chronic LIMB ISCHEMIA diagonosis and management.pptx

A presentation on chronic limb ischemia

1. CHRONIC LIMB ISCHEMIA MEDICAL AND SURGICAL MANAGEMENT MODERATORS DR. MAHIM KOSHARIYA (MS) DR. VIJAY TEKAM( MS) DR. JYOTI S MARAN(MCH) DR. NIKHIL TEKWANI (MS) PRESENTER- DR.SHIVANI RSO-2 GENERAL SURGERY

2. contents DEFINITION RISK FACTORS ETIOPATHOGENESIS CLINICAL SPECTRUM MANAGEMENT

3. Peripheral vascular diseases Peripheral arterial disease is a chronic progressive atherosclerotic disease leading to partial or total peripheral vascular occlusion. Incidence : Approx 202 million across the globe suffer from Peripheral Arterial Disease with 23.5% increase in first decade of 21 st century owing to population aging , the global epidemic of diabetes,hypertension , obesity and persistence of tobacco smoking in many parts of world. Peripheral Artery disease typically affects the abdominal aorta, iliac arteries, lower limbs and occasionally upper extremities.

4. Limb ischemia ACUTE LIMB ISCHEMIA - A sudden onset (<2 weeks ) of severe pain , pallor, paralysis, pulse deficit, paresthesia and poikilothermia in a previously asymptomatic patient due to either thrombotic or embolic event or due to acute exacerbation of the pre-existing atherosclerotic disease. CHRONIC LIMB ISCHEMIA -A Long history (>2 weeks) of reduced walking distance with claudication pain is suggestive of atherosclerotic disease. ACUTE ON CHRONIC ISCHEMIA - A sudden worsening of symptoms in a patient who has a long history of claudication may suggest thrombosis of a critically stenosed vessel. (>40% of stenosis)

5. definition A diagnosis of Critical limb threatening ischemia requires objectively documented atherosclerotic PAD (Peripheral arterial disease) in association with ischemic rest pain or tissue loss (ulceration or gangrene).

6. etiology LOWER LIMB VASCULITIS ATHEROSCLEROSIS Thromboangitis obliterans Pseudoxanthoma elasticum Popliteal entrapement syndrome UPPER LIMB ISCHEMIA ATHEROSCLEROSIS Takayasu arteritis •Raynaud's disease •Thoracic outlet obstruction •Other rarer causes Mixed cryoglobulinemia Dermatomyositis Systemic scleroderma

7. PATHOPHYSIOLOGY Initiation and progression of atherosclerotic plaque

8. Although atherosclerosis is systemic in nature , atherosclerosis has propensity to develop at specific anatomic locations within arterial tree. Coronary, carotid and AORTO ILIAC LESIONS occur at branching points FEMORAL ARTERY- lesions mostly occur at distal portion at the adductor hiatus SINGLE LEVEL DISEASE involving aortoiliac or femoropopliteal segment in patients presenting with claudication Or multilevel lesions in critical limb threatening ischemia such as femoropopliteal arteries and anterior and tibial arteries with sparing of peroneal arteries, In diabetics profunda femoris arteries and infrapopliteal arteries

9. CLINICAL spectrum Asymptomatic (70-80%) Intermittent claudication Atypical symptoms (Exertional leg pain that – may involve areas other than the calves – may not stop the patient from walking – may not resolve within 10 minutes of rest) Critical limb ischemia – Rest Pain – Ulceration – Necrosis/Gangrene Acute limb ischemia

10. Characteristic features of VASCULAR CLAUDICATION 1.  Always precipitated by activity 2. Relieved by taking rest 3. It is a cramp like pain felt over the muscles 4.Is always reproducible. Intermittent claudication is the most classic symptom of PAD Leriche syndrome is a form of PAD affecting the aortic bifurcation. It specifically presents with buttock or thigh pain and associated erectile dysfunction Claudication Claudication Distance-It is the distance travelled by a person with Peripheral Occlusive Vascular Disease before the onset of Pain.It is thought to be due to the accumulation of Substance P and Lactic acid.

