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Peripheral Vascular Disease (PVD): Examination & Diagnosis

by Kevin Pei, MD
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    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.

    00:52 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 Any ratio less than 0.7 likely induces claudication.

    02:01 Remember, ankle brachial index is extremely sensitive and specific.

    02:05 And additional studies are usually not necessary to simply diagnose peripheral occlusive arterial disease.

    02:12 But remember, imaging may be useful for surgical planning.

    02:18 Unfortunately, routine laboratory studies are unlikely to be helpful unless there's some infection going on.

    02:24 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.

    02:35 Let's move on to some helpful imaging diagnosis.

    02:39 Using a duplex, again, it’s operator dependent.

    02:42 It's an ultrasound technology that introduces no radiation to the patient.

    02:47 The duplex has the additional advantage of giving velocities.

    02:50 Recall, velocities are higher in stenotic regions.

    02:55 And with a Doppler or ultrasound, we can also get some anatomic idea.

    03:00 Next, this image shows a fairly classic CT angiography.

    03:05 Arteriograms is the gold standard0 for diagnosis of vascular disease.

    03:10 As a multidetector slice CAT scan’s cross-sectional imaging improves, CTs are slowly replacing invasive arteriograms.

    03:20 Here, highlighted by the circle as well as the arrow, this arteriogram shows narrowing and occlusion in the tibial system.

    03:27 If you look further down the extremity, you notice that there are some wisps of contrast filling.

    03:33 That's called reconstitution and runoff.

    03:36 Increasingly, magnetic resonance imaging is being used for arterial disease.

    03:42 Here, you see a nice depiction of an MRA.

    03:46 There appears to be some occlusive disease in the right lower extremity.

    03:50 And lastly, given all the cross-sectional imaging, modern technology allows us to do 3-D reconstructions.

    03:57 Here, you see a nice example of aneurysms just above the knee.

    04:02 They’re marked in red.


    About the Lecture

    The lecture Peripheral Vascular Disease (PVD): Examination & Diagnosis by Kevin Pei, MD is from the course Special Surgery.


    Included Quiz Questions

    1. < 0.7
    2. < 0.1
    3. < 0.2
    4. < 0.9
    5. < 0.4
    1. CT Arteriogram
    2. Treadmill Test
    3. Magnetic Resonance Angiogram
    4. Doppler Ultrasound
    5. Blood Tests

    Author of lecture Peripheral Vascular Disease (PVD): Examination & Diagnosis

     Kevin Pei, MD

    Kevin Pei, MD


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