A thorough history and physical examination can accurately suggest a diagnosis of PVD 80% to 90% of the time.


The vast majority of disorders related to the peripheral vascular system are (1) atherosclerosis involving the arterial tree or (2) thrombophlebitis involving the venous circulation— both predominantly affecting the lower extremities more so than the upper extremities or viscera. Patients with suspected vascular disease typically present for evaluation with varying types of limb pain or discomfort, ulcerations or gangrene of the extremities, or swelling of the affected limb.

Most limb pain or discomfort typically falls into three etiologies: vascular, musculoskeletal, or neuropathic. Most limb swelling is caused by venous obstruction or insufficiency, increased venous pressure (e.g., CHF), decreased oncotic pressure (e.g., hypoproteinemia, hypoalbumin-emia), lymphedema, or lipedema. Many patients, particularly the elderly, have multifactorial etiologies of pain or swelling that can usually be distinguished by a thorough history and physical examination. Using a systematic approach with key pointed questions, a presumptive diagnosis can often be deduced on clinical grounds and subsequently confirmed with noninvasive testing. The history should focus on identifying risk factors for atherosclerosis. The past medical history should concentrate on prior vascular events such as MI, stroke, amputation, DVT and revascularizations in any vascular bed either percutaneously or surgically, as well as, but not limited to, a history of CHF, back problems, osteoarthritis, inflammatory conditions (e.g., rheumatoid arthritis, plantar fasciitis, polymyalgia rheumatic), gout, varicose veins, and lymphatic obstruction (e.g., after surgery or radiation therapy).

The etiology of leg pain can be determined by the characteristics, severity, location, duration, frequency, and precipitating or alleviating factors of the discomfort. Claudication is typically described as a cramping or aching discomfort in the muscle associated with exertion and alleviated with rest. Most often this occurs in the calf, but it can occur in the hip and buttocks if there is occlusive disease in the aortoil-iac segment. Nocturnal cramping of the calf and foot is not typically vascular in etiology and is most likely caused by an exaggerated neuromuscular response to stretch that occurs while sleeping.

Critical limb ischemia can cause resting pain that is constant throughout the day and night. A classic description of nocturnal pain from CLI is a moderate to severe aching paresthesia/dysesthesia while lying horizontal that is alleviated by dangling the leg over the side of the bed. Pain from CLI can be so severe that it may not be relieved by narcotic analgesia. On the other hand, diabetic patients with severe peripheral neuropathy may be completely insensate despite significant tissue loss. Distinguishing the etiology of constant resting limb pain between a vascular and nonvascular etiology can be done by physical examination and noninvasive testing. Pain that occurs at rest may be caused by CLI if other findings in the history and examination support the diagnosis of advanced atherosclerosis. Otherwise, pain that occurs at rest, with change in position, or simply standing without exertion, is more typically musculoskeletal or neuropathic in nature. Tables 27-11 and 27-12 list the distinguishing features and differential diagnosis of the most common types of leg pain and swelling, respectively.

For example, acute loss of motor and sensory function in the distal extremities, particularly with associated acute severe pain, pallor, and coolness of the limb, is a sign of acute arterial occlusion. However, chronic motor and sensory loss may be vascular in etiology but more likely is neuropathic. Several standardized classification schemes exist for categorizing the severity of both acute and chronic limb ischemia. Table 27-13 is the revised Rutherford-Baker classification for acute limb ischemia, and Table 27-14 is the combined Fontaine classification (more popular in Europe) and the Rutherford-Baker scheme for CLI (Dormandy and Rutherford, 2000; Rutherford et al., 1997).

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