Peripheral Vascular Disease Treatment & Management
- Author: Everett Stephens, MD; Chief Editor: David FM Brown, MD more...
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 The balloon is passed distal to the lesion; the balloon is inflated, and the catheter is withdrawn along with the embolus.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.
An initial study shows promise in relieving the pain of 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 show promise for those affected with focal PAD pain.[7]
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