Mark Reed, DPM

DABFAS FAPWCA

OC Center for Wound Healing & Foot Care -- Dr. Mark Reed  - USC / UCSF

714-528-3668


Peripheral Vascular Disease

 

Circulation disorders includes a large number of different problems with one thing in common, they result in poor blood flow. Specifically, the term peripheral vascular disease refers to blood flow impairment into the feet and legs (although it could include the arms and hands as well).

 

Blood is circulated throughout the human body by the strong, muscular pump called the heart. With each heartbeat, blood is pushed along through blood vessels called arteries that carry the oxygen and nutrient rich blood to all parts of the body including the legs and the feet. The individual cells in the body take up the oxygen and nutrients. Then a second set of blood vessels known as veins carry the oxygen depleted blood back to the heart and lungs to get more oxygen, and again be pumped throughout the body. Peripheral vascular disease may refer to arterial inflow disorders, (arterial insufficiency) or venous outflow disorders (venous insufficiency).

 

Arterial Insufficiency

 

Arterial inflow disorders are categorized by the size of the artery involved. If a large artery in the thigh or behind the knee becomes blocked by cholesterol deposits this is referred to as large vessel disease or atherosclerosis. The result may be a painful ischemic foot, which means there is a severe lack of arterial blood flow from the heart into the foot. If smaller arteries like those in the lower leg or foot is blocked, this is referred to as small vessel disease, or arteriosclerosis. This too can result in ischemia of the foot. Small vessel disease is seen more often in diabetics but can affect non-diabetics as well. If the skin of the feet or legs lacks adequate blood flow a sore will develop which may be difficult to heal. These sores are known as ischemic ulcers. Any blockage to arterial inflow will result in a circulation problem to the body tissues downstream. Occasionally a small blockage will occur in the small arteries that supply blood to a toe. This is known as a " Blue Toe Syndrome." Another arterial inflow problem may result when the smooth muscles that control the size of the arteries go into spasm. The arterial muscle spasm can block the blood from circulating into the foot. One common vasospastic disorder is called Raynaud's Syndrome. A second vasospastic disorder is called acrocyanosis.

 

Venous Insufficiency

 

Venous outflow disorders refer to problems getting blood from the foot back to the heart. There are two sets of veins in the feet and legs to help bring the blood back toward the heart. The superficial venous network refers to veins located just beneath the skin. The deep venous networks are veins located closer to the bones and are not visible when looking at the foot or legs.

 

Varicose veins refer to an enlargement of the veins and a loss in the ability of the vein to properly maintain blood flow back toward the heart. When this occurs blood can collect in the feet and legs. Superficial varicose veins may appear as unsightly cords or a small bunch of grapes, which usually appear on the tops of the feet, around the ankles and may extend upward to the knees and thighs. Deep varicose veins while usually not visible will result in chronic swelling of the feet, ankles and legs. When the blood is not circulated from the feet back to the heart gravity will cause the fluid to collect in the feet and ankles. This results in swelling, called edema. Chronic edema over a long period of time may cause a discoloration of the skin around the ankles. The skin can become inflamed and is known as venous stasis dermatitis. If left untreated the skin will become weakened and a weeping sore will develop, usually on the inside of the ankle called a venous stasis ulcer.

 

A potentially serious consequence of blood collecting in the feet and legs is the formation of blood clots in the veins. A superficial vein blood clot will result in a painful, inflamed superficial vein called superficial phlebitis. When a blood clot forms in a deep vein, it is called deep venous thrombosis, or deep phlebitis. This is a serious condition that causes painful swelling of the leg and may result in part of the clot breaking free. If the clot should travel back up to the heart and get caught in the lungs, it is referred to as a pulmonary embolus which can be life threatening and requires emergency treatment.

 

The Ischemic Foot

 

The term "ischemic foot" refers to a lack of adequate arterial blood flow from the heart to the foot. There are a wide variety of possible causes for poor arterial circulation into the foot including arterial blockage from cholesterol deposits, arterial blood clots, arterial spasm, or arterial injury. The ischemic foot is also referred to as having arterial insufficiency, meaning there is not enough blood reaching the foot to provide the oxygen and nutrient needs required for the cells to continue to function.

 

Diagnosis

 

The result of insufficient blood supply to the foot can manifest itself in a variety of ways depending upon how severe the impairment to circulation. Early symptoms may include cold feet, purple or red discoloration of the toes, or muscle cramping after walking short distances (intermittent claudication). Later findings may include a sore that won't heal (ischemic ulcer), pain at night while resting in bed, or tissue death to part of the foot (gangrene).

 

The diagnosis of ischemia is made by reviewing the patient's symptoms, examination of the foot, and special testing to evaluate the circulation. The examination should reveal cold skin temperature, and skin atrophy that causes the skin to appear shiny or paper thin with loss of normal hair on tops of the toes and on the lower leg. There is often a color change associated with ischemic feet. This may show as a purple discoloration of the toes, white blanching of the toes when the foot is elevated, and red discoloration when the foot is hanging down. Additionally, the two arterial pulses in the foot will not be as strong as normal or may be entirely absent. Certainly, the presence of a pale looking ulcer, or black gangrenous toes would be an ominous sign of poor circulation.

