Clinical examination peripheral vascular disease

1. CLINICAL EXAMINATION OF PERIPHERAL VASCULAR DISEASES

2. What is PVD? Definition: Also known as PAD or PAOD. Occlusive disease of the arteries of the extremity. charac . by a reduction in blood flow and hence 0 2 through the peripheral vessels when the need of the tissues for 0 2 exceeds the supply, areas of ischemia and necrosis will develop

3. Pathophysiology : Arterial narrowing  Decreased blood flow = Pain Pain results from an imbalance between supply and demand of blood flow that fails to satisfy ongoing metabolic requirements.

4. Factors that can contribute to the development of peripheral vascular disorders :   atherosclerotic changes thrombus formation embolization  coagulability of blood hypertension inflammatory process/infection

5. CAUSES OF ISCHEAMIA LARGE ARTERY OCCLUSION - Atherosclerosis -Embolism. SMALL ARTERY OCCLUSION - Buerger`s disease - Raynaud`s disease -embolism -scleroderma -physical agents – Trauma,radiation,electric burns,pressure necrosis

6. ATHEROSCLEROSIS AGE - above 50yrs Vessels involved – medium sized & large vessels aorta,femoral,carotids . Nature of vessel- Thickned Pathology – Deposition of atheromatous plaque in the intima . Risk factors – smoking, diabetes,hypertensive , obesity,hypercholesterolaemia .

7. TAO (BUERGER`S DISEASE) Age -20-40 yrs Sex – Exclusively males Vessel involved –Small & medium sized arteries. Nature of vessel – Not thickned . Pathology – Diffusion inflammatory reaction involving all coats of vessels results obliterans . Risk factors – Smoking, hypercoagulable , autonomic hyperactivity, low socioeconomic .

8. RAYNAUD`S DISEASE (PRIMARY RAYNAUD`S PHENOMENON) -Occur in young females. -Upper limbs more involved than lower limbs. Its episodic digital ischeamia on exposure to cold Peripheral pulses are normal. Recurrent attacks.

9. Atherosclerosis

10. Thromboangitis Obliterans

11. CLINICAL EXAMINATION HISTORY 1. AGE & SEX Atherosclerosis – Older AGE M~ F BURGER`S Disease - Mostly men age 20-40yrs RAYNAUD`S DISEASE – Young women Diabetic arteriopathy - middle age

12. 2. LIMBS AFFECTED Lower limbs – B uergers`s disease - A therosclerotic -gangrene Upper limbs- Raynaud`s disease Superficial gangrene of fingers - Raynauds disease - cervical rib - scalenus anticus syndrome

13. 3.BILATERAL & UNILATERAL BILATERAL –BURGER`S - Raynaud`s disease. Atherosclerotic – intially UL later B/L. UNILATRAL – Embolus. Diabetic gangrenous – U/L or B/L.

14. 4. MODE OF ONSET Spontaneously & gradually -Atherosclerosis gangrene - Raynaud`s disease - Buerger`s disease Suddenly - embolic gangrene Traumatic & infection - Diabetic

15. 5.PAIN - site - charcter -radiation TYPES -Intermittent claudication . claudication distance Grades I,II,II ( boyd`s classification) - Rest pain

16. 5.EFFECTS OF HEAT & COLD Raynaud`s phenomenon Raynaud`s disease -local syncope - local asphyxia - local recovery ----- local gangrene

17. 6. PARAESTHESIA - Numbness. - pins and needles sensation. 7.HISTORY OF SUPERFICAIL PHLEBITIS: 8.INVOLVMENT OF OTHER ARTERIES - Transient attack, fainting .(stroke) - chest pain (coronary arteries) - abdominal pain ( mesentric arteries) - blurred vision (retinal areteries )

18. HISTORY IMPOTENCE B/L internal iliac artey occlusion. PAST HISTORY cardiac attacks, embolic, frost bite. PERSONAL HISTORY\: Smoking. FAMILY HISTORY:

19. PHYSICAL EXAMINATION LOCAL EXAMINATION 1.INSPECTION Change in colour Pallor – sudden occlusion of arteries - spasm of arteries in raynaud`s . Congestion& cyanosed -severe ischemia & pre gangrenous stage

20. 2.SIGNS OF ISCHEMIA 1.Thinning of skin 2.Diminished growth of hair, 3.Loss of subcutaneous fat, 4.Trophic changes in nails 5.Muscle wasting 6.Minor ulceration over pressure area

21. 3.BUERGER`S POSTURAL TEST: B auerger angle (vascular angle) -normal indiviual legs will be pink raised above 90degree -severe ischemia buerger angle less than 30 degree 4.CAPILLARY FILLING TIME -severe ischaemic it take 20-30 sec. 5.VENOUS FILLING TIME - Noramal 5 sec. -In ischaemic limb veins collapsed.

