Definition
A.Peripheral vascular disease (PVD) is a general term that encompasses all occlusive or inflammatory diseases that occur within the peripheral arteries, veins, and lymphatics. These conditions include peripheral arterial disease (PAD), deep vein thrombosis (DVT), superficial thrombophlebitis, lymphedema, and chronic venous diseases. Chronic venous diseases include chronic venous insufficiency (CVI) and varicose veins:
1.CVI:
a.It is estimated that six to seven million adults in the United States have CVI. CVI is twice as common in females as in males.
b.Peak incidence is seen in women between 40 and 50 years of age.
2.Varicose veins:
a.The Vascular Disease Foundation states that more than 24 million Americans have varicose veins. They are usually thought to be more common in females; however, there is a higher incidence in males, especially African American males.
Pathogenesis
A.CVI: Venous insufficiency is caused by incompetent valves that allow valvular reflux and subsequently venous hypertension (HTN). In CVI, persistent ambulatory venous HTN leads to obstruction of venous flow, which produces local tissue anoxia, inflammation, and at times even tissue necrosis. This process eventually causes subcutaneous fibrosing panniculitis and additional venous and lymphatic outlet obstruction.
B.Varicose veins: Varicose veins are a form of CVI. The same incompetent valves that cause valvular reflux and subsequently venous HTN in CVI also cause varicose veins. This influx of volume and pressure causes the vessels to dilate, twist, and bulge.
Predisposing Factors
A.CVI:
1.Age.
2.Gender, being female.
3.Prolonged standing or sitting.
4.Prior history of DVT.
5.Stature, more common in tall persons.
6.Obesity.
B.Varicose veins:
1.Genetics:
a.Risk increases to 90% if both parents have varicose veins.
b.If one parent is affected, the risk increases by 25% for men and 62% for women.
2.Age.
3.Pregnancy.
4.Prolonged standing.
5.Restrictive clothing.
6.Obesity.
7.Ligamentous laxity:
a.A history of hernia(s).
b.Flat feet.
8.Smoking.
Common Complaints
A.CVI:
1.Extremity edema.
2.Pain worse when standing, usually dull, aching, or cramping.
3.Pain improved with elevation.
4.Itching sensation.
5.Feeling of heaviness in extremity.
6.Hyperpigmentation.
7.Thickening and hardening of the skin.
8.Ulcerations.
B.Varicose veins:
1.Pain, usually burning, aching, or itching.
2.Blue veins that protrude above the surface of the skin.
3.Leg fatigue.
4.Edema.
5.Symptoms worsening toward the end of the day.
Potential Complications
A.CVI:
1.Cellulitis.
2.Peripheral neuropathy.
3.Varicose veins.
4.Abscess.
5.Ulceration.
6.Stasis dermatitis.
7.DVT.
B.Varicose veins:
1.Stasis dermatitis.
2.Stasis ulceration.
3.Petechial hemorrhage.
4.Chronic edema.
5.Superficial thrombophlebitis.
6.Hyperpigmentation.
7.Eczema.
Subjective Data
A.Ask patient when the symptom(s) were first noticed.
B.Have patient describe duration of symptoms.
C.Ask patient to describe pain, for example, crushing, stabbing, or burning.
D.Ask the patient what makes the symptoms better and what makes them worse.
E.Have patient rate pain on a scale of 0 to 10, with 0 being no pain.
F.Ask patient to list all medications currently being taken, particularly substances not prescribed and illicit drugs such as cocaine.
G.Review recent history of invasive procedures or surgery.
H.Review medical history for heart disease, diabetes, HTN, and DVT.
I.Ask patient if he or she has an increase in the size of lower extremities after being on his or her feet. Discern if one leg is worse than the other.
Physical Examination
A.CVI:
1.Vital signs:
a.Check blood pressure (BP) and document resting heart rate, respirations, temperature (if indicated), height, and weight.
2.Inspect:
a.Inspect extremity for edema, hyperpigmentation, erythema, difference in temperature.
b.Inspect and document any varicosities.
3.Palpate:
a.Palpate distended veins, noting tenderness.
b.Perform the cough impulse test to determine turbulent retrograde flow.
c.Perform the tap test to determine if the great saphenous vein is distended with blood.