 

When these findings are present further testing is usually required. This will often include arterial Doppler testing. This test uses sound waves to listen to the blood flow through the arteries and is able to record the quality of the blood flow and also the blood pressure. If the quality of blood flow is poor and the pressure is greatly diminished, this would indicate a lack of adequate blood flow. A second test may be required to further determine where the arterial blockage is located and how much blood is able to squeeze past the blockage. This test is known as an arteriogram. The arteriogram requires the injection of a special dye into the artery so that the artery will be visible when an x-ray is taken. This x-ray can then show where the artery is blocked and how much blood can flow past the blockage.

 

Treatment

 

In the early stages of ischemia of the foot, the doctor will often recommend a program of walking exercises to increase blood flow, protective shoes and insoles, if necessary, to protect the skin from rubbing producing irritations which may lead to ulcerations. Medications are also available to help improve the blood flow into the feet.

 

In more advanced stages of ischemia, a referral to a vascular specialist is appropriate for further evaluation. Oftentimes, if the patient is in otherwise good general health, a surgery may be recommended to bypass the blocked artery or to clean out the area of blockage. This can be major surgery, however in these cases, failure to improve the circulation into the foot may result in gangrene, which may ultimately require amputation of part of the foot or leg. The surgery is an attempt to save the foot and leg from the impending amputation. The surgery has improved over the years and the chances for success are now greater than ever before. However, each individual needs to be evaluated as to the potential risks and possible benefits from this type of surgery.

 

Venous Stasis

Venous stasis refers to loss of proper function of the veins in the legs that would normally carry blood back toward the heart. This may occur following injury to the veins, which can result in blood clots in the superficial veins known as superficial phlebitis, or following blood clots in the deep veins known as deep venous thrombosis . Swelling in the lower legs and ankle can also occur as a result of heart disease called Chronic Congestive Heart Failure and due to kidney disease. In some instances the cause of the swelling may not be easily identified.

Diagnosis

Individuals with this condition usually exhibit edema, which means swelling, of the legs and ankles. The superficial veins in the legs may be varicosed, causing the veins to be enlarged and appear as a cord or a bunch of grapes. Patients often complain of a feeling of fullness, aching, or tiredness in their legs. These symptoms are worse with standing, and are relieved when the legs are elevated.

As the condition progresses the blood continues to collect in the feet, ankles, and legs. The pigmentation from the red blood cells stains the skin from the inside, and a reddish-brown discoloration develops on the skin. This is called venous stasis dermatitis.

In severe cases of long-standing venous stasis, the skin begins to lose its elasticity, and a sore may develop on the inside of the ankle. This is known as venous stasis ulceration. This ulcer often will drain large amount of fluid and will have a red base. Secondary infection can complicate the ulcer and will require antibiotic treatment.

Further testing may be requested by your doctor to further evaluate the condition of your veins. This may include venous Doppler testing, which uses sound waves to listen to the blood flow through the veins. If there is a suspicion of an acute thrombosis (blood clots), a venogram may be requested. This enables the veins to be visible on x-rays, and the blood clot can be identified with greater certainty. Identification of deep vein thrombosis is important, because failure to properly treat may result in a blood clot breaking loose in the leg and traveling to the lungs called pulmonary embolus, which can be fatal.

Treatment

The most common treatments for venous stasis are rest, elevation, and compression stockings. When elevating your feet the ideal position is to have your feet above the level of your heart. This permits greater return of blood back toward the heart. This usually means you are lying down with your legs raised with pillows.

The compressive stockings come in different lengths. A knee high stocking may be sufficient if the swelling is confined to the lower legs and ankles. However if the swelling extends up to the knee, then a thigh high or panty hose style elastic stocking may be required. The compression stockings are also available in a variety of compression strengths. The greater the compression the more squeeze the stocking will apply to the leg. Generally, over-the-counter elastic stockings are available (without prescription) in most pharmacies or surgical supply stores. These have a compression range of 10 to 20 mm compression. If these do not provide enough compression to control the edema, then a prescription compression stocking may be necessary. These begin at 30 to 40 mm compression, and are often referred to as T.E.D. stockings. In more severe cases a higher level of compression may be necessary. These stockings often need to be custom sized to each individual leg, otherwise they are difficult to put on and may not provide even compression throughout the extremity. Your doctor may also use medications to reduce the swelling called Diuretics. Diuretics increase the output of urine and your doctor should closely monitor the use of this medication. If the cause of the swelling is due to heart problems or kidney problems your doctor will evaluate the need to adequately treat these conditions.

DISCLAIMER: MATERIAL ON THIS SITE IS BEING PROVIDED FOR EDUCATIONAL AND INFORMATION PURPOSES AND IS NOT MEANT TO REPLACE THE DIAGNOSIS OR CARE PROVIDED BY YOUR OWN MEDICAL PROFESSIONAL. This information should not be used for diagnosing or treating a health problem or disease or prescribing any medication. Visit a health care professional to proceed with any treatment for a health problem.
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