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					GUIDELINES IN SUPPORT OF PVD CARE PATHWAYS

Evidence demonstrates that the first line clinical test for the detection of
arterial occlusive disease is the presence or absence of pulses in the limb
(QIS 2003). Upon palpation, if either the posterior tibial or dorsalis pedis
pulse can be detected for both feet the pulses may be recorded as present. If
in either foot there is an absence of both the posterior tibial and dorsalis
pedis the pulses are recorded as absent. Other clinical signs and symptoms
and a detailed history will assist in the diagnosis of occlusive disease:

  Table 2.
  Clinical signs & symptoms of arterial occlusive disease

  Absence of both dorsalis pedis and posterior tibial pulses
  Intermittent claudication
  Night or rest pain relieved by hanging leg out of bed or taking a couple of steps
  White or bluish colouration – dusky red colour on dependency (rubor)
  Monophasic and low pitch Doppler sounds.
  ABPI below 0.5
  Absolute toe pressure below 30 mmHg.
  Key aspects of history

  Smoker
  History of lower extremity event (amputation or ulceration attributed to PVD)
  Diabetes
  Hypertension
  Lipid profile (high cholesterol)
  Co-existing angina or history of stroke / TIA or ischaemic heart disease
  Sendentary lifestyle.

Pulses present

   Where either the posterior tibial or dorsalis pedis can be palpated for both
   feet and there are no other signs and symptoms of PVD (see tables 2-6)
   tissue viability is considered to be ‘normal’. These patients will be
   assessed for podiatry needs and assigned to an appropriate care
   programme or discharged.

   Where either the posterior tibial or dorsalis pedis can be palpated for both
   feet but there are other signs and symptoms of PVD, a doppler may be
   used to assist diagnosis. A monophasic doppler sound indicates that
   despite being able to palpate a pulse, there is evidence of arterial
   occlusive disease. This scenario is rare as in the event of a monophasic
pulse the associated level of arterial occlusion would mean it very unlikely
that a pulse could be palpated. On detecting a monophasic doppler signal,
the community podiatrist would refer these patients to a specialist
podiatrist for further tests, education and monitoring.

A bi or triphasic doppler sound would indicate that there is no arterial
occlusive disease and therefore other causes of PVD should be
considered such as, vasospasticity, venous, lymphatic or microvascular
disorder (see tables 3-6 below).


Table 3.
Clinical Signs & Symptoms of vasospastic disorder

Palpable peripheral pulses and / or bi or triphasic Doppler sounds.
Seasonal variation in signs & symptoms i.e. symptoms worse in cold weather
White or bluish colouration when in initial cold phase, hot red and itchy on
hyperaemic phase.
Digits tapered appearance – hands affected as well as feet.
ABPI normal 1.0 (+/- 0.1)
Absolute toe pressure normal – approx 80 mmHg.
Key aspects of history

Possible history of connective tissue disease e.g. Rheumatoid disease
Possible smoker
Often female

If a patient presents with signs and symptoms of vasospasticity they
should be advised on the appropriate hosiery and footwear to prevent the
cold phase from occurring. Woollen or natural materials for socks or
stockings and avoiding use of those made from synthetic materials such
as nylon is advised. Fleece lined boots, slippers, gloves, and at night use
of bed socks should be suggested. The podiatrist may prescribe insulating
insoles such as evazote or plastazote through completing a prescription
form and forwarding an insole template to the local biomechanics team.
Patients should be encouraged to warm their feet up slowly when in the
cold phase rather than putting their feet in hot water or against heaters.
Smoking will exacerbate vasospasticity due to the powerful vasconstrictor
effect of the chemicals contained in cigarette smoke. Patients should be
advised and encouraged to attend local smoking cessation programmes.

In severe cases of vasospastic disorder e.g. suspected Raynauds disorder
where the signs and symptoms are severe and are not improving through
care planning and education, a referral to the patients G.P. for nifedipine
(calcium channel blocker) or peripheral vasodilator drug e.g. naftidrofuryl
should be considered.
Table 4.
Clinical Signs & Symptoms venous disease

Palpable peripheral pulses and / or bi or triphasic Doppler sounds.
Varicosities visible
Phlebitis (current or in the past)
Peripheral oedema worsening during the day
Aching legs on standing
Eczema and haemosiderin deposits on skin
ABPI normal 1.0 (+/- 0.1)
Absolute toe pressure normal – approx 80 mmHg.