11. Differential diagonosis Neurological •Spinal stenosis •Nerve root compression •Peripheral neuropathy •Nerve entrapment Musculoskeletal •Osteoarthritis •Muscle strain •Baker cyst Vascular •Chronic venous insufficiency •Thrombophlebitis •Deep venous thrombosis •Raynaud phenomenon • Thromboangiitis obliterans

12. Rest Pain (I schemia of the somatic nerves -cry of the dying nerves) Grade IV Boyd’s classification (ABI<0.5) Patient typically complains of pain which is constant, and usually occurs in the forefoot across the metatarsophalangeal joint. It is worse at night and requires placing the foot in a dependent position to wean off pain (hen-holding position) •Exacerbate on lying down or elevation of foot •Lessened by hanging the foot down or sleeping on a chair

13. Critical limb threatening ischemia CLTI is the advanced form of chronic limb ischaemia . (Fontaine stage III-IV or Rutherford Cat 4-6) Common in diabetics: present in 50–70% of cases, presents mostly as neuro- ischaemic diabetic foot ulcers. It can be clinically defined in three ways: Ischaemic rest pain for > 2 weeks duration Presence of ischaemic lesions, non healing wound or ulcer, or gangrene objectively attributable to the arterial occlusive disease ABPI less than 0.5

14. Natural history COMPLICATIONS Healing ulcer Gangrene Amputation required in 1-2% ( 5% in DM) Erectile dysfunction Sepsis (secondary to infected gangrene) acute-on-chronic ischaemia reduced mobility IMPAIREDquality of life

15. APPROACH TO MANAGEMENT HISTORY (Elicit pertinence of symptoms- claudication or rest pain with degree of disability associated with them. Evaluation of cardiovascular risk factors, drug history h/o prior revascularisation ) GENERAL EXAMINATION PULSE- PALPATION OF ALL PERIPHERAL PULSES BLOOD PRESSURE- TO BE MEASURED IN B/L ARMS SYSTEMIC EXAMINATION- RULE OUT ANY NEUROPATHY, CVS EXAMINATION TO RULE OUT CARDIAC MURMURS, GALLOP OR ARRYTHMIA P/A EXAMINATION TO RULE OUT ABDOMINAL AORTA ANEURYSM.

16. LOCAL EXAMINATION-

17. CBC RBS RFT HBA1C, LIPID PROFILE CRP THROBOPHILLIA SCREENING TEST ECG, 2D ECHO RESTING ABI FUNCTIONAL TREADMILL TESTING SEGMENTAL BLOOD PRESSURE ASSESMENT DUPLEX USG CT/MR ANGIOGRAPHY

18. RESTING ABI LIMITATION-Its sensitivity is poorer in patients with noncompressible vessels in diabetes or end-stage CKD because of medial calcification. • Alternative tests such as toe pressure, toebrachial index (TBI) or Doppler waveform analysis of ankle arteries are useful.

19. INTERPRETATION OF ANKLE BRACHIAL INDEX Use resting ABI to establish diagnosis in those with suspected PAD with 1 or more of the following: exertional leg symptoms, nonhealing wounds, age ≥65 years, or ≥50 years with a history of smoking or diabetes. • Use ABI to confirm and diagnosis and establish a baseline in all new patients with PAD, regardless of severity • Use toe-brachial index to establish a diagnosis of PAD in those with non COMPRESSIBLE VESSELS

20. EXERCISE ABI The exercise ABI test involves walking on a treadmill at a speed of 3.0km/ hr at an incline of 5 degrees for 5 minutes (250 meters) or until the patients is forced to stop because of claudication, breathing difficulties or fatigue. The patient referred for exercise testing should be of adequate coronary and respiratory health to undertake the test.

21. SEGMENTAL BLOOD PRESSURE ASSESSMENT Segmental BP is measured at multiple levels (upper and lower thigh, upper calf and ankle) Pressure reductions between levels help to localise the occlusion Normally pressures increase as one moves further down the leg (>20 mmHg gradient abnormal) Test is inaccurate in calcified artery walls. USEFUL FOR ANATOMICAL LOCALISATION

22. USG DUPLEX (USG-B WITH PULSED DOPPLER) GOLD STANDARD INVESTIGATION • 85–90% sensitivity and >95% specificity to detect stenosis >50% Initially evaluated with Doppler ultrasound, to assess the severity and anatomical location of any occlusion. USES IN CHRONIC LIMB ISCHEMIA- 1.DIAGONOSIS A normal DUS at rest should be completed by a post-exercise test when iliac stenosis is suspected, because of lower sensitivity. • Safe and cost-effective method of determining PAD location, stenosis severity, and length of stenosis or occlusion, hemodynamic severity, and plaque characteristics. 2. SURGICAL MANAGEMENT- DUS is also important to address vein quality for bypass substitutes. 2.FOLLOW UP It is the method of choice for routine follow-up after revascularization

23. MR ANGIOGRAPHY MRA / CTA both provide excellent high-quality vascular imaging MRA has 90% sensitivity and 97% specificity in identifying hemodynamically significant lesions. Advantages : ability to identify small runoff vessels that sometimes may not be seen with DSA. Drawback: MRA tends to overestimate the degree of stenosis. It cannot visualize arterial calcifications, useful for the estimation of stenosis severity in highly calcified lesions.

