Peripheral arterial disease by Dr Denebo Jebeso.pptx

peripheral arterial disease seminar

1. SEMINAR ON PAD Presenter : Dr. Denebo J(R1 ) Moderator: Dr. Belay (MD,Ass’t Prof of IM) Sept. 2023

2. OUTLINE Introduction Epidemiology Risk factor Pathophysiology Clinical features Diagnosis Principles of management prognosis

3. INTRODUCTION ASCVD can be subdivided into four major areas: Coronary heart disease manifesting as myocardial infarction, angina pectoris, congestive heart failure, and sudden cardiac death Cerebrovascular disease manifesting as stroke and transient ischemic attack Peripheral artery disease manifesting as intermittent claudication and critical limb ischemia Aortic atherosclerosis and thoracic or abdominal aortic aneurysm

4. PAD Defined as an abnormal narrowing of  arteries  other than those that supply the heart or brain. The lower extremities are most commonly affected. Most often caused by: atherosclerotic plaque thrombosis embolism, vasculitis, Fibromuscular dysplasia, or entrapment

5. Cont’d… Clinical manifestations depend on the: vessels involved, extent and rate of obstruction, presence of collateral blood flow. Patients with PAD also have limb morbidity: Intermittent claudication chronic critical limb ischemia acute limb ischemia tissue loss.

6. EPIDEMOLOGY The prevalence of PAD based on abnormal ABI values ranges from: approximately 6% in persons 40 years and older 15% to 20% in 65 years and older Affects: 8 to 10 million in the USA more than 200 million people worldwide Men more affected in most studies Blacks more affected than non Hispanic white

7. C ont’d…. P revalence of claudication 1.0% to 4.5% in older than 40 years. Generally indicate that 10% to 30% of patients with PAD have claudication. The incidence of CLI is approximately 22 per 100,000 per year,affecting1% to 2% of patients with PAD

8. Cont’d... prevalence and incidence of ALI among patients with symptomatic PAD 1% to 2% per year. The incidence of amputation ranges from 112 to 250 per million per year.

9. C ont’d… A cross-sectional community based survey was conducted on 178 sampled individuals aged 40 years and above in Jimma town, Southwest Ethiopia from June 15 to July 15, 2011. Has concluded the overall prevalence of peripheral arterial disease was 10.8% .

10. RISK FACTORS DM Dyslipidemia Smoking CKD HTN Inflammation Age and sex

11. PATHOPHYSIOLOGY Segmental lesions that cause stenosis or occlusion are usually localized to large and medium-size vessels. The pathology of the lesions includes: Atherosclerotic plaques with calcium deposition, thinning of the media. patchy destruction of muscle and elastic fibers. fragmentation of the internal elastic lamina, and thrombi composed of platelets and fibrin. The pathobiology of PAD involves inflammation

12. Cont’d… Atherosclerotic lesions occur preferentially at arterial branch points, which are sites of increased turbulence , altered shear stress, and intimal injury Involvement of the distal vasculature is most common in elderly individuals and patients with diabetes mellitus.

13. CLINICAL FEATURES The primary sites of involvement are the: abdominal aorta and iliac arteries (30% of symptomatic patients) femoral and popliteal arteries (80–90% of patients) tibial and peroneal arteries (40–50% of patients ) The location of the symptom is often related to the site of the most proximal stenosis. Buttock, hip, or thigh claudication typically occurs in patients with obstruction of the aorta and iliac arteries.

14. Cont’d… Fewer than 50% of patients with PAD are symptomatic, Intermittent claudication: defined as a pain, ache, cramp, numbness, or a sense of fatigue in the muscles; occurs during exercise and is relieved by rest. Rest pain or a feeling of cold or numbness in the foot and toes who developed critical limb ischemia

15. DDx FOR INTERMITTENT CLAUIDICATION

16. WIFI Threatened limb classification system

17. Hx and P/E Personal and family clinical history should always be assessed. Family history includes: coronary artery disease (CAD), cerebrovascular disease, aortic aneurysm, as well as LEAD. Clinical history includes The evaluation of CV risk factors and co-morbidities Physical activity should be assessed. Questionnaires and functional status provide reasonably accurate outcome measures .

