Peripheral Vascular Disease
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Peripheral vascular disease (PVD) is a nearly pandemic condition that has the potential to cause loss of limb or even loss of life. PVD manifests as insufficient tissue perfusion initiated by existing atherosclerosis acutely compounded by either emboli or thrombi. Many people live daily with significant degrees of PVD; however, in settings such as acute limb ischemia, this latent disease can suddenly become life-threatening and necessitate emergency intervention to minimize morbidity and mortality. [1, 2]
For patient education information, see Peripheral Vascular Disease.
PVD, also known as arteriosclerosis obliterans, is primarily the result of atherosclerosis. The atheroma consists of a core of cholesterol joined to proteins with a fibrous intravascular covering. The atherosclerotic process may gradually progress to complete occlusion of medium-sized and large arteries. The disease typically is segmental, with significant variation from patient to patient.
Vascular disease may manifest acutely when thrombi, emboli, or acute trauma compromises perfusion. Thromboses are often of an atheromatous nature and occur in the lower extremities more frequently than in the upper extremities. Multiple factors predispose patients to thrombosis. These factors include sepsis, hypotension, low cardiac output (see the Cardiac Output calculator), aneurysms, aortic dissection, bypass grafts, and underlying atherosclerotic narrowing of the arterial lumen.
Emboli, the most common cause of sudden ischemia, usually are of cardiac origin (80%); they also can originate from proximal atheroma, tumor, or foreign objects. Emboli tend to lodge at artery bifurcations or in areas where vessels abruptly narrow. The femoral artery bifurcation is the most common site (43%), followed by the iliac arteries (18%), the aorta (15%), and the popliteal arteries (15%).
The site of occlusion, the presence of collateral circulation, and the nature of the occlusion (thrombus or embolus) determine the severity of the acute manifestation. Emboli tend to carry higher morbidity because the extremity has not had time to develop collateral circulation. Whether caused by embolus or thrombus, occlusion results in both proximal and distal thrombus formation as a consequence of flow stagnation.
Female sex appears to have an effect on outcomes after lower-extremity interventions for peripheral arterial disease (PAD). In a retrospective study (2004-2009) evaluating data from 12,379 patients (41% women) in 16 centers participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium PVI registry who underwent these procedures, female sex was associated with a higher rate of vascular complications, transfusions, and embolism, but no differences wer eseen for inpatient mortality, myocardial infarction (MI), or stroke or transient ischemic attack. [3] Despite the higher complication rates in women, the investigators reported similar overall procedural success rates between the sexes.
In another retrospective study that evaluated data over 6 years from 23,870 index transfemoral vascular access procedures from cross-matching the Eastern Danish Heart Registry with the Danish Vascular Registry, Dencker et al noted a low risk of major vascular complications (0.54%) with femoral access following coronary angiography and percutaneous coronary intervention (PCI). [4] Risk factors for such complications included left-side access, the presence of PAD, and female sex. [4]
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[Guideline] Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017 Mar 21. 135(12):e726-e779. [Medline]. [Full Text].
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Roy TL, Chen HJ, Dueck AD, Wright GA. Magnetic resonance imaging characteristics of lesions relate to the difficulty of peripheral arterial endovascular procedures. J Vasc Surg. 2017 Dec 13. [Medline].
Everett Stephens, MD Assistant Clinical Professor, Department of Emergency Medicine, University of Louisville School of Medicine
Everett Stephens, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Department of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, National Association of EMS Physicians
Disclosure: Medical Director for: SironaHealth.
Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates
Disclosure: Nothing to disclose.
David A Peak, MD Associate Residency Director of Harvard Affiliated Emergency Medicine Residency; Attending Physician, Massachusetts General Hospital; Assistant Professor, Harvard Medical School
David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, American Medical Association
Disclosure: Partner received salary from Pfizer for employment.
Peripheral Vascular Disease
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