Peripheral arterial Disease (PAD)

introduction, causes, risk factors, symptoms, examination, investigations and management of peripheral arterial disease.
how to assess the patient and what will be the complications of PAD, physiotherapy treatment for PAD

1. PERIPHERAL ARTERIAL DISEASE (PAD) T.SUNIL KUMAR

2. INTRODUCTION PAD is a clinical term that denotes an occlusive disease arising from narrowing of the arteries distal to the arch of the aorta. Peripheral artery disease (also called peripheral arterial disease) is a common circulatory problem in which narrowed arteries reduceS blood flow to THE limbs.

3. Atherosclerosis Obliterans IT IS OCCLUSIVE ARTERIAL DISEASE MOST COMMONLY AFFECTING ABDOMINAL AORTA &ARTERIES OF LOWER LIMS Risk factors – Main factors leading to progressive narrowing of the major arteries of the legs are smoking, hypertension, diabetes mellitus and hyperlipidaemia.

4. Symptoms 1. Intermittent claudication – Severe Cramping Pains Or Discomfort On Walking Which Disappears After Short Rest And Recurs When The Walk Is Resumed. The Symptom Is Due To Inability Of Narrow Arteries To Provide Additional Blood Supply Necessary For The Exercising Muscles.

5. The Position Of Pain Of Claudication Depends On The Level Of Arterial Lesion – (A) Calf Claudication – Usually Due To Obstruction In Femoro -popliteal Segment. (B) Thigh Claudication – Usually Due To Iliac Occlusion With Associated Buttock Claudications . (C) Claudication Of Buttocks, Thighs And Calves With Impotency In Males – Aortic Bifurcation Lesion.

6. 2. Rest pain – is less common and suggests more advanced disease. Pain due to acute arterial occlusion – Severe pain in tissues distal to the site of obstruction aggravated by limb movement. (b) Pain due to ischaemic neuropathy – Severe burning or lancinating type of pain occurring usually in paroxysms and worse at night. (c) Pain of pregangrene – Burning, throbbing type of pain which may make the patient sit up in bed and hold his legs. Pain aggravated by heat.

7. 3. Other symptoms – Numbness and tingling and feeling of coldness in the involved extremity. The occurrence of sepsis in minor abrasions of the feet may be the first evidence of incipient ischaemia in the limb.

8. Examination (a) Inspection – of feet. In presence of rest pain, feet and toes will be cold with purple or bluish discolouration . In more advanced cases ( pregangrene ) atrophic skin, poor colour and sluggish capillary circulation. (b) Palpation – ( i ) Absence of pulses below the femoral pulse (femoral artery is most commonly involved) in affected leg. If buttock or thigh claudication is present, the femoral pulse will be weak or absent indicating aortoiliac disease. At times pulsations are present at rest and disappear on exertion.

9. (ii) Abdomen – to exclude aneurysm of abdominal aorta. (iii) Distal to obstruction limbs are cold to touch. (c) Auscultation – of abdominal aorta, iliac arteries and femoral arteries down to the popliteal fossa may reveal stenosis by presence of a bruit.

10. Investigations 1. Ankle brachial pressure index – Under normal conditions, systolic BP in the legs is slightly greater than that in the upper limb. The ankle brachial pressure index calculated from the ratio of ankle to brachial systolic pressure, is a sensitive index of arterial insufficiency. The highest pressure measured in any ankle artery is used as the numeratory of the index, a value > 1.0 is normal, and a value < 0.9 is abnormal.

11. Measurement with Doppler probe A hand held pencil Doppler probe is placed over a patIent pedal artery and the foot raised against a pole calibrated in mm Hg. The point at which the pedal signal disappears is taken as the ankle pressure. 2. Exercise test – is performed by exercising the patient for 5 minutes say on a tread mill. The ankle brachial pressure index is measured before and after exercise. A pressure drop (due to peripheral vasodilation) of 25% or more indicates significant arterial disease.

12. 3. ECG – for evidence of ischaemia. 4. Angiography – to define extent of disease and possibility of bypass surgery or endarterectomy. 5. Specialist diagnostic and therapeutic devices: (a) Pressure wires with built-in pressure sensor at tip to measure translesional peripheral (and renal artery) gradients to determine hemodynamic importance.

13. (b) Intravascular ultrasound for lesion assessment and for optimization after angioplasty or stenting. (c) Specific atherectomy devices to debulk, slice and remove plaque through long segments of heavily calcified lesions. (d) Excimer laser technology for endovascular ablation for total occlusions.

14. Management Of chronic peripheral ischaemic disease. Medical treatment – Indications: (a) If intermittent claudication is the only symptom and it does not interfere with the patient’s employment. (b) Diabetes mellitus is not associated. (c) Presence of extensive disease contraindicates surgical interference. (d) Failure of surgery to relieve symptoms.

15. 1. Measures to Prevent Progress of the Disease •• Rest if presence of rest pain, wound or gangrene. •• No smoking. •• Reduction of obesity. •• Care of feet – Skin should be protected from trauma, shoes should be comfortable. Avoid tight garters. Trim nails carefully. Avoid sitting with legs crossed. No operative removal of corns. If skin is dry, apply oil at night and dusting powder during day. Control of fungus infection.

16. (a) Antiplatelet therapy – Aspirin 75–300 mg/day, if aspirin sensitivity, dipyridamole (200 mg bd) or clopidogrel (75 mg/day) or prasugrel (10 mg/day) or Ticagrelor 90 mg bd. (b) Cilostazol 100 mg bd one hr. before or two hrs. after breakfast and dinner if exercise alone is ineffective. It should not be used in patients of congestive cardiac failure.

17. (c) Pentoxifylline, xanthine oxidase inhibitor, decreases blood viscosity and anti-proliferative action. (d) Control of lipaemia in atherosclerosis. (e) Adