Pbs peripheral vascular dieases in humans

What is peripheral vascular disease?

Peripheral vascular disease (PVD) is a slow and progressive disorder of the blood vessels. Narrowing, blockage, or spasms in a blood vessel can cause PVD.

PVD may affect any blood vessel outside of the heart. This includes the arteries, veins, or lymphatic vessels. Organs supplied by these vessels, such as the brain or legs, may not get enough blood flow for healthy function. The legs and feet are most often affected.

Peripheral vascular disease is also called peripheral arterial disease (PAD).

What causes peripheral vascular disease?

The most common cause of PVD is atherosclerosis. This is the buildup of plaque inside the artery wall. Plaque reduces the amount of blood flow to the limbs. It decreases

1. Peripheral Arterial
Disease

2. Peripheral arterial
disease (PAD)
•Disorders that change natural flow of blood
through the arteries of the peripheral
circulation
–Affects legs >> arm
•Typically appears in patients ages >50
•Normal structure and function of aorta and its
visceral branches are altered.

3. Types of PAD
1.Occlusive peripheral arterial disease
2.Peripheral aneurysms
3.Arterio-venous fistula
4.Arteritis and vasospastic conditions

6. Case history 1
•72 years old male, ex-laborer,
•P/C bilateral calf pain for two months
•Pain –cramping, reproducible upon
walking 300m and relieved with rest
•He is a smoker with 30 pack years
•Hypertension for 2 years

7. Discussion
1.What are your differential diagnosis?
2.Elaborate your diagnosis with history and
examination?
3.What investigations will you perform?
4.How would you manage this patient?

8. Occlusive peripheral
arterial disease

9. Occlusive peripheral
arterial disease
1. Chronic limb ischaemia
Progressive disease-can be managed conservatively, with or without surgical
intervention.
Gradual occlusion
–Collateral circulation may develop
–Tissue adapts gradually to ↓ blood flow
–Less risk of sudden tissue death
Features –intermittent claudication, rest pain, ulceration
2. Acute limb ischemia
An emergency that requires assessment and surgical treatment. Sudden arterial
occlusion.
Features-pain, pallor, paresthesia, paralysis, pulselessness
–Profound & irreversible sudden tissue death

10. Physiologic Effects
•If diminished blood flow to tissues
–Tissue integrity is challenged if demands
exceed supply of oxygen & nutrients
–Ischemia & eventual death of tissue if
inadequate blood flow

11. Chronic limb ischemia
History
1.Progression and severity
2.DDx
3.Site
4.Aetiology
5.PAD complications
6.Systemic illnesses affecting PAD
7.Fitness for sx
8.Psychosocial impact

12. Progression and severity
•Gradual onset by a progressive pathology
•Fontaine classification

13. Intermittent claudication
•Classic symptom of PAD
–Ischemic muscle pain, cramping,
precipitated by a constant level of exercise
–Resolves within 10 minutes or less with
rest
–Reproducible
–Increases when walking uphill, walking in
high speeds, heavy labor

14. Rest pain
•When arterial insufficiency is severe
–Burning pain in forefoot at rest
–Elevating leg increases pain, dependent
position relieves pain
–Often occurs at night
–Even the tough of clothes worsens it

15. Ulcers and gangrene
•Atrophy of the skin and underlying muscles
Delayed healing Wound infection Tissue
necrosis Arterial ulcers
•Non-healing arterial ulcers and gangrene are the
most serious complications
•May result in amputation

18. DDx
•Intermittent claudication
•Venous claudication
•Neurogenic claudication
•Musculoskeletal pain

19. Site

20. Aetiology
•Obstructions from atherosclerotic plaque or thrombus
•Risk factors for atherosclerosis -
❖Non-modifiable –elderly male, family history
❖Modifiable –DM, HTN, DL, obesity, sedentary life style /
smoking
•Vasculitis –Buerger’s disease
•Occlusive disease of small to medium sized arteries, occurs in
young male smokers. Shows inflammatory changes in walls of the
arteries and veins
•Trauma

21. Complications of
atherosclerosis affecting
other organ systems
•TIA / stroke
•IHD
•Mesenteric angina
•Impotence
•Renal artery stenosis hypertension

22. Systemic illnesses affecting
oxygen delivery to limbs
•Anemia
•COPD
•HF
•Vasoconstrictors

23. Assessing fitness for
surgery

25. Psychosocial impact of
chronic limb ischemia
•Daily activities
•Effect on occupation
•Dependency
•Carer burden
•Psychological –depression, suicidality

26. Examining a patient with
chronic limb ischemia
•Features of ischemia
•Assessing the extent of the disease
•Features suggestive of
atherosclerosis/vasculitis/trauma
•Other manifestations of atherosclerosis
•Systemic diseases complicating PAD