24. CT ANGIOGRAPHY Advantages: visualization of calcifications, clips, stents, bypasses and concomitant aneurysms. • Limitations: general (radiation, nephrotoxicity and allergies), severe calcifications (impeding the appreciation of stenosis, mostly in distal arteries

25. treatment Management in PERIPHERAL VASCULAR DISEASE IS A MULTIDISCIPLINARY APPROACH. Management is divided into two broad categories • aimed at decreasing cardiovascular events and • improving symptoms

26. MECDICAL treatment LIFESTYLE MODIFICATIONS IN approximately 70% individual chronic limb ischemia is rather stable with minimal symptoms if modifiable risk factors are kept in check with lifestyle modification, good glycemic control, Such as- 1.DIET- Low glycemic index food, DIETARY APPROACH TO STOP HYPERTENSION (DASH), AVOID FOLATE SUPPLEMENTATION. 2.Strict control of hyperglycemia (hba1c <6%) 3.Avoid precipitating factors— Cold 4 Stop smoking

27. 5. PHYSICAL ACTIVITY: Structured exercise program in hospital or outpatient facility • Intermittent walking exercise is used as the treatment modality. • Superervised by qualified healthcare provider(s). • Patients may not initially achieve these targets, and a • 30- to 45-minute length sessions • conducted 4 to 5 times a week (minimum total 3 hour a week ) X 12 WEEKS 6. Attainment of ideal body weight 6.limb care ( foot cleaning Application of moisturiser )

28. PHARMACOTHERAPY VASODILATORS 1.Nifedipine 2.Xanthinol nicotinate 3.Pentoxifylline 400 mg TDS PO (non selective PDE INHIBITOR) MOA- Decreases blood viscocity Increases flexibity of RBC, minimises rouleax formation and improves microcirculation. ANTIPLATELETS Drugs Low dose Asprin 75 mg -325 MG OD PO (Irreversible cox-1 inhibitor) Clopidogrel 75 mg OD PO (MOA- binds to P2RY12 RECEPTOR to inhibit ADP mediated PLATELET ACTIVATION AND AGGREGATION) Advantages of DAPT is to reduce the incidence of MI, STROKE AND VASCULAR DEATH in patients of PAD.

29. Cilastazol – MECHANISM OF ACTION-PDE3 INHIBITOR DOSAGE- 50MG/100 mg BD PO ADVANTAGES- INCREASESWALKING DISTANCES AS COMPARED TO PLACEBO OR PETOXIFYLLINE C/I- CLASS III OR IV HEART FAILURE Naftidrofuryl is a 5-HT-2-receptor antagonist, inhibits glucose uptake and increases ATP levels. It has fewer side effects than cilostazol and should be considered where available LIPID LOWERING AGENTS - Atrovastatin 10- 40 mg OD PO USE- to keep target LDL ,100MG/DL and <70 mg/dl if disease involves two vascular beds. ANTIHYPERTENSIVES ANALGESICS

30. Novel emerging medical therapies for peripheral arterial disease ANTIPLATELET DRUGS Ticagrelor (reversible P2Y12 Ib ) Vorapaxar(protease activator receptor-1 PAR-1 INHIBITOR) LIPID LOWERING AGENTS EVOLOCUMAB GENE THERAPY AND TARGETTED THERAPY Therapeutic angiogenesis by IM Administration of internal ribosome carried VEGF. Various therapies are being evolved around 27 potential mirna for PAD that targets JAK-STAT pathways, CEP. CELL THERAPY Still in preclinical trials, mesenchymal stem cells are injected by i /m or i /v route. It activates cytoprotective and regenerative pathways to recover limb ischemia

31. SURGICAL MANAGEMENT INDICATION Surgical intervention is required if risk factor modification has been discussed; 1.Supervised exercise has failed to improve symptoms. 2.critical limb ischaemia There are two main surgical options available: 1.Angioplasty with or without stenting 2.Bypass grafting : diffuse disease or in younger patients

32. Percutaneous transluminal ballon angioplasty

33. Open surgical therapy AORTOILIAC OCCLUSIVE DISEASE- Aortobifemoral grafting is the treatment of choice in low risk patients with diffuse aortoiliac stenoses and occlusions. It can be performed through transperitoneal or retroperitoneal approach and can be coupled with distal endarterectomy or profundaplsty for improved outflow.

