PERIPHERAL ARTERIAL DISEASE and its presentation.pptx

Signs and symptoms in pvd

1. PERIPHERAL ARTERIAL DISEASE Presenter : Dr. PAVAN KUMAR 2 ND YEAR PG Moderator : Dr. RAJASHEKARA BABU PROFESSOR & HOD DEPARTMENT OF GENERAL SURGERY

2. INTRODUCTION AND DEFINITION EPDEMIOLOGY AND RISK FACTORS CLINICAL PRESENTATION SYMPTOMS INVESTIGATIONS MANAGEMENT

3. INTRODUCTION Peripheral Arterial Disease (PAD) is a chronic condition characterized by narrowing or blockage of the arteries outside the heart, most commonly affecting the lower limbs causing ischemia to lower limbs. It is primarily caused by atherosclerosis , where fatty deposits (plaques) build up in the arterial walls, leading to reduced blood flow

4. Atherosclerosis is a systemic disease of the large and medium-sized arteries causing luminal narrowing (focal or diffuse) due to the accumulation of lipid and fibrous material affecting the intimal and medial layers of the vessel. Atherosclerosis of the arteries of the lower extremities is defined as peripheral artery disease (PAD). Other uncommon arteriopathies and vasculities that may produce peripheral ischemia are non-atherosclerotic conditions include giant cell arteritis, Takayasu arteritis, polyarteritis nodosa, Wegener granulomatosis, thrombo-angiitis obliterans (Buerger disease), Behcet disease, emboli

5. EPIDEMIOLOGY AND RISK FACTORS Risk factors for PAD are similar to those that promote the development of coronary atherosclerosis.  Age > 50 years Common in male > females DM, HTN Hypercholesterolaemia and hyperlipidemia Cigarette smoking Sedentary lifestyle, obesity Family history

6. PRESENTATION PAD is slow progressing disease, hence it takes time to present clinically while it already developing inside a person D istribution of clinical presentation of PAD in patients ≥50 years of age ● Asymptomatic – 20 to 50% ● Atypical leg pain or intermittent claudication – 40 to 50% ● Classic claudication – 10 to 35% ● Threatened limb – 1 to 2%

7. Classification ischemic limb

8. CLINICAL FEATURES Specific questions to evaluate PAD include : Does the patient have any pain with ambulation? If so, how far can the patient walk before the pain occurs? Does the pain cause the patient to stop walking? If so, after how much time is the patient able to resume walking? Does the pain recur after a similar walking distance? Has the patient's ability to walk diminished over time or altered the patient's lifestyle in any way? Does the patient experience any pain in the extremity that wakens them from sleep? If so, where is the pain located? Is the pain relieved once the foot is hung over the side of the bed? Does pain cause the patient to sleep sitting in a chair? Has the patient noticed any nonhealing wounds or ulcers on the toes? If so, how long have the wounds or ulcers been present? If wounds have occurred in the past, what measures were used to promote healing?

9. SYMPTOMS Claudication pain Claudio means “I limp” in latin . It is a crampy pain in the muscles of limb. Due to arterial occlusion, metabolites like lactic acid and substance P accumulate in muscles and causes pain The pain depends on site of arterial occlusion Most common site is calf muscles Pain in foot – block in lower tibial and plantar vessels Pain in calf – block in femoropopliteal segment Pain in thigh – block in superficial femoral artery Pian in buttock – block in common iliac or aortoiliac segment often when associated with impotence is called as Leriche’s syndrome

10. Ischemic rest pain It is continuous aching in calf or feet and toes or in any region even at rest depending on site of obstruction Rest pain signifies severe decompensated ischemia, and pain aggravates in lying down and elevating foot , it may often be reduced on hanging the foot down Rest pain is worse at night and so patient is sleepless at night. During sleep heart rate and blood pressure diminishes which further aggravates the hypoperfused limb.

11. Some present with non healing ulcers/wounds, skin discoloration and gangrene of limb Critical limb ischemia It is persistently recurring ischemic rest pain for 2 weeks, which requires regular analgesics for >2 weeks or ulceration/ gangrene of foot/toes

12. Arterial ulcer over plantar aspect of foot Venous ulcer over gaiter’s area

13. INVESTIGATIONS Proper history, evaluation of risk factors, physical examination for pulses itself corelates for diagnosis of PAD For patients with atypical symptoms or an equivocal pulse examination, the ankle-brachial index (with or without exercise) is diagnostic for arterial obstruction if ≤0.9 ABPI – ankle brachial pressure index Maximum systolic BP at ankle Maximum systolic BP at brachial artery

14. ABPI 0.9-1.3 – normal <0.9 – intermittent claudication <0.5 – rest pain <0.3 – critical limb ischemia/imminent necrosis Doppler Ultrasound – Assesses arterial flow and stenosis. Treadmill Test – Evaluates exercise tolerance and claudication distance.

15. Imaging CT Angiography (CTA) – Non-invasive, detailed arterial mapping. MR Angiography (MRA) – Preferred in renal dysfunction (avoids contrast nephropathy). Digital Subtraction Angiography (DSA) – Gold standard for intervention planning.

16. MANAGEMENT Based on clinial presentations Lifestyle modifictaions like diet control, exercises, control of risk factors like DM,HTN PAD is associated with high cardiovascular morbidity and mortality, Antithrombotic therapy is strongly recommended to reduce major adverse cardiac events(MACE’s) like low dose aspirin Antiplatelets agents such as clopidogrel or ticlopidine Lipid lowering therapy – rosuvastatin(20-40 mg/day), simvastatin(40-80 mg/day)

17. Control of HTN – target SBP<140 and DBP<90 Control of DM – target HbA1c <7 Cilostazol – Phosphodiesterase-3 inhibitor, improves walking distance. Pentoxifylline – Improves microcirculation (less commonly used)

18. Surgical management for chronic limb threating ischemia(CLTI)/ critical limb ischemia, includes initial assessment of degree of damage done using Limb staging with WIfI (wound, ischemia, foot infection) The global vascular guideline has defined guidelines for revascularization and predict the outcome. Introduced 3 new concepts Patient, limb, anatomy (PLAN) Target artery path(TAP) Global limb anatomic staging system(GLASS)

19. GLASS STAGES I,II,III corelates to low,intermediate , high

20. ENDOVASCULAR THERAPY AND OPEN SURGICAL THERAPY EVT has exploded due to rapid evolution of devices and techniques over the two decades Endovascular Procedures generally preferred in short-segment stenosis includes Percutaneous Transluminal Angioplasty (PTA) Stenting (Balloon-expandable or self-expanding) Recent advacements in EVT includes drug eluting stents which release Sirolimus or Paclitaxel to prevent restenosis

21. Surgical Management (For long-segment or critical limb ischemia) Bypass Surgery ( Femoro -popliteal, aorto-femoral, or tibial bypass using autologous veins or synthetic grafts) Endarterectomy (Plaque removal, used in carotid or femoral arteries) Amputation (Last resort in non-viable limbs with gangrene)

22. Autologous vein conduits include ipsilateral and contralateral great saphenous vein(GSV), short saphenous vein(SSV), femoral vein, endarterectomized superficial femoral artery, radial artery. Prosthetic conduits include Dacron, heparin bonded dacron , polytetrafluoroethylene(PTFE) with/without heparin bonded.

23. Endarterectomy Procedure: Direct removal of atherosclerotic plaque from the arterial lumen. Indications: Common femoral artery disease (where stents are less effective). Carotid artery stenosis (Carotid Endarterectomy - CEA). Limitation: Not suitable for diffuse disease or small vessels.

24. THANK YOU