18. P/E Complete CVS exam is mandatory. Beyond their diagnostic importance, clinical signs have a prognostic value . Individuals with carotid bruits have twice the risk of myocardial infarction and CV death as compared with those without. Inter-arm blood pressure (BP) asymmetry (≥15 mmHg) is a marker of vascular disease risk and death. A femoral bruit is an independent marker for ischemic cardiac events.

19. Physical exam for PAD

20. Labx Testing in PAD

21. Diagnostic methods for PADs Resting ABI Physiological testing Anatomical assessment

22. Cont’d… ABI Useful for the diagnosis and surveillance of LEAD A strong marker of generalized atherosclerosis and CV risk An ABI of 0.90 or less is on average associated with a two- to threefold increased risk of total and CV death. An ABI greater than 1.40 represents arterial stiffening (medial arterial calcification ).

23. Screening other vascular beds AAA : The prevalence of AAA among patients with PAD increased with age, beginning in patients ≥55 years of age, and was highest in patients ≥75 There are no data on AAA screening in patients with asymptomatic PAD Carotid artery : Of all strokes, 10–15% follow thromboembolism from a 50–99% internal carotid artery stenosis Carotid artery stenosis refers to a ≥ 50 % stenosis of the extracranial internal carotid artery (ICA ) Renal artery Coronary

24. Aortic A neursysm An aneurysm is defined as a pathologic dilation of a segment of a blood vessel. True aneurysm: involves all vessel wall layers (intima, media, adventitia) Pseudoaneurysm : does not involve all layers; breach in intima/media that allows blood to collect between media and adventitia Aneurysms can rupture, thrombose, embolize , erode, and fistulize

25. Classifcation shape fusiform : concentric; involves full circumference of vessel wall saccular : eccentric; involves only a portion of vessel wall ( higher risk of rupture due to unequal distribution of pressure) location TAA: ascending, transverse arch, descending thoracoabdominal AAA

26. AAA Suprarenal : starts above the renal arteries but does not involve the thoracic aorta Pararenal : starts at the renal arteries but the superior mesenteric artery origin is not aneurysmal juxtarenal : starts immediately distal to renal arteries (there is no normal aorta immediately distal to the origin of the renal arteries); renal artery origin is not aneurysmal infrarenal : 90-98 % starts distal to the renal arteries (there is some normal aorta immediately distal to the origin of the renal arteries)

27. ETIOLOGY

28. Clinical Features 75 % asymptomatic most commonly in the abdominal aorta common presentation: due to acute expansion or rupture syncope pain ( abdominal, flank , back) hypotension palpable pulsatile mass above the umbilicus distal pulses may be intact

29. Investigation B lood work: CBC , electrolytes, urea, creatinine, PTT, INR, blood type, and cross match Abdominal U/S (approaching 100% sensitivity, up to ± 0.6 cm accuracy in size determination) – useful for screening and surveillance CT with contrast (accurate anatomic visualization, size determination, EVAR planning) Peripheral arterial DUS (rule out aneurysms elsewhere, e.g. popliteal)

30. T reatment CONSERVATIVE For asymptomatic aneurysms that do not meet the size threshold for repair Cardiovascular risk factor reduction Watchful waiting , U/S surveillance with frequency depending on size and location SURGICAL Open surgery (laparotomy or retroperitoneal ) EVAR : newer procedure INDICATION R uptured S ymptomatic (tenderness on palpation of the aneurysm) AAA : size >5.5 cm (men) or >5.0 cm (women) Rapid growth greater than 0.5 cm/6 mo or 1 cm/ yr

31. Prognosis The natural history of patients with P AD is influenced by the extent of coexisting coronary artery and cerebrovascular disease . Approximately one-third to one-half of patients with symptomatic P AD have evidence of CAD based on clinical presentation and electrocardiogram Over one-half have significant CAD by coronary angiography . 15–25 % 5-year mortality rate and a two- to fourfold increased risk of death from cardiovascular disease .

