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. Lymphedema is a chronic condition caused by the accumulation of lymphatic fluid in the interstitial tissue.
Incidence
A.Almost one million Americans have lymphedema, and the incidence worldwide is projected to approach 100 million.
Pathogenesis
A.Lymphedema occurs when lymph fluid is unable to flow in a normal manner and accumulates in an extremity. The propensity for lymphedema can be inherited or caused by propensity for lymphedema can be inherited or caused by another condition such as lymphangitis, malignancy, filariasis, or prior removal of lymph nodes.
Predisposing Factors
A.Cancer.
B.Radiation therapy.
C.Surgical removal of lymph nodes.
D.Infection.
E.Congenital disorder involving the structure of the lymph system:
1.Milroy’s disease.
2.Meige’s disease.
Common Complaints
A.Severe edema that is consistent with the distal aspect of the extremity.
B.Hard skin over edematous area.
C.Loss of range of motion.
Potential Complications
A.Infection, including lymphangitis and cellulitis.
B.Lymphangiosarcoma.
Subjective Data
A.Ask patient when the symptom(s) were first noticed.
B.Have patient describe duration of symptoms.
C.Review any history of cancer, radiation, and chemotherapy.
D.Review recent history of invasive procedures or surgery.
E.Ask patient to list all medications currently being taken, particularly substances not prescribed and illicit drugs such as cocaine.
F.Ask patient to describe any pain.
G.Ask the patient what makes the symptoms better and what makes them worse.
H.Have patient rate discomfort on a scale of 0 to 10, with 0 being comfortable.
Physical Examination
A.Vital signs:
1.Check blood pressure (BP) and document resting heart rate, respirations, temperature, height, and weight.
B.Inspect:
1.Assess for signs of erythema, increased temperature, and edema.
C.Palpate:
1.Palpate lymph nodes distal and proximal to the site.
2.Palpate pulses distal and proximal in all extremities.
3.Palpate extremity for tenderness.
D.Auscultate:
1.Auscultate heart: Rate, rhythm, heart sounds, murmur, and gallops.
2.Auscultate lungs: Lung sounds in all fields.
Diagnostic Tests
A.Complete blood count (CBC) with differential.
B.CT.
C.Doppler ultrasound.
D.MRI.
E.Lymphoscintigraphy.
Differential Diagnosis
A.Lymphedema.
B.Venous insufficiency.
C.Congestive heart failure (CHF).
D.Lipiderma.
E.Deep vein thrombosis (DVT).
Plan
A. 
See Section III: Patient Teaching Guide “Lymphedema.”
1.Protect your arm or leg while recovering from cancer treatment.
2.Avoid heavy lifting, if it is an arm.
3.Avoid strenuous exercise.
4.Avoid heat on your arm or leg.
5.Avoid tight clothing.
6.Inspect the affected limb daily, noting any cracks or cuts.
7.Apply lotion daily to protect and prevent dry skin.
B.Nonpharmaceutical therapy:
1.Extremity elevation.
2.Compression stockings or wrapping of affected limb.
3.Pneumatic compression boot.
4.Therapeutic massage, specifically manual lymph drainage.
5.Referral to a lymphedema therapist.
6.Referral to physical therapy for home exercise program.
C.Surgery:
1.Lymphaticovenular bypass.
2.Lymphovenous bypass.
Follow-Up
A.Follow-up is determined by patient’s needs, frequency and intensity of symptoms, and presence of other medical conditions.
B.PVD manifesting persistent symptoms should always be followed by a cardiologist.
C.Emergent issues/instructions:
1.Patients should contact the office if they are experiencing any new symptom(s) not present at their last office visit.
2.Patients should contact the office if they have any of these symptoms:
a.Fever over 101°F.
b.Increased redness, pain, tenderness to touch, and/or warmth in affected arm or leg.
c.New pain, swelling, or warmth in an arm or leg.
Consultation/Referral
A.If you suspect acute limb ischemia, refer patient for immediate hospitalization to obtain diagnostic testing to determine the presence of a thrombus and restore circulation to the affected extremity.
B.If chronic limb ischemia has led to ulceration and/or superimposed infection, hospitalization is indicated to initiate a wound care consultation and diagnostic testing to determine the degree of arterial occlusion.
C.Referral to a cardiologist is indicated in the presence of persistent PVD symptoms.
D.Referral to a lymphedema therapist and physical therapist is indicated to best manage chronic lymphedema.