4.Auscultate:
a.Auscultate heart: Rate, rhythm, heart sounds, murmur, and gallops.
b.Auscultate lungs: Lung sounds in all fields.
B.Varicose veins:
1.Patient presenting with any of the following should be quickly assessed for the need to call emergency services/911 for immediate transport to the hospital:
a.A bleeding varicosity with eroded surrounding skin.
b.A varicosity that has bled and is at risk for bleeding again.
c.An ulceration that is worsening and/or painful despite treatment.
2.Vital signs:
a.Check BP and document resting heart rate, respirations, temperature (if indicated), height, and weight.
3.Inspect:
a.Inspect skin for superficial veins that are raised above the skin’s surface; patient should be standing.
b.Inspect extremity for edema, hyperpigmentation, and eczema.
4.Palpate:
a.Palpate distended veins, noting tenderness.
5.Auscultate:
a.Auscultate heart: Rate, rhythm, heart sounds, murmur, and gallops.
b.Auscultate lungs: Assess lung sounds.
Diagnostic Tests
A.CVI:
1.Trendelenburg test.
2.Perthes test.
3.Doppler ankle/brachial index (ABI).
4.Duplex ultrasound.
5.Venography, not utilized often because of expense and risk of phlebitis.
B.Varicose veins:
1.Trendelenburg test.
2.Perthes test.
3.Duplex ultrasound.
Differential Diagnosis
A.CVI:
1.DVT.
2.Ulceration.
3.Infection.
4.PAD.
5.Varicose veins with risk of hemorrhage.
B.Varicose veins:
1.Arthritis.
2.Peripheral neuritis.
3.Nerve root compression.
4.Telangiectasia.
5.DVT.
6.Inflammatory liposclerosis.
Plan
A.General prevention:
1.Avoid prolonged standing or sitting.
2.Exercise on a regular basis.
3.Encourage smoking cessation, weight loss, and exercise, if applicable.
4.Encourage strategies to better manage other chronic medical conditions that directly affect the progression of PAD, that is, diabetes, dyslipidemia, obesity, and HTN.
B.CVI:
1.Nonpharmaceutical therapy:
a.Extremity elevation.
b.Compression stockings.
c.Exercise.
d.Venous ulcerations treated with wound care and compression therapy.
2.Pharmaceutical therapy:
a.Diuretics: Management of edema, short-term administration:
i.Hydrochlorothiazide.
ii.Antiplatelet: May increase the speed of healing to ulcerations:
•Aspirin: 325 mg tablet.
Beers Criteria caution: (a) Use aspirin with caution in older adults over age 80 with no history of cardiovascular disease (CVD): No clear evidence that aspirin provides primary prevention for cardiac events, but there is a risk for gastrointestinal (GI) bleeds. (b) In adults 65 and older, avoid use of greater than 325 mg due to risk of GI bleed, unless other alternatives are not effective and the patient can take a gastroprotective agent. (c) In older adults more than 75 years old, or adults older than 65 taking corticosteroids, anticoagulants, or antiplatelet agents, there is an increased risk of upper GI bleeds. The use of proton pump inhibitors (PPIs) reduces but does not eliminate risk. The risk for GI bleed increases with duration of use of nonsteroidal anti-inflammatory drugs (NSAIDs), including high-dose aspirin (ASA). At 1 year, the risk is 2% to 4% and this increases with each subsequent year
•Systemic antibiotics: Management of infection in persons demonstrating an increase in pain, erythema, or increase in size of ulceration.
3.Surgery:
a.Venous ablation, for patients who continue to be symptomatic after 6 months of nonpharmacologic therapies. Types of ablation: Chemical, thermal, and mechanical.
C.Varicose veins:
1. 
See Section III: Patient Teaching Guide “Chronic Venous Insufficiency and Varicose Veins“:
a.If prolonged standing is required, shift weight from one leg to the other.
b.Do not sit with legs dependent.
2.Nonpharmaceutical therapy:
a.Extremity elevation.
b.Compression stockings.
c.Exercise.
3.Surgery:
a.Radiofrequency ablation.
b.Endovenous laser therapy.
c.Phlebectomy.
d.Foam sclerotherapy.
e.Vein litigation.
Follow-Up
A.Follow-up is determined by patient’s needs, frequency and intensity of symptoms, and the presence of other medical conditions.