32. Cont’d… Mortality rates are highest in those with the most severe P AD. The ABI worsens in almost 40% of patients, and symptoms progress in ∼20–25% when assessed over a period of 5 years. Approximately 11% of patients with symptomatic P AD ultimately develop critical limb ischemia 25–30 % of patients with critical limb ischemia undergo amputation within 1 year . The prognosis is worse in patients who continue to smoke cigarettes or have diabetes mellitus.

33. PRINCIPLE OF MGT Goals Preserve viability (save the leg) Preserve life (avoid complicated procedures in sick patients) Improve function and alleviate symptoms Prevent deterioration and recurrence

34. Cont’d … The therapeutic approach includes two aspects Addressing specific symptoms of any localization and the risk related to a specific lesion. Evaluating for CV event General CV prevention is of the utmost importance and management should be multidisciplinary. best pharmacological therapy non-pharmacological measures such as smoking cessation, healthy diet, weight loss, and regular physical exercise

35. MEDICAL THERAPY Anti platelets Statin Anti hypertensive Anti coagulation smoking cessation Glycemic control

36. Improving quality of life and preserve limb viability Training exercise : The greatest benefit occurs when sessions are at least 30 minutes in duration , And take place at least three times per week for 6 months . foot care : kept clean, moisturing ,well fitting and protective shoe Cilostazol Statin therapy may be beneficial Revascularization

37. Peripheral Artery Revascularization There is no evidence to suggest that early revascularization in selected patients with asymptomatic PAD prevents progression to symptomatic disease Main goals Functional improvement To provide optimal early and late complications Options : Endovascular ( angioplasty,atheroctomy,stenting ) Surgical ( bypass,endarterectomy ) Hybrid

38. Acute limb ischemia Occurs when arterial occlusion results in the sudden cessation of blood flow to an extremity. The severity of ischemia and the viability of the extremity depend on the Location and extent of the occlusion Presence and subsequent development of collateral blood vessels. Principal causes of acute arterial occlusion include Embolism Thrombus in situ Arterial dissection Trauma

39. Cont’d… Among patients with atherosclerosis presenting with ALI in a recent study, approximately 18% required amputation,and 15 % either died or were unable to return home after hospitalization The symptoms and signs is often recalled as the “six Ps”: pain paresthesias pallor pulselessness poikilothermia and paralysis

40. C l inical categories of ALI

41. Dx A diagnosis of acute extremity ischemia can generally be made based upon: The history and physical examination, Assessment of the ankle-brachial index bilaterally Vascular imaging

42. Treatment of ALI Pt should be Anti coagulated with IV heparin Revascularization Amputation Anti pain Long-term anticoagulation is indicated when acute limb ischemia is caused by cardiac thromboembolism. Emboli resulting from infective endocarditis, the presence of prosthetic heart valves, or atrial myxoma often require surgical intervention to remove the cause

43. Revascularization Therapy Catheter-directed thrombolysis Thrombectomy Surgical thromboembolectomy

44. Cont’d… Arterial bypass Procedures are used to restore blood flow when a large proximal vessel is occluded. Intra arterial thrombolytic therapy is most effective when acute arterial occlusion is recent (<2 weeks) and caused by a thrombus Surgical revascularization is preferred when restoration of blood flow must occur within 24 h to prevent limb loss or when symptoms of occlusion have been present for >2 weeks.

45. REFRENCES Harrison 21th edition Braunwald heart disease 12th edition Uptodate 2023 online 2016,AHA PAD Guideline 2017, ESC PAD Guideline Tronto note 2022

46. THANK YOU