22. IN GANGRENE - Extent & color of gangrene. -TYPE dry (mummified) . wet (putrefying). -LINE OF DEMARCATION. - SKIP LESIONS

23. PALPATION 1. Skin temperature . 2.capillary filling time . 3.venous filling time. 4.crossed leg test ( fuchsig test): oscillatory movements obsent popliteal block . 5.Cold and warm water test.

24. TEST FOR UPPER LIMBS: - Elevated arm test. -Allen`s test. - Costoclavicular compressive manoeurve . - Hyperabduction manoeurve - GANGREANGENOUS AREA. -CREPITUS. -LIMB ABOVE GANGRENOUS AREA.

25. PALPATION OF BLOOD VESSELS. LOWE LIMBS - Dorsalis pedis -posterior tibial -anterior tibial - popliteal -femoral UPPER LIMB -radial & ulnar -brachial subclavian common carotid. Superficaial temporal .

26. Examination of arterial wall - P Iulse -condition of wall - thrombosis of vessel. CERVICAL RIB - Adson`s test. NEUROLOGICAL EXAMINATION: AUSCULTATION systolic bruit. In occlusion -Blood pressure of both arms. -Ankle brachial pressure index. -Heart for murmur etc.

27. Differential diagnosis of limb pain Arteritis Ischemic intermittent claudication Nerve root pain, sciatica, neurogenic pseudoclaudication (spinal stenosis ) Peripheral nerve pain ( eg , diabetic neuropathy) Phlebitic syndrome after deep venous thrombosis Thromboangiitis obliterans ( Buerger disease) Venous claudication

28. INVESTIGATION: complte blood picture. blood sugar. blood lipid profile. -Doppler ultrasound blood flow detector. -Duplex scan. - Plethysmography . - Angiography

29. 1.Modification factors Smoking Cessation Rigorous BSL con BP reduction Lipid Lowering Therapy 2 EXERCISE: Claudication exercise rehabilitation program 45-60mins 3x weekly for 12 weeks 6 months later +6.5mins walking time (before pain)

30. 3.MEDICAL MANAGEMENT : Antiplatelet therapy e.g. Aspirin/ Clopidogrel Phosphodiesterase Inhibitor e.g. Cilostazol Foot Care

31. PCI / SURGERY Indications/Considerations: Poor response to exercise rehabilitation + pharmacologic therapy. Significantly disabled by claudication , poor QOL The patient is able to benefit from an improvement in claudication The individual’s anticipated natural hx and prognosis Morphology of the lesion (low risk + high probabilty of operation success) PCI: Angioplasty and Stenting Should be offered first to patients with significant comorbidities who are not expected to live more than 1-2 years

32. Bypass Surgery: Reverse the saphenous vein for femoro-popliteal bypass Synthetic prosthesis for aorto -iliac or ilio -femoral bypass Others = iliac endarterectomy & thrombolysis Current Cochrane review = not enough evidence for Bypass>PCI Amputation: Last Resort

33. ACUTE ARTERIAL DISEASE sudden occlusion of major peripheral artery. due to: -Arterial embolus -Trauma -Acute arterial thrombosis

34. FEATURES OF ACUTE LIMB ISCHEAMIA PAIN PALLOR PULSELESNESS PERISHING COLD (POIKILOTHERMIA) PARASTHESIAS PARALYSIS

35. INVESTIGATION -Angiography TREATMENT - THRMOBOLYSIS SURGICAL - embolectomy

36. GANGRENE Gangrene implies death of macroscopic portions of tissue; the term necrosis may be used synonymously. It often affects the distal part of a limb because of arterial obstruction (from thrombosis, embolus or arteritis ).

37. TYPES - Dry gangrene Wet gangrene. Signs of gangrene . 1.change of colour pale,bluish purple and finally black. 2. loss of temperture . 3.loss of sensation. 4.loss of pulsation. 5.loss of function.

38. DRY GANGRENE

39. Wet gangrene

40. Causes of ischaemia -Large vessel occlusion. Small vessel occlusion. CAUSES OF GANGRENE . cardiovascular -traumatic . -Infective. -Diabetic -Nervous diseases -Physical gangrene . Frost bite

41. TREATMENT - amputation.

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