Peripheral Vascular Disease Treatment & Management
- Author: Everett Stephens, MD; Chief Editor: Erik D Schraga, MD more...
Currently, therapeutic recommendations include single-agent antiplatelet agents for prevention of cardiovascular events in patients wth asymptomatic and symptomatic peripheral arterial disease (PAD). These medications should be used in conjunction with efforts to reduce risk factors, including smoking cessation and exercise therapy.
Statins have been linked to improved prognosis in other vasculopathies, including renovascular and cardiovascular events. Although lacking an immediate effect on any vascular process, statins show promise in slowing the progression of atherosclerotic disease systemically.
When conservative measures fail to improve quality of life and function, endovascular procedures are considered. However, the timing and need for revascularization are related to the general primary presentations of claudication, critical limb ischemia, and acute limb ischemia, in which urgent intervention is critical limb ischemia.[1, 2]
Prehospital and Emergency Department Care
Prehospital care for peripheral vascular disease (PVD) involves the basics: control ABCs (airway, breathing, circulation), obtain intravenous access, and administer oxygen. In general, do not elevate the extremity. Note and record the distal pulses and skin condition. Perform and document a neurological examination of the affected extremities.
Early emergency department care involves attention to the ABCs, intravenous access, and obtaining baseline laboratory studies. Obtain an electrocardiogram (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.
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 peripheral vascular disease (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.
An initial study has shown promise in relieving the pain of peripheral arterial disease (PAD) with topically applied lidocaine spray. Suzuki and colleagues studied 24 subjects with PAD and noted a significant drop in pain associated with PAD by applying an 8% lidocaine metered dose spray to the affected areas. Blood levels of lidocaine were minimal, and this technique may have therapeutic potential for those affected with focal PAD pain.
Patients who have significant peripheral vascular disease but whose illness is not so severe or acute that it requires inpatient treatment may be discharged with appropriate follow-up. However, counsel these patients regarding the potential effects of various activities and medications on the course of their illness. Advise patients to stop smoking and to avoid cold exposures and medications that can lead to vasoconstriction, including medications used for migraines and over-the-counter medications.
Some recreational drugs (eg, cocaine) may have a deleterious effect on peripheral arterial tone, and beta-blockers may exacerbate the condition.
Consultation with providers who will be following the patient after discharge from the emergency department is advised when making decisions regarding the discontinuation of medications used for chronic medical conditions.
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