Peripheral Vascular Disease
GENERAL PRINCIPLES
Diabetes and smoking are the strongest risk factors for PVD. In patients with diabetes, the risk of PVD is increased by age, duration of diabetes, and presence of peripheral neuropathy.
PVD is a marker for systemic vascular disease involving coronary, cerebral, and renal vessels. Persons with diabetes and PVD have increased risk for subsequent MI or stroke regardless of PVD symptoms.DIAGNOSIS
Clinical Presentation
Symptoms of PVD include intermittent claudication, rest pain, tissue loss, and gangrene, but patients with diabetes may have fewer symptoms because of concomitant neuropathy.
Physical Examination
Physical examination findings include diminished pulses, dependent rubor, pallor on elevation, absence of hair growth, dystrophic toenails, and cool, dry, fissured skin.
Diagnostic Testing
• The ankle-to-brachial index (ABI), defined as the ratio of the systolic blood pressure in the ankle divided by the systolic blood pressure at the arm, is the best initial diagnostic test. An ABI lt;0.9 by a handheld 5- to 10-MHz Doppler probe has a 95% sensitivity for detecting angiogram-positive PVD.
• ABI should be performed in patients with diabetes with signs or symptoms of PVD.
TREATMENT
• Risk factors should be controlled, with similar goals described for CAD.
• Antiplatelet agents such as clopidogrel (75 mg/d) have additional benefits when compared with aspirin in patients with diabetes and PVD.
• Patients with intermittent claudication could also benefit from exercise rehabilitation and cilostazol (100 mg bid). This medication is contraindicated in patients with CHF.