Vascular Assessment and Disease

This guide is intended as a basic education aid for patients and nothing else. Podiatrists play a major role in the treatment of vascular disease within the lower-limb. A Podiatrist can assess and treat vascular disease to a certain extent but usually works within a team environment to ensure the best possible care for each patient. 

Pain on Walking (Arterial Disease)

Many people experience pain in their legs brought on by exercise such as walking a short distance.  The pain is relieved by a brief period of rest.  The pain is often described as cramping, tightness, heaviness, fatigue or "giving out".  In medical terms this is called intermittent claudication.  This type of leg pain may be a symptom of a potentially serious blood vessel disorder called peripheral arterial disease (PAD).  People may also experience leg pain from simple muscle cramps but this is most often at rest or after excessive exercise.  Symptoms of PAD occur when the demand for blood to the leg muscles is not being met because of "clogged arteries".  It is often worse when carrying a burden, walking up a hill or at an accelerated pace.

Risk Factors for Arterial Disease

• Family history of bad circulation or Cardiovascular disease

• High Cholesterol (inherited / diet)

• Smoking

• Diabetes

Symptoms of Arterial Disease

• Tingling / numbness

• Cold feet

• Hair loss

• Temperature changes, very cold or very hot foot

• Non healing ulcers

• Swelling within the legs (Oedema)

Treatment

Dependent upon severity and progression of disease.

• Lifestyle modifications  (low fat diet / exercise / stop smoking)

• Medication (Daily Asprin)

• Surgery (Laser assisted angioplasty, angioplasty, balloon angioplasty, thrombectomy)

• Thrombolytic therapy

• Mechanical cathetar

Diet changes can stop additional cholesterol being deposited within the arteries whilst walking could develop alternate blood supply to areas that have been blocked by fat within the arteries. Smoking causes damage to the linings of arteries by stopping damage automatically ceases. Medication can help improve blood flow, surgery is reserved for exceptionally severe disease i.e. pain at rest, possible loss of limb, previous treatment failure. Balloon angioplasty can fail to open some blockages, which causes reoccurrence of the original blockage. Stents are wire mesh tubes which improve angioplasty results. A balloon opens the artery and the stent stops artery collapsing.  Lasers can be used to remove blockages and then angioplasty can be utilised. Blockages can occur on stents and cause 100% blockage of an artery these can be treated with "clot busting" drugs or Thrombolytic therapy, common drugs are Stretokinase.
 

Forms of Bypass Surgery

ODEMA (Swelling within the legs)

Swelling has many causative factors i.e. heart failure, liver disease, stomach surgery. Lymphedema is accumulation of fluid and protein that causes swelling within the legs. Sometimes this occurs via an unknown reason (idiopathic), it can also be congenital; occur in the teenage years (Lymphedema praecox), or late in life lymphedma tarda. Swelling can occur in poor arterial and venous supplies. This leaves a skin that is becomes hard and elastic, infections can easily arise. Treatment revolves around manual lymphatic drainage, compression bandages, and skin care.

VARICOSE VEINS

• Extremely common problem (obesity is thought to aid development of varicose veins)
• Develop when vein walls become weak and dilate
• Genetics
• Trauma
• Pregnancy (possibly linked to hormonal changes)

Within the leg are thin walled veins, which allow blood to flow in one direction, if these veins dilate they become incompetent, blood will flow backwards. Gravity pulls blood towards the feet this accompanied with excessive pressure dilates the veins and gives them the characteristic varicose appearance. Varicose veins range in size and severity they can be symptomatic (swelling, burning, aching, stinging) or asymptomatic. Skin changes consisting of brown/red discolouration, firm areas of skin (lipodermatosclerosis), phlebitis, and ultimately ulcers may arise.

Treatment

• Compression stockings
• Sclerotherapy (vein injection)
• Laser therapy
• Surgery
• Catheters

Venous Ulcers

The venous system comprises of superficial and deep veins. Superficial veins are located in skin and muscles whilst deep veins are in between the muscles. Perforating muscle veins connects both systems. The calf muscles greatly aid return of venous blood to the heart this occurs when walking or running. Venous ulcers commonly occur in patients with a leg history of leg swelling, varicose veins, diabetes, DVT's. The ulcer base can be covered with yellow fibrous tissue and green/yellow discharge if infection is present, they can weep copious amounts of fluid. Ulcers are commonly located below the knee, and inner ankles, the borders are irregular and surrounding skin is discoloured and oedematous. The skin may appear tight, shiny, warm and red. A plethora of factors can trigger a venous ulcer these include pregnancy, DVT, work environment, obesity, old age, previous ulceration, injury (fracture/surgery). Ulcers are painless and have a raw, weeping appearance.

Treatment

• Wound care and correction of underlying problem
• Antibiotics for infection if present
• Steroids for skin problems (watch for thin skin)
• Compression bandages
• Diagnostic tests (Duplex/Doppler/ABI index)
• Angioplasty or bypass surgery

The posterior tibial pulse		The Dorsalis Pedis Pulse

The Ankle Brachial Index test (ABI) can be utilised by a Podiatrist to assess the circulation of the feet. A Podiatrist will take the blood pressure in the ankle and the left arm, by dividing the systolic ankle value with the systolic brachial value, a number is reached called the ABI. A value of 1.0 to 0.85 is considered normal, 0.8 - 0.6 show some vascular disease whilst values of less than 0.6 show severe vascular disease. The ABI value determines treatment type. Suspected abnormally high values can be rechecked by taking the blood pressure in toe! Artery blockages can be detected by a non-invasive Duplex scan (Doppler&Ultrasound).