34. Femorofemoral bypass - alternative in high risk patients with unilateral iliac disease. The disadvantage is a lower patency rates. Axillobifemoral bypass - less invasive option in case of high risk patient or in setting of infected field. Aortoiliac endarterectomy - Rather uncommon, can be used for diseases localised to distal aorta and common iliac vessels. It is removal of thrombus along with diseased intima through an arteriotomy. There are three methods— (1) Open method (2) Semi-closed (3) Wiley’s eversion endarterectomy. Advantages are that it avoids prosthetic graft and its complications— reocclusion and restenosis

35. 2. FEMORAL, POPLITEAL AND TIBIAL OCCLUSIVE DISEASE- SUPERFICIAL FEMORAL ARTERY occlusion , a femoral above knee popliteal Bypass maybe constructed For a lesion below knee, a distal bypass maybe performed to the below knee popliteal, posterior tibial, anterior tibial or peroneal arteries. If all tibial vesels are occluded, pedal vessels serve as suitable outflow vessels. ENDARTERECTOMY is indicated for severe stenosis of COMMON FEMORAL ARTERY AND PROFUNDA FEMORIS ARTERY

36. GRAFTS USED- A NATURAL SINGLE SEGMENT GSV IS THE CONDUIT OF CHOICE (in situ or reverse) 2.CRYOPRESERVED VEIN GRAFT (umbilical vein 3 mm) B. SYNTHETIC DACRON WOVEN DACRON COATED PTFE GRAFT

37. Lumbar sympathectomy

38. omentoplasty

39. AMPUTATION INDICATION 1.Unsuitable for revascularisation with ischaemia causing incurable symptoms or 2. Gangrene leading to sepsis. Assessment for risk of amputation: WIFI CLASSIFICATION

40. Ilizarov technique PRINCIPLE- Distraction OSTEOGENESIS promotes angiogenesis ADVANTAGES- Reduction in severity of pain Improved in claudication distance BETTER healing of ulcers TECHNIQUE- Corticotomy is performed on anteriomedial side of tibia. Percutaneous multiple small vertical are made and longitudinal osteotomy done to separate various fragments which are distracted apart by cross wire technique. POST OP- POD7 Distraction is started with the rate of 0.25 mm 4 times/day. For a period of 12 weeks

41. 3. UPPER EXTREMITY OCCLUSIVE DISEASE - FOR PROXIMAL SUBCLAVIAN DISEASE, if i /l common carotid is patent carotid subclavian bypass orsubclavian artery transposition is done. But if i /l carotid artery is blocked plan for subclavian subclavian bypass. INTRAOPERTIVE CARE Administration of ufHEPARIN (80-100 U/KG) shortly after cross clamping. Aptt monitoring BE WATCHFUL ABOUT A/E OF HEPARIN AND USE OF RVERSAL AGENTS IF NECESSARY POST OPERATIVE CARE ICU CARE EARLY AMBULATION IV ANTIBIOTICS REGULAR ASSESMENT OF DISTAL PULSES CONTINUOUS MONITORING AND RAPID INTERVENTION

42. PAD is common and has a significant impact upon cardiovascular outcomes Treatment of PAD, even asymptomatic, should focus on risk factor modification/risk reduction Treatment of INTERMITTENT CLAUDICATION should include exercise therapy, drug therapy and selective use of revascularization Treatment for CLTI warrants aggressive efforts at revascularization, including surgery, to reduce the risk of amputation

43. REFERENCES Sabiston textbook of SURGERY 21 ST EDITION Schwatrz’s Principles of SURGERY 11 TH EDITION 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease •2017 ESC Clinical Practice Guidelines: Peripheral Arterial Diseases (Diagnosis and Treatment of) Guidelines THE WASHINGTON MANUAL OF SURGERY JOURNAL OF VASCULAR SURGERY 2007