Key aspects of history

Possible history of leg ulceration around malleolus initiated by slight trauma
Possible history of deep vein thrombosis or pulmonary embolism
Family history of venous thrombotic disease

If a patient presents with the signs and symptoms of venous insufficiency,
it should be established whether the patient has been assessed by a
community or practice nursing team for body weight control, compression
hosiery, exercise programmes etc. If a patient presents with, or develops
venous ulceration the podiatrist should establish if the patient is being
seen at a leg ulcer clinic, by a community or practice nursing team for
dressings and compression bandaging. For severe signs and symptoms or
non healing ulceration consider with the relevant nursing team, a multi-
disciplinary approach to care and possible referral to vascular clinic for
duplex scanning, compression therapy and/or surgical intervention.

Table 5.
Clinical Signs & Symptoms lymphatic disease

Palpable peripheral pulses and / or bi or triphasic Doppler sounds
No varicosities
Oedema not relieved by elevation
Bi or triphasic Doppler sounds.
ABPI normal 1.0 (+/- 0.1)
Absolute toe pressure normal – approx 80 mmHg.

Key aspects of history

Onset of signs and symptoms from young age:
Any family history of leg swelling or any history of infection.
Any history of infection in the limb including fungal infections.
Any history of malignancies or radiotherapy / surgical interventions.
   Patients with lymphatic disease will present with severe oedema not
   alleviated with elevation. Patients with lymphatic disorder are usually
   known by G.P. and/or the vascular clinic due to early onset and the
   severity of the signs and symptoms. Any deterioration in the patients
   condition should be referred to the G.P. or vascular clinic.

  Table 6.
  Clinical Signs & Symptoms microvascular disease

  Diabetes mellitus
  Pulses may be present or absent - dependent on any co-existing arterial
  occlusive disease
  Evidence of neuropathy, +/- retinopathy, +/- nephropathy
  Dusky red colour on dependency (rubor)
  Possible distention of dorsal veins as an indication of arterio-venous shunting
  Thin fragile skin and nails.
  Diabetes for long duration / poor control
  History of non healing ulceration

Microvascular disease is uncommon and affects patients with a long duration
of diabetes that have co-existing neuropathy and often a history of slow or
non healing ulceration. In line with the diabetes care programme, the risk
category and history of these patients indicates that these patients should be
referred to community or hospital specialist podiatrists for intervention and
education.

Pulses absent

If in either foot there is an absence of both the posterior tibial and dorsalis
pedis the pulses are assessed as absent. The podiatrist should use the
Doppler to confirm a diagnosis in order to identify whom to refer to and the
urgency of the referral.

Doppler sounds bi or triphasic and no other signs and symptoms of
PVD:
This indicates that the difficulty in palpating the pulses is not due to occlusive
disease (may be anatomical variation of artery position). The patient has no
clinical evidence of PVD and tissue viability is therefore likely to be ‘normal’.
These patients will be assessed for podiatry needs and assigned to an
appropriate care programme or discharged.

Doppler sounds bi or triphasic with signs and symptoms of PVD:
A bi or triphasic Doppler sound would indicate that there is no arterial
occlusive disease and therefore other causes of PVD should be considered
such as, vasospasticity, venous, lymphatic or microvascular disease (see
tables 3-6 above).
Doppler sounds monophasic with signs and symptoms of PVD.
Where the Doppler sounds are monophasic intervention on some level is
required. If there is no accompanying deterioration in claudication distance (if
patient is sufficiently mobile), and there is no new onset of pain or changes in
colour or temperature of the foot, the patient should be referred to the
specialist podiatrist for further tests, education and monitoring.

Where the doppler sounds are monophasic or cannot be detected at all and
the patient has one of the following clinical pictures immediate referral is
required:

   Acute occlusion (limb threatening)
   Indicated by the five ‘p’s

                   Pain (constant and severe and sudden onset)
                   Pallor (white foot / limb)
                   Paraesthia
                   Pulselessness
                   Perishing cold
These patients require immediate referral direct to the vascular service or to
accident and emergency

Chronic deteriorating occlusive disease
If the Doppler sounds are monophasic and the claudication distance is
deteriorating (if patient is sufficiently mobile), or there is a sudden onset or
increasingly severe rest or night pain the patient should be referred direct to
the vascular service as an emergency.

				
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