Peripheral Vascular Disease Workup
- Author: Everett Stephens, MD; Chief Editor: David FM Brown, MD more...
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.[4] Higher levels of activity in daily life have been shown to decrease these levels.[5] 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.[6]
- 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.
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