eMedicine Specialties > Emergency Medicine > Cardiovascular

Peripheral Vascular Disease: Differential Diagnoses & Workup

Author: Everett Stephens, MD, Assistant Clinical Professor, Department of Emergency Medicine, University of Louisville
Contributor Information and Disclosures

Updated: Jan 5, 2009

Differential Diagnoses

Aneurysm, Abdominal
Lumbar (Intervertebral) Disk Disorders
Ankle Injury, Soft Tissue
Thrombophlebitis, Septic
Back Pain, Mechanical
Thrombophlebitis, Superficial
Deep Venous Thrombosis and Thrombophlebitis
Trauma, Peripheral Vascular Injuries

Workup

Laboratory Studies

  • Routine blood tests generally are indicated in the evaluation of patients with suspected serious compromise of vascular flow to an extremity. CBC, BUN, creatinine, and electrolytes studies help evaluate factors that might lead to worsening of peripheral perfusion. Risk factors for the development of vascular disease (lipid profile, coagulation tests) can also be evaluated, although not necessarily in the ED setting.
  • An ECG may be obtained to look for evidence of dysrhythmia, chamber enlargement, or MI.
  • Elevated levels of inflammatory blood markers such as D dimer, C-reactive protein, interleukin 6, and homocysteine have been linked to decreased lower extremity tolerance of exercise.3 Higher levels of activity in daily life have been shown to decrease these levels.4 The applicability to practice in Emergency Medicine is unknown. 

Imaging Studies

  • Plain films are of little use in the setting of PVD. Doppler ultrasonographic 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.
  • Magnetic resonance imaging (MRI) may be of some clinical benefit due to its high visual detail. Plaques are imaged easily, as is the difference between vessel wall and flowing blood. MRI also has the benefits of angiography to provide even higher detail and can replace traditional arteriography. The utility of MRI is limited in the emergency setting, often due to location of the device and the technical skill required to interpret the highly detailed images.
  • Computerized tomography (CT) can be of use to the emergency physician since it does not have the time and availability constraints of MRI. Although noncontrast studies can be useful to image calcification and arteriosclerosis, contrast studies are most useful to image arterial insufficiency. Renal function should be confirmed before contrast administration, since PVD often coexists with risk factors for contrast-induced renal failure.

Other Tests

  • The ankle-brachial index (ABI) is a useful test to compare pressures in the lower extremity to the upper extremity. Blood pressure normally is slightly higher in the lower extremities than in the upper extremities. Comparison to the contralateral side may suggest the degree of ischemia.
  • The ABI is obtained by applying blood pressure cuffs to the calf and the upper arm. The blood pressure is measured, and the systolic ankle pressure is divided by the systolic brachial pressure. Normal ABI is more than 1; a value less than 0.95 is considered abnormal. This test can be influenced by arteriosclerosis and small vessel disease (eg, diabetes), reducing reliability. Progressive PAD, indicated by ABI decline of greater than 0.15, has been associated with increased cardiovascular disease risk.5
  • Transcutaneous oximetry affords assessment of impaired flow secondary to both microvascular and macrovascular disruption. Its use is increasing, especially in the realm of wound care and patients with diabetes. Transcutaneous oximetry has not been studied extensively in emergent occlusion.

Procedures

  • The criterion standard for intraluminal obstruction has always been arteriography, although this is both potentially risky and often unobtainable in the emergency setting. The delay associated with obtaining arteriography in the setting of obvious limb ischemia can delay definitive treatment to deleterious effect. If time allows, arteriography can prove useful in discriminating thrombotic disease from embolic disease.

More on Peripheral Vascular Disease

Overview: Peripheral Vascular Disease
Differential Diagnoses & Workup: Peripheral Vascular Disease
Treatment & Medication: Peripheral Vascular Disease
Follow-up: Peripheral Vascular Disease
References
[ CLOSE WINDOW ]

References

  1. 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. Jun 2008;54(1):21-30. [Medline].

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

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

  4. 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. Nov 1 2008;102(9):1263-8. [Medline].

  5. Criqui MH, Ninomiya JK, Wingard DL, et al. Progression of peripheral arterial disease predicts cardiovascular disease morbidity and mortality. J Am Coll Cardiol. Nov 18 2008;52(21):1736-42. [Medline].

  6. Aufderheide TP. Peripheral arteriovascular disease. In: Emergency Medicine: Concepts and Clinical Practice. 1998:1826-44.

  7. Feldman AJ. Acute extremity ischemia and thrombophlebitis. In: Emergency Medicine: A Comprehensive Study Guide. 1996:389-94.

  8. Hauser CJ, Klein SR, Mehringer CM, et al. Superiority of transcutaneous oximetry in noninvasive vascular diagnosis in patients with diabetes. Arch Surg. Jun 1984;119(6):690-4. [Medline].

  9. Hedin U, Wahlberg E. Gene therapy and vascular disease: potential applications in vascular surgery. Eur J Vasc Endovasc Surg. Feb 1997;13(2):101-11. [Medline].

  10. Henein MY, Anagnostopoulos C, Das SK, et al. Left ventricular long axis disturbances as predictors for thallium perfusion defects in patients with known peripheral vascular disease. Heart. Mar 1998;79(3):295-300. [Medline].

  11. Howell JM. Acquired diseases of the arteries and veins. In: Emergency Medicine. 1998:203-6.

  12. Levien DH. Vascular surgery. In: Introduction to Surgery. 2nd ed. 1993:208-14.

  13. Schwartz GR. Nontraumatic organ system emergencies. In: Principles and Practice of Emergency Medicine. 1992:1382-90.

  14. Semashko DC. Vascular emergencies. Mt Sinai J Med. Sep-Oct 1997;64(4-5):316-22. [Medline].

  15. Yousuf AM, Pai NB. Noninvasive evaluation of vascular diseases. Hosp Physician. Apr 1991;48-52.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

PVD, peripheral vascular disease, arteriosclerosis obliterans, circulation disorder, functional peripheral vascular disease, organic peripheral vascular diseases, atherosclerosis, emboli, thrombi, atheroma, vascular disease, cardiac emboli, coronary artery disease, myocardial infarction, MI, atrial fibrillation, transient ischemic attack, stroke, renal disease, smoking, hyperlipidemia, diabetes mellitus, hyperviscosity, phlebitis, autoimmune disease, vasculitides, arthritis, coagulopathy

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Everett Stephens, MD, Assistant Clinical Professor, Department of Emergency Medicine, University of Louisville
Everett Stephens, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

David A Peak, MD, Assistant Residency Director of Harvard Affiliated Emergency Medicine Residency, Attending Physician, Massachusetts General Hospital; Consulting Staff, Department of Hyperbaric Medicine, Massachusetts Eye and Ear Infirmary
David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gary Setnik, MD, Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians and National Association of EMS Physicians
Disclosure: Intellicare Salary Management position; South Middlesex EMS Consortium Salary Management position

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Schering  Honoraria Speaking and teaching

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.