Vascular Disorders and Clinical Management
Arterial disease
Peripheral artery disease causes exertional claudication relieved by rest, diminished pulses, hair loss, shiny skin, thickened nails, and cool extremities. The ankle–brachial index is the screening test: 0.90–1.30 normal, <0.90 abnormal, ≤0.50 severe, ≥1.30 falsely elevated from noncompressible vessels (diabetes, CKD, advanced age). Critical limb ischemia causes rest pain worse at night and relieved by dependency, plus ulcers or gangrene. Arterial ulcers are punched-out, painful, and located laterally or on toe tips.
Venous disease
Chronic venous insufficiency produces dependent edema, brown hemosiderin staining, stasis dermatitis, and shallow ulcers near the medial malleolus. DVT is usually unilateral swelling with calf tenderness; Homan's sign is unreliable and should not be used to rule in or out. PE presents with dyspnea, pleuritic pain, tachycardia, and hypoxemia; massive PE adds hypotension and may require reperfusion.
Aortic and carotid
Aortic dissection: sudden tearing pain radiating to the back, ≥20 mmHg inter-arm BP difference, pulse deficit, new aortic regurgitation murmur - type A is a surgical emergency. Ultrasound screening for abdominal aortic aneurysm is recommended for men 65–75 with a smoking history; elective repair is considered near 5.5 cm. Carotid stenosis presents with bruit or TIA; symptomatic high-grade stenosis may need endarterectomy.
Traps
- Never elevate an ischemic limb above the heart; keep it dependent.
- Compression therapy is contraindicated in severe PAD (ABI <0.5).
- Pulse oximetry is unreliable in PAD.
- Measure blood pressure in both arms when dissection is suspected.
Rule of thumb
ABI = ankle systolic ÷ brachial systolic. Ankle 84 with brachial 120 gives 0.70 - moderate PAD.