. coronary artery disease
2. cerebrovascular disease
-most is highest with the most severe PAD
-It can be worse in patients who continue to
smoke cigarette and those with DM

13. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-Rx:
1. Risk factor modification and antiplatelet
therapy should be intiated to improve
cardiovascular outcomes
2. Cessation of cigarette smoking
-counseling and adjunctive drug therapy with
nicotine patch, bupropion or varenicline
increases cessation rates and reduces recidivism

14. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-Rx:
3. ACE inhibitors – symptomatic PAD
4. B-adrenergic blockers – HTN with coexistent CAD
-reduce post revascularization complications
5. Statins
NCEP – LDL cholesterol <100mg/dl
6. Clopidogrel
-inhinits platelet aggregation via its effect on
ADP-dependent platelet fibrinogen binding
-more efficient than aspirin in decreasing M&M

15. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-Rx:
7. Cilostazol – phosphodiesterase inhibitor with
vasodilator and antiplatelet properties, increases
claudication distance
8. Pentoxifylline – xanthine derivative; decreases
blood viscosity to increase red cell flexibility,
increasing blood flow to the microcirculation and
enhancing tissue oxygenation

16. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-Rx:
*WARFARIN not used in patients with CHRONIC PAD
9. Supportive measures
-meticulous care of feet
-shock blocks under the head of the bed and canopy
over the feet
-exercise regularly and at progressively more
strenuous levels (30-45 min session, 3-5 times/wk for 12
weeks)
-advise to walk until near maximum caludication
discomfort occurs, then resting until the symptoms
resolve before resuming ambulation

17. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
PERIPHERAL ARTERIAL DISEASE:
-Rx:
10. Revascularization
-indicated for pts with disabling, progressive,
or severe symptoms of intermittent claudication
despite medical therapy or those with critical
limb ischemia

18. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
FIBROMUSCULAR DYSPLASIA:
-Definition:
-hyperplastic disorder affecting medium-sized and
small arteries
-common in FEMALES
-usually involves RENAL and CAROTID arteries but
can affect extremity vessels, most common are the
ILIAC ARTERIES
- “string of beads”” appearance

19. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
FIBROMUSCULAR DYSPLASIA:
-Histologic classifications:
1. Intimal Fibroplasia
2. Adventitial Hyperplasia
3. Medial Dysplasia
a. medial fibroplasia
-MOST COMMON
b. perimedial fibroplasia
c. medial hyperplasia

20. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
FIBROMUSCULAR DYSPLASIA:
-S/Sx:
1. Claudication
2. Rest pain
-Tx:
1. Percutaneous Transluminal angiography
(PTA)
2. Surgical reconstruction

21. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
FIBROMUSCULAR DYSPLASIA:
-S/Sx:
1. Claudication
2. Rest pain
-Tx:
1. Percutaneous Transluminal angiography
(PTA)
2. Surgical reconstruction

22. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
THROMBOANGITIS OBLITERANS / BUERGER’S
DISEASE:
-Definition:
-an inflammatory occlusive vascular disorder
involving small and medium-sized arteries and
veins in the distal upper and lower extremities
-common in men <40 years
-with definite relation to cigarette smoking

23. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
THROMBOANGITIS OBLITERANS / BUERGER’S
DISEASE:
-Pathogenesis:
INITIAL STAGE: polymorphonuclear leukocytes
infiltrate arterial and venous walls
internal elastic lamina is preserved but
inflammatory thrombus develops
Mononuclear cells, fibroblasts and giants cells
replace the neutrophils
LATER STAGES: Perivascular fibrosis, organized
thrombus, recanalization

24. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
THROMBOANGITIS OBLITERANS / BUERGER’S DISEASE:
-S/Sx:
-TRIAD
1. Claudication of affected extremity
-affects distal vessels (calves, forearms)
2. Raynaud’s phenomenon
3. Migratory superficial vein thrombophlebitis
-trophic nail changes
-reduces/absent pulses on ulna, radius, tibia
-smooth, tapering segmental lesions in the distal vessels
-collateral vessels at site of occlusio

25. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
THROMBOANGITIS OBLITERANS / BUERGER’S
DISEASE:
-Dx:
-excisional biopsy and pathologic examination of
the involved vessel
-Rx:
-no specific treatment EXCEPT ABSTENTATION
FROM TOBACCO

26. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
ACUTE ARTERIAL OCCLUSION:
-Definition:
-results in the sudden cessation of blood flow to an
extremity
-TWO PRINCIPAL CAUSES:
1. embolism
2. thrombus in situ
-paradoxically, may originate from a venous
thrombus that entered the systemic circulation via a
patent foramen ovale or septal defect

27. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
ACUTE ARTERIAL OCCLUSION:
-EMBOLISM
-most common sources: heart, aorta, large
arteries
-emboli tend to lodge at vessel bifurcation
because the vessel caliber decreases at these
sites
-in the lower extremities, emboli lodge more
frequently in femoral A, iliac A, aorta, popliteal A
and tibioperoneal A.

28. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
ACUTE ARTERIAL OCCLUSION:
-THROMBUS IN SITU
-occurs more frequently in atherosclerotic vessels
at the site of an atherosclerotic plaque or
aneurysm and in arterial bypass grafts
-may complicate arterial punctures and
placement of catheters
-associated with polycythemia and
hypercoagulable disorders

29. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
ACUTE ARTERIAL OCCLUSION:
-S/Sx:
-severe pain, paresthesia, numbness, coldness
develop in the involved extremity within 1 hour
-paralysis may happen in severe ischemia
-loss of pulses distal to occlusion
-pallor/cyanosis
-hyporeflexia/areflexia
-weakness and muscle stiffening

30. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
ACUTE ARTERIAL OCCLUSION:
-Dx:
1. Arteriography
-useful in confirming Dx and demonstrating
location and extent of occlusion

31. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
ACUTE ARTERIAL OCCLUSION:
-Rx:
1. Heparin
-to prevent propagation of clot
2. Throboembolectomy/Arterial bypass procedure
3. Intraarterial thrombolytic therapy with
recombinant tissue plasminogen activator or
urokinase
*meticulous observation for hemorrhagic
complications is required during intraarterial
thrombolytic therapy

32. VASCULAR DISEASES OF THE
EXTREMITIES – Arterial Disorders
ATHEROEMBOLISM:
-Definition:
-multiple small deposits of fibrin, platelets, and
cholesterol debris embolize from proximal
atherosclerotic lesions or aneurysmal sites