27. Case history 1
•72 years old male, ex-laborer,
•P/C bilateral calf pain for two months
•Pain –cramping, reproducible upon walking 300m and relieved with rest
•Systemic inquiry is unremarkable
•He is a smoker with 30 pack years
•Hypertension for 2 years
•Diagnosis –peripheral arterial disease affecting femoral
artery, Fontaine class IIa, possibly due to
atherosclerosis, with no other apparent systemic
manifestations

28. Are we having fun yet?

29. Investigating chronic limb
ischemia
•Confirming ischemia -ABPI
•Assessing distribution –gold standard is DSA, CTA, arterial duplex,
MRA
•Assessing severity –ABPI, arterial duplex
•Investigating the cause –lipid profile, FBS, blood pressure series
•Systemic complications of PAD –ECG, carotid duplex, serum
creatinine, ECHO
•Systemic illnesses affecting oxygen delivery –CXR, FBC

30. ABPI
•ABI (ankle-brachial index) –ratio of ankle
systolic blood pressure to the arm systolic
blood pressure

31. DSA
•Gold standard
•Injection of a radio-opaque dye into the
arterial tree
•Seldinger technique used
•Percutaneous access to CFA
•Advantages and potential complications

33. CTA
•Minimally invasive alternative to DSA
•Beneficial where DSA is not possible or
produces poor images
•The major concern is exposure to ionizing
radiation and use of iodinated contrast

35. Arterial duplex
•Non-invasive technique
•Using ultrasound
•To visualize blood flow, velocity of flow,
changes of direction and areas of high/low
flow

37. MRA
•Having advantages over DSA and CTA

38. Management
depends on disease severity
Fontaine grade I and II –conservative management
OR
Fontaine II, IV and disabling claudication –imaging followed by
revascularization
•Revascularization types –bypass surgery, endovascular balloon
angioplasty with stenting
+
Managing PAD complications
Managing systemic illnesses
Septic wet gangrene –septic protocol, source control +/-amputation
Dry gangrene +/-amputation

39. Goals of conservative
management
•Modify the modifiable risk factors
•Supervised walking exercise therapy to increase the
claudication distance
•Pain management
•Foot care
•Controlling cardiac risk factors -optimum blood
glucose and lipid levels
•Cilostazol, Pentoxyphylline ?

40. Foot care guidelines -Same
as diabetic foot care
•Prevent foot injury
and blisters
•Treat any injury or
blister immediately
•Use neutral soaps
& body lotions-
prevent skin drying
•Pat skin dry –avoid
vigorous rubbing
•Stockings or socks -
clean and dry
•Soak fingernails and
toenails before
trimming
•Trim nails straight
across –may need
podiatrist
•Don’t cut corns and
calluses

41. Endovascular
interventions
Angioplasty
•Widens area & flattens plaque against wall of artery
Stents
-prevent re-collapse & re-occlusion
•Complications from procedure
–Hematoma, bleeding
–Distal embolization, intimal damage artery

43. Stents
Small metal mesh tubes

44. Surgical interventions
•Bypass surgery
•Femoral/popliteal
•Aorto femoral
•Femoro femoral
•Axillary bifemoral
•Aorto bifemoral

47. Case history 1
•72 years old male, ex-laborer,
•P/C bilateral calf pain for two months
•Pain –cramping, reproducible upon
walking 300m and relieved with rest
•He is a smoker with 30 pack years
•Hypertension for 2 years

48. Discussion
•1. what are your differential diagnosis?
•2. elaborate your diagnosis with history
and examination?
•3. what investigations will you perform?
•4. how would you manage this patient?

49. I am PRR-fectly ready for
whatever comes next

50. Case history 2
•72 years old male, ex-laborer,
•P/C bilateral rest pain forefoot for two weeks
•Pain –burning type, worsening at night when sleeping, reduced
when legs hanging down
•Systemic inquiry is unremarkable
•He is a smoker with 30 pack years
•Hypertension for 2 years

51. DDx
•Acute limb ischemia
•Cellulitis
•Compartment syndrome
•DVT

52. Discussion
•5. how would your management differ in
case 2, compared to case 1?

53. Acute arterial occlusion
•Embolic occlusion
–Arm and leg
–Brain –TIA / stroke
–Retina –amaurosis fugax
–Mesentery –mesenteric ischemia, gangrene,
perforation
•Trauma

54. Acute limb ischemia
Causes :
Arterial embolism –thrombi,
air, septic, fat
Trauma
Thrombosis of popliteal artery
Popliteal artery entrapment

55. •ALI is an emergency that requires
emergency surgical treatment
•Ischemia beyond six hours usually
irreversible and results in limb loss

56. •Bed side assessment should be aimed
•Confirming the Dx
•Assessing the severity of limb ischemia
•Identifying the cause (embolic cause)

57. clinical features
●no history of prior claudication●severe pain and numbness●skin -cold, pale, mottled. blanching →
non-blanching●paresthesia ●paralysis●rhabdomyolysis

58. clinical features
●pulses absent●palpable,thrusting femoral pulses
a similar picture will occur in the arm with
brachial embolus.