Duplex Scan of Fatty Plaque

Can I use Self Treatment With Arterial and Vascular Ulcers? Self-treatment is not recommended consultation with a Podiatrist, vascular surgeon, or GP is recommended.  X-rays may be used to determine bone involvement.. If circulation is poor then referral to a vascular surgeon is indicated. If an artery is blocked then the level of the blockage needs to be determined (Doppler or Duplex scan), this can determine if surgery is needed. Balloon angioplasty, and stents are used to improve blood flow.

ARTERIAL ULCERS

Arterial leg ulcers are caused by poor blood circulation.  Arteries are the tubes which carry blood from the heart to the body's tissues. The tissues receive oxygen and nutrients from the blood. Deoxygenated blood contains waste by-products it's carried via the veins to the heart. Arterial ulcers can occur due to narrowed arteries (arteriosclerosis) and poor circulation. These ulcers can effect toes, feet, & heels. Feet and legs are cold, and appear whitish/bluish and shiny. The ulcers are painful the pain can increase if legs are rested and elevated a reversal of symptoms occurs on non-elevated limbs. Patients with ulcers often suffer intermittent claudication, a painful condition occurring when decreased amounts of oxygen are received in the muscles, cramp like pains arise. Pain diminishes on standing and exercise.

Factors which can trigger an ulcer are :-

• Smoking
• High blood pressure
• Diabetes
• Arthritis (rheumatoid arthritis)
• Old leg ulcers
• Coronary heart disease, including coronary thrombosis
• Arteriosclerosis in the legs

What can be done to prevent arterial/venous leg ulcers (this is not a complete list of preventative measures)?

• Stop smoking
• Lose weight
• Decrease fat in your diet, ask your doctor about dietry advice
• Exercise, this improves circulation, in some cases can form new blood vessels (co-laterals)
• Good fitting shoes
• Examine your feet on a regular basis and have a VASCULAR assessment with a Podiatrist
• Sit with your legs raised whenever you have the chance, this helps venous ulcers
• Walk around from time to time to activate your calf muscles, helps circulation and prevent DVT
• Support stocking may be useful consult a practice nurse of doctor before usage

How are leg ulcers diagnosed?

• Appearance and location of ulcers
• Venous ulcers may need ultrasound, Arterial ulcers have arteries examined
• ABI values (See above for explanation)
• Intermittent claudication (early warning sign)

How is Arterial (ischaemic) leg ulcers diagnosed?

• Very painful (night time)
• Patient may "dangle the foot" out of the bed for relief
• Diabetes, kidney failure, heart disease, smoking, clotting disorders, high cholesterol
• Base of ulcers doesn't normally bleed
• Yellow, brown, grey, blackened colour
• Location, pressure points i.e. heels, toes, protruding bones
• Previous history of trauma i.e. rubbing of socks
• Ulcer border looks "punched out", border not surrounded by callous
• Redness to foot when dangled and pale white / yellow when elevated
• Foot very cold, with poor / absent foot pulses

What sort of treatment is required for a vascular ulcer?

Antibiotics for infection, Ulcer debridement if needed, Minimise trauma, and finally surgery (angioplasty/bypass). Many other forms of treatment exist but these are among the more common modalities.

HYPERCOAGUABLE STATES

This is a group of disorders (inherited/acquired), which change blood coagulation. These abnormalities include elevated levels of selected blood coagulation factors (fibrinogen, factor VIII, and prothrombin), deficiencies of natural anticoagulant proteins (antithrombin, protein C and protein S), elevated blood counts; stick platelets, fibrinolytic system derangements, and blood vessel lining (endothelial cell) dysfunction. Each patient has very differing needs.

One of the most common developments with Hypercoaguable states is the development of the thrombosis. Clinical evaluation can help thrombosis management, and determine which patients would most benefit special laboratory testing. Assessments includes thrombosis risk, recent traumas (surgery), family thrombosis history, oral contraception usage. History of thrombosis is important and the patients age at the time of a first thrombosis. The location of thrombosis, and whether thromboses involve the arterial vascular tree, venous system, or both are also important components to the clinical evaluation.

Patients considered for Hypercoaguable testing include: -

• A family history of thrombosis
• A history of recurrent idiopathic (without clear cause) thrombosis
• A thrombosis at an early age (less than age 45)
• A thrombosis following minimal provocation
• A thrombosis in an unusual site (portal, mesenteric, cranial veins)
• A thrombosis in association with a history of early fetal loss

Tests are only used if they have proven value and will provide a benefit for the patient.  Changes in the blood coagulation system related to several illnesses and stress can influence many special coagulation tests and potentially lead to an incorrect diagnosis. Testing usually begins with assessment of the prothrombin time, activated partial thromboplastin time (PTT), fibrinogen level, and thrombin time.

Blood clots within the deep veins of the leg; DVT are responsible for symptoms of leg swelling and destruction of the venous valves with resultant leg ulceration. Thrombolytic therapy (clot busters) can be used to dissolve the clot, restoring a channel in the vein for blood-flow. In addition, quick removal of the clot may preserve valve function and lessen the long-term symptoms of DVT

Hypercoagulable state testing should be reserved for individuals who have had an objectively documented thrombosis and who, following careful clinical history evaluation, are deemed to be most likely to have an underlying coagulation defect. Hypercoagulable state testing is not only performed to sometimes benefit the patient him/herself but also to benefit asymptomatic and potentially at risk relatives. The entire clinical and family situation must be taken into consideration in order to insure that testing is being performed in a setting where the results will be specifically used to make prophylactic and/or therapeutic recommendations.