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AnkletoBrachialIndex(ABI)
>1.3
Noncompressiblevesselsduetocalcifiedarteries(ex:DM)
0.91.3
Normal
<0.7
Claudication
<0.4
Restpain
RatioofsystolicBPattheankletothesystolicBPatthearm
ArterialDisease
ChronicArterialInsufficiency
(PVD)
Occlusiveatherscleroticdiseaseofthelowerextremities
Risks:
Smokingdiabetesatherosclerosis
Sites:
Superficialfemoralartery(inHunterscanal)#1
Poplitealartery
Aortoiliacocclusivedisease(Lerichesyndrome)
Sx:
Intermittentclaudication
Calfonlyinsuperficialfemoralandpoplitealarteries
Buttox,hip,calfinaortoiliacocclusivedisease
Diminishedpulses
Smooth/shinyskinlossofhairandsweatglands
Restpainatnighthangfootoffbedforrelief
Ischemiculcersgangrene/necrosis
Dx:
ABI<0.9
Tx:
STOPsmoking
Cilostazol
Aspirin
Surgery
Pentoxifylline
AcuteArterialOcclusion
Embolizationofcommonfemoralartery
Risks:
afibendocarditisatherosclerosis
Sx:
(5Ps)
Pain(acuteonset)
Pallor
Polar(cold)
Paralysis
Paresthesias
Pulselessness
Arteriography
ImmediatelyanticoagulatewithIVheparin
Emergentembolectomyviacutdown
Fogartyballooncatheter
Dx:
Tx:
Sx:
CompartmentSyndrome
5Psofarterialocclusion
Indicationsforemergentfasciotomy:
Deltapressure=diastolicbpcompartmentpressure
Deltapressure<30
Compartmentpressure>40
VenousDisease
ChronicVenous
Insufficiency
HistoryofDVTvalvesdestroyedbecomingincompetentcausinggravitational
buildupandalackofpassageoutofsuperficialveinsintodeepveins
Risks:
previousDVT
Sx:
AmbulatoryvenousHTN
Edemarelievedbyelevationoflowerextremity
Brawny(brownblack)skinpigmentationfromextravasationofRBCs
Venousulcersdevelopmediallyabovemedialmalleolus
Skinbecomesthin,atrophic,shiny,cyanotic
Achy/tightnessworseatendofthedayandwithsitting/inactivestanding
Ulcersarelesspainfulvsarterialinsufficiency
Dx:
Clinical
Tx:
Legelevation
Compressionsocks
Unnavenousboot
Splitthicknessskingraft
Superficial
Thrombophlebitis
Virchow'sTriad:
Endothelialinjury
Venousstasis
Hypercoagulability
Locations:
Upperextremities:siteofIVinfusions
Lowerextremities:varicoseveins(greatersaphenousvenoussystem)
Sx:
Painandtenderness
Induration
Erythemaalongthecourseofthevein
Atenderpalpablecord
Dx:
Clinical
Tx:
Mildanalgesic(aspirin)
Bedrestandelevation
Hotcompresses
Monitorforriskofcellulitis
NOanticoagulationneeded(lowriskofPE)
DeepVenous
Thrombosis
Risks:
Virchowstriad
age>60
malignancy
prolongedimmobilization
hypercoagulablestates
majorsurgeryortrauma
cardiacdisease
pregnancy/estrogenuse
Sx:
Usuallyasymptomatic
Lowerextremitypainandswelling(worsewithdependency)
Homanssign
Palpablecord
Fever
Dx:
DopplerDuplexUS:proximalthrombi(poplitealandfemoral)
Venography:distalthrombi(calf)
Impedanceplethysmography:proximalthrombi
DDimertesting:usedtoruleoutDVT
Complications:
PE
Chronicvenousinsufficiencyin50%ofcases
Phlegmasiaceruleadolens:
severelegedemacompromisesarterial
supplyimpairedsensoryandmotorfunction
Tx:
Anticoagulationfor612months(goalINR=23)
Thrombolytictherapy:speedsupresolutionofclotsandisindicatedinPE
withhemodynamicinstability
ProphylacticIVCFIlter(GreenfieldFilter):ifwarfarincontraindicated
Prophylaxisaftersurgery:pneumaticcompressiondevices
WellsScorefor
PE
Pts
Clinicalsigns/symptomsofDVT
PEmostlikelydx
Tachycardia>100
1.5
Immobilization/surgeryin4wks
1.5
PriorDVT/PE
1.5
Hemoptysis
Activemalignancy
Likelihood
5:likely
04:unlikely
RiskStratification
7:high
26:intermediate
<2:low
WellsScorefor
DVT
Pts
Activecancer
Paralysis,paresis,recentplasterLEcasting
Localizedtendernessalongdeepveinsystem
Entirelegswollen
Calfswelling3cmlargerthanasymptomaticside
Pittingedemaconfinedtosymptomaticleg
Collateralsuperficialveins
PreviouslydocumentedDVT
AlternateDxaslikelyasDVT
Likelihood
2:likely
01:unlikely