Peripheral Vascular Disease (PVD): Examination & Diagnosis

00:01 Now, whenever I'm faced with a patient who complains of malperfusion in the lower extremities, sometimes call claudication or rest pain, I ask myself some very important questions.

00:13 Number one, how far can the patient walk? Two, is there pain when the patient wakes up? And three, are there any ulcers or signs of malperfusion.

00:25 With the answers to these three common and important questions, one can have a very good idea of the level of the vessel stenosis and whether anastomosis is even present.

00:39 Let's take a look at some physical findings? And very importantly, differentiate claudication versus rest pain.

00:46 In claudication, pain is usually induced with exercise, but resolves with rest.

00:51 And this occurs over approximately two to five minutes as opposed to rest pain.

00:56 Rest pain usually is in the forefoot and toes and the pain can be worsened if the leg is raised or in a recumbent position.

01:03 This make sense.

01:04 In a recumbent and/or raised position, there's even further decreased flow.

01:10 And sometimes, the pain is relieved by dangling the foot or the feet over the bed.

01:15 We alluded to this ankle brachial index, also called an ABI.

01:20 As you examine the pulses, very importantly, check every pulse from the abdominal aorta down to the femoral system, popliteal, dorsalis pedis and posterior tibial system.

01:33 How can you objectively identify whether or not there is a pressure drop gradient from your brachial to your ankle? Well, it’s by the angle brachial index.

01:43 An ABI, or the ratio between systolic blood pressure in your ankle and the systolic blood pressure in your arm, less than 0.4 is highly suggestive of rest pain.

01:55 Remember, ankle brachial index is extremely sensitive and specific.

01:59 And additional studies are usually not necessary to simply diagnose peripheral occlusive arterial disease.

02:05 But remember, imaging may be useful for surgical planning.

02:12 Unfortunately, routine laboratory studies are unlikely to be helpful unless there's some infection going on.

02:18 Whether it's an non-healing toe or a gangrene, you may see an infection and an elevated white blood cell count as a result.

02:29 Let's move on to some helpful imaging diagnosis.

02:33 Using a duplex, again, it’s operator dependent.

02:36 It's an ultrasound technology that introduces no radiation to the patient.

02:41 The duplex has the additional advantage of giving velocities.

02:44 Recall, velocities are higher in stenotic regions.

02:49 And with a Doppler or ultrasound, we can also get some anatomic idea.

02:54 Next, this image shows a fairly classic CT angiography.

02:59 Arteriograms is the gold standard0 for diagnosis of vascular disease.

03:04 As a multidetector slice CAT scan’s cross-sectional imaging improves, CTs are slowly replacing invasive arteriograms.

03:14 Here, highlighted by the circle as well as the arrow, this arteriogram shows narrowing and occlusion in the tibial system.

03:20 If you look further down the extremity, you notice that there are some wisps of contrast filling.

03:26 That's called reconstitution and runoff.

03:30 Increasingly, magnetic resonance imaging is being used for arterial disease.

03:36 Here, you see a nice depiction of an MRA.

03:39 There appears to be some occlusive disease in the right lower extremity.

03:44 And lastly, given all the cross-sectional imaging, modern technology allows us to do 3-D reconstructions.

03:51 Here, you see a nice example of aneurysms just above the knee.

03:55 They’re marked in red.