The Good, The Bad, and The Ugly - viabuf.com

The Good,The Bad, and The
Ugly:

Common Vascular Maladies of the Legs and How
YOU CAN Manage Them With Confidence!

Vascular Disease of the Legs

 Very common in North America/Europe
with approximately 10% of population
eventually affected

 Arterial
 Venous
 Mixed

The Presentation of Vascular
Disease in the Office:Arterial

 Claudication
 Ulcers
 Leg pain
 Gangrene
 Color changes
 Temperature changes

Presentation:Venous disease

 Swelling, usually bilateral
 Discoloration, dusky red to brawny
 Aching
 Visible varicosities
 Ulcers
 Dermatitis, often weeping

Mixed Arterial/Venous Disease

 Often swollen
 Venous ulcers
 Toe ischemia: dry gangrene
 Arterial ulcers
 Cooler than expected

Who gets which kind?

 ARTERIAL  VENOUS

 Smokers  Obese
 DM of either type
 Lipid disorders  Pulmonary
 Vasculitis hypertension
 Embolic events
 COPD

 Vein stripping

 Other extremity
surgery

 Estrogen use

Arterial Venous

 Arterial/arteriolar  Resistance to venous
narrowing due to return
obstructive/destructive
lesions  Resistance to lymphatic
drainage
 Forward flow reduced, less
supply  Stasis of fluid within tissues
causing swelling
 Ischemic changes
 Transudation of fluids/cells
into interstitium of tissues

Pathophysiology

Hydraulic Principles

 Arteries deliver blood to distal tissues at
some pressure, which is diffused by
arteriolar beds which have enormous
capacity to act as a fluid “sink”

 Blood and fluid must return otherwise it
would stay pooled in extremities

 Veins and lymphatics act as return “sewer
lines”

Venous valves prevent backflow of blood and venous “pumping” of muscle
pooling contraction forces the
blood forward in a vein,
valves prevent
backflow…backflow
results in venous pooling
dependently…eventually
the fluid pressure
becomes so great, water
exudes out of vessels and
manifests in swelling

Venous incompetence = poor
venous return

 It’s really quite simple: if valves are
incompetent, venous pooling occurs
according to gravity!

 The legs swell as hydraulic pressure
pushes fluid out of the cells and into the
interstitial space rather than into
venules>veins>back into general
circulation

 Poor venous return causes venous stasis

Venous incompetence is commonly
caused by:

 Obesity

 Estrogens

 Prolonged states which impair venous
return

 Extremity surgery/trauma

 Venous thrombus

The number 1 cause
of poor venous
return in Erie
County and YOUR
office:

OBESITY: meet the “Pannus”

Why the pannus?

 Pannus is heavy, immobile, and puts
pressure against the femoral veins and
lymphatics which are really quite
superficial (remember putting in femoral
lines?)

 Increased pressure = decreased flow =
increased hydraulic pressure = venous
stasis = venous stasis dermatitis =
(eventually) venous ulcers

Venous stasis looks
like this to start:
brawny
discoloration,
redness

Admittedly advanced venous stasis dermatitis

As time passes,
venous stasis turns
into venous
ulceration

A moderate venous stasis ulcer

Office management

 Quick poll: who would treat with antibiotics?
Who would punt to ER?

 THIS IS NOT AN EMERGENT
CONDITION, rather this is a chronic
condition which the primary office is very
capable of managing

 Workup: venous (and perhaps arterial)
doppler studies; medication review

 Treatment: weight loss, COMPRESSION,
consideration of IR referral for venous
therapy

Compression

 In early stages, BEFORE ulcer, suggest
compression stockings: 30-40 mm
compression (all you need to do is write
a script…most pharmacies, and all surgical
supply stores carry them)

 Once ulcer has formed, consider a
compression dressing (Unna Boot,
Ichythopaste, Dome Paste etc) for several
months

Applying a compression dressing is
easy: wrap like an ACE wrap

Leave the dressing on for 2
weeks…

 Then cut it off with heavy scissors (most
drug companies will even give you a pair
for free!) and re-apply a dressing

 May take up to several months to heal a
deep ulcer

Arterial issues

 Arterial ulcers form as a result of
inadequate blood supply to an area which
gets a prolonged contact pressure…heels,
MTP joints, sole of foot

 Often a component of lack of sensation
(neuropathy) which does not detect the
prolonged contact pressure…common in
diabetics

Arterial ulcer

 Clean edges
 Not usually painful

An arterial ulcer

Workup

 History: claudication, diabetes, neuropathy
(both?), trauma, medication

 Labs: metabolic profile, HbA1C, UA,
perhaps wound culture (usually mixed
flora)

 Physical exam: neurofilament testing for
sensation, arterial pulses

 Vascular arterial studies

Treatment

 Correction of potentially correctable things:
better DM control, better shoes (or
admonition to wear them), foam padding to
unload pressure

 Sharp debridement of edges of ulcer with a
scalpel blade…you want to cut all white stuff
off, then placement of biologic dressing

 Consultation with podiatrist/vascular
specialist (?re-vascularization potential)

 Antibiotics are rarely indicated and do not
cure these

Biologic dressings I use (and you can
too!)

 To get rid of the necrotic stuff I can’t cut
out, try Smith&Nephew Intrasite Gel

 After debridement,Allevyn dressing

 See back within 5-7 days

Arterial issues:The Black Toe

 Usually due to acute occlusion of a
nutrient artery by some kind of embolus,
but may also be due to wider arterial
supply breakdown (like with trauma,
frostbite)

 Often associated with atrial fibrillation
whether anticoagulated or not

Black toe =
ischemia
ischemia =
gangrene, eventually

Area of necrosis on a toe due to ischemia

Gangrene is not necessarily an
emergency!

 Obviously if foot is swollen and putrid,
send to me, otherwise:

 This probably will become a dry gangrene,
and eventually separate all on its own
from healthier tissue

 Treatment: correction of underlying
problem that got toe this way in first
place; debridement

The “blue toe”

 Often due to a shower
of emboli, but also may
be a Reynaud’s-type
condition

 Check heart rhythm (a
fib)

 Send to ER if NEW
atrial fib, or significant
pain; otherwise
outpatient vascular
studies and referral

Mixed arterial/venous disease

 These patients have significant vascular
and metabolic issues

 Usually obese, diabetic, and with
significant arterial vascular disease

 Treatment ultimately hinges on the
arterial supply of the affected area and
potential for revascularization

 Compression dressings not helpful, nor
are diuretics or antibiotics

Examples of mixed arterio-venous
disease of legs

Management

 These will often need initial inpatient
management for dressings, vascular
studies, debridement and potentially
pulsation pressure/hyperbaric therapy

 Revascularization is consideration if ABI <
0.8 in affected limb

 These are ugly diseases

What is it?
How would you manage case?

PATH QUIZ!!!

78 yo male smoker, black toes

67 yo diabetic, female, loves heels

Obese 56 yo sleep apneic male

 first office visit on LEFT; RIGHT today