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.