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How to Assess for PVD with Claudications and Ankle Brachial Index: A Complete Guide

Updated: Mar 17

Introduction

Intermittent claudication is pain that usually an individual feels in calf muscles, thighs, and buttock muscles on exercise or exertion with Peripheral Vascular Disease (PVD). It is also known as vascular claudication. It is different from neurogenic claudication, which occurs due to compression on spinal nerves. Measuring the Ankle-Brachial Index plays a crucial role in the early assessment of PVD. Normally, it remains between 0.9 to 1.4; below 0.9, it indicates PVD.

Peripheral Vascular Disease (PVD)

Peripheral Vascular Disease, also known as peripheral arterial disease, is a disease of blood vessels that supply blood to organs other than the heart and brain. It has a high global burden; in 2019, an estimated 113.4 million people worldwide lived with PVD, with a global prevalence of 1.52%. In India, PVD is underrecognized and undertreated, posing a significant public health burden with prevalence rates ranging from 7.6% to 26.7%.


Image 1. Showing Common anatomical sites of Peripheral vascular disease.
Image 1. Showing Common anatomical sites of Peripheral vascular disease.

Causes of PVD

In PVD, blood flow is restricted in legs, arms, and other organs due to plaque buildup inside the blood vessels as a result of endothelial dysfunction. Narrowing of arteries can reduce blood flow, leading to intermittent claudication (pain, numbness, and burning sensation on physical activity), the cardinal sign of PVD.


Image 2. Showing a Atherosclerotic artery.
Image 2. Showing a Atherosclerotic artery.

Risk Factors

  • Smoking: Major risk factor as it can damage blood vessels and increase the risk of plaque buildup.

  • High Blood Pressure: Can precipitate plaque formation in blood vessels.

  • High Cholesterol: Especially high LDL can cause plaque buildup, but high triglycerides levels and low HDL levels can also contribute.

  • Diabetes: Known for its macrovascular and microvascular complications, significantly causing plaque buildup.

  • Aging: Associated with atherosclerosis and isolated systolic hypertension in elderly people.

  • Obesity: Often linked with dyslipidemia, a risk factor for PVD.

  • Family History: Positive family history of CAD, stroke, or PAD can increase the risk of PAD.

Signs and Symptoms of PVD

  • Intermittent Claudication: Pain, cramping, or burning sensation in calf muscles, thighs, and buttocks, aggravated by physical activity and relieved by rest.

  • Coldness: Affected limb may feel colder than the other limb due to reduced blood supply.

  • Limb Weakness: Weakness or numbness in the affected limb, especially during exercise.

  • Muscle Wasting: Muscular atrophy is common, and the affected limb may look thinner than the normal limb.

  • Skin Discoloration: Skin may appear pale or bluish, thin, shiny, or smooth.

  • Hair Loss: Common due to compromised blood supply to hair follicles in the affected limb.

  • Decreased Arterial Pulsations: Decreased arterial pulsations in femoral, popliteal, and tibial arteries.

  • Pain at Rest: In severe cases, pain may be felt at rest, especially at night, and may be aggravated by touch.

  • Non-Healing Ulcers: Common in the affected limb.

  • Gangrene: Common in advanced disease due to compromised or absent blood supply, typically dry in nature.

Diagnosis

  • History and Physical Examination: Initial assessment includes skin examination, temperature changes, and checking for femoral, popliteal, and tibial pulses.

  • Edinburgh Claudication Questionnaire (ECQ): Identifies and assesses claudication symptoms.

  • Ankle-Brachial Index (ABI) Test: Measures blood pressure in both ankle and elbow joints. ABI is normal between 0.9 to 1.4; below 0.9 indicates PVD.


    Image 3. Step 1of obtaining ABI, recording of systolic blood pressure in Brachial artery by using blood pressure calf placed on arm and doppler probe placed on brachial artery.
    Image 3. Step 1of obtaining ABI, recording of systolic blood pressure in Brachial artery by using blood pressure calf placed on arm and doppler probe placed on brachial artery.

    Image 4. Step 2. of obtaining ABI, recording of systolic blood pressure of anterior tibial artery by placing blood pressure calf on lower leg and doppler probe plaed on anterior tibial artery.
    Image 4. Step 2. of obtaining ABI, recording of systolic blood pressure of anterior tibial artery by placing blood pressure calf on lower leg and doppler probe plaed on anterior tibial artery.

  • Exercise Treadmill Test: Measures blood pressure before and after exercise to assess blood flow changes.

  • Arterial Doppler Study: Non-invasive test detecting blood flow using the Doppler effect.

  • Magnetic Resonance Angiography (MRA): Accurately visualizes blood vessel anatomy and localizes stenosis.

  • Angiography or Arteriography: Invasive procedure to assess blockage or stenosis, with the possibility of stent placement.

Management

  • Lifestyle Modifications: Daily exercise, smoking cessation, healthy diet, and stress management.

  • Pharmacotherapy:

    • Antiplatelets: Prevent blood clots; DAPT may be prescribed in severe cases.

    • Cilostazole: Prevents claudication but may take up to 12 weeks to show results.

    • Statins: Used in patients with dyslipidemia to prevent further plaque formation.

    • Antihypertensives: Control blood pressure and prevent endothelial dysfunction.

    • Diabetes Management: Achieving good glycemic control is advised.

  • Surgery:

    • Angioplasty: Includes balloon angioplasty, atherectomy, laser angioplasty, and balloon and stent angioplasty.

    • Peripheral Artery Bypass Surgery: Rerouting blood flow using a graft.

Complications

PVD can cause serious and life-threatening complications, including heart attack, stroke, amputation, limb ischemia, pain, infection, gangrene, and poor wound healing.

Role of Ayurveda

Mild to moderate PVD can be treated with Ayurveda, which offers promising results. Various Rasayanas in Ayurveda prevent oxidative stress and endothelial dysfunction, thus preventing plaque formation. Examples include Amlaki Rasayan, Haridra Khand, Trikatu, and Ashwagandha.

Case Presentation

  1. At Diagnosis: A 56-year-old male smoker presented with a non-healing ulcer over the great toe of the right foot for three months. He reported moderate intermittent claudication in his calf muscles and thighs, along with weakness in the right lower limb. The Edinburgh Claudication Questionnaire suggested PVD. Examination revealed an ABI of 0.636, along with muscle wasting in right thigh,indicating moderate to severe PVD. He was advised to quit smoking, make lifestyle modifications, and start pharmacotherapy.


    Image 5. Showing non healing ulcer over great toe right foot.
    Image 5. Showing non healing ulcer over great toe right foot.

    Image 6. Showing marked muscle wasting in right lower limb.
    Image 6. Showing marked muscle wasting in right lower limb.

  2. After Complications: A 69-year-old male smoker with a history of hypertension, T2DM, and BPH, under regular treatment, presented with a history of Buerger's disease deteriorated by frostbite and infection, leading to amputations. Despite multiple requests to stop smoking, he continued. Examination was normal, including ABI, and he was asymptomatic and satisfied with the treatment.


    Image 7. Showing complications of PVD, amputation of left foot done in 1993 Burzer's disease a type of PVD complicated by Frost bite and amputation of 2nd and 3rd toe right foot complicated by a foot infection in 2010.
    Image 7. Showing complications of PVD, amputation of left foot done in 1993 Burzer's disease a type of PVD complicated by Frost bite and amputation of 2nd and 3rd toe right foot complicated by a foot infection in 2010.



 
 
 

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