59. Clinical features -ALI
•Rutherford’s classification

60. Investigations
•To identify the cause
•ECG, 2DECHO
•To assess complications
•Creatine kinase, Serum creatinine
•Prior to intervention
–DUS or CTA

61. Management
•Intravenous heparin to prevent the
extension of the thrombus, until the
embolus is treated
•Pain relief
•Embolectomy and/or thrombolysis
•If the limb cannot be salvaged
amputation

62. Embolectomy
•Artery is exposed and the clot is removed.
•Post op long term anticoagulation with
warfarin

63. Thrombolysis
•Intra arterial thrombolysis done if ischemia
is not so severe
•Contraindications –recent stroke,
pregnancy, bleeding diathesis, over 80
years

64. Aneurysmal disorders
•Aortic
•Iliac
•Femoral
•popliteal

65. Abdominal aortic
aneurysms
•Can be symptomatic or asymptomatic
•Symptomatic –abdominal discomfort followed by
sudden severe back and abdominal pain
Risk of rupture increased with size
Choice of operation –open surgical repair or
endovascular aneurysmal repair
Ruptured aortic aneurysm surgical emergency,
triad of severe abdominal/back pain, hypotension
and pulsatile abdominal mass.

66. Peripheral aneurysms
•Popliteal –
•accounts for 70% of all peripheral aneurysms.
•Swelling behind the knee or severe ischemia
following embolization
•Confirmed with DUS
•Very rarely rupture
•Femoral
•Uncommon
•Conservative treatment
•Iliac
•Occurs with conjunction with aortic aneurysm

67. Arterio-venous fistula•Communication between an artery and
vein due to either congenital
malformations or trauma.•For haemodialysis purposes we create AV
fistula surgically.
•Examination -Pulsatile swelling (if
superficial) / thrill on palpation / machinery
murmur
•Investigations –duplex scan and/or
angiography

68. Management
•Embolization
•Excision surgery

69. Arteritis and vasospastic
conditions
•Thromboangiitisobliterans (Buerger’s
disease)
occlusive disease of small and medium
sized arteries.
Occurs mainly in young Male smoker
Histologically, inflammatory changes in
walls of vessels, leading to thrombosis.
Treatment: Total abstinence from smoking
For established occlusion -treated as
atheromatous disease

70. •Raynaud’s disease
Idiopathic condition usually occurs in young
women and affects the hands more than
feet.
There is abnormal sensitivity in the arteriole
response to cold –vessels constrict and
digits turn white and became incapable for
fine movements
Then became dusky (bluish) , finally became
red.

71. Treatment: protection from cold and avoid nail
bed and pulp infections.
electrically heated gloves

72. •Raynaud’s syndrome
Similar features of Raynaud's disease but
more aggressive than that.
Here there will be underlying causes -CTD
Treatment: conservative measures outlined
above
collagen disease frequently
leads to necrosis of digits –vasospastic
antagonists useful ( Nifedipine)

74. Amputation
•Indications
can divide into 3 categories 1.Dead –dry gangrene 2.Deadly –wet gangrene, crush injury,
osteosarcoma3.Dead loss –Retaining limb is worse than
having it : severe pain, gross
malformation

76. Principles of amputation
3 main principles1.Selecting appropriate level2.Amputation level must take into account
the fitting of prosthetic limb.3.Asses joints ( contracture or arthritis
may influence the level)

77. •Types of amputation levels
1. Major : • Below knee amputation
• Above knee amputation
• Gritti stokes amputation-involving
knee
• Ankle amputation
• Forefoot amputation
2. Minor : simple amputations the base of digit
, useful in diabetes and severe Raynaud's.

79. Post operative care of an
amputee
•Pain relief: morphine , epidural
•Prevent pressure ulcers
•Physiotherapy –prevent flexion deformity,
build-up muscle power
•Early mobilization
•Prosthesis
•Home environment alteration

80. Complications of
amputation
•Early
–Hemorrhage, hematoma, infection, DVT
•Late
–Phantom limb, phantom pain, ulceration of
stump, bone spur, neuroma