eMedicine Specialties > Emergency Medicine > Cardiovascular

Peripheral Vascular Disease: Treatment & Medication

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

Updated: Jan 5, 2009

Treatment

Prehospital Care

Prehospital care for peripheral vascular disease (PVD) involves the basics: control ABCs, obtain intravenous 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.

Emergency Department Care

Attention to the ABCs, intravenous access, and obtaining baseline laboratory studies should occur early in the ED visit. Obtain an ECG and chest radiograph.

Treatment of either thrombi or emboli in the setting of peripheral vascular disease 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 less than 50 mm Hg should prompt consideration of emergent surgical referral.

In some cases of emboli, intra-arterial thrombolytic agents may be useful. The exact technique of administration varies, in both dosage and time of administration. Remember that intra-arterial thrombolysis remains investigational. Obviously, such thrombolytic therapy is contraindicated in the presence of active internal bleeding, intracranial bleeding, or bleeding at noncompressible sites.

Consultations

Early surgical consultation in patients with acute limb ischemia is prudent. Depending on the case, the surgeon may involve interventional radiology or proceed operatively. Emboli may be treated successfully by Fogarty catheter (ie, an intravascular catheter with a balloon at the tip). The balloon is passed distal to the lesion; the balloon is inflated, and the catheter is withdrawn along with the embolus. This technique most commonly is used for iliac, femoral, or popliteal emboli.

Definitive treatment of hemodynamically significant aortoiliac disease is usually by aortobifemoral bypass. Its 5-year patency rate is approximately 90%. Those patients in whom PVD becomes significant, however, often have a plethora of comorbid medical conditions, such as cardiovascular disease, diabetes, and chronic obstructive pulmonary disease, which increase procedural morbidity and mortality. Axillobifemoral bypass and femoral-femoral bypass are alternatives, both of which have lower 5-year patencies but have lower procedural mortality.

Some areas of arteriostenosis can be revascularized with percutaneous transluminal coronary angioplasty (PTCA). If the occlusion is complete, a laser may be useful in making a small hole through which to pass the balloon. Restenosis is a concern with PTCA, particularly for larger lesions. Stents and lasers are still considered experimental.

Medication

The goal of pharmacotherapy is to reduce morbidity and to prevent complications.

Anticoagulants

Anticoagulants reduce thrombin generation and fibrin formation and minimize clot propagation.


Heparin

Augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. Does not actively lyse but is able to inhibit further thrombogenesis. Prevents reaccumulation of clot after spontaneous fibrinolysis.

Adult

80 U/kg IV bolus, followed by infusion of 18 U/kg/h

Pediatric

Administer as in adults

Digoxin, nicotine, tetracycline, and antihistamines may decrease effects; NSAIDs, aspirin, dextran, dipyridamole, and hydroxychloroquine may increase toxicity

Documented hypersensitivity; subacute bacterial endocarditis; active bleeding; history of heparin-induced thrombocytopenia

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

In neonates, preservative-free heparin is recommended to avoid possible toxicity (gasping syndrome) by benzyl alcohol, which is used as preservative; caution in severe hypotension and shock; recent neurosurgery (within 6 wk), major surgery within 48 h, known bleeding diathesis, childbirth within 24 h, thrombocytopenia

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
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References

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Further Reading

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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

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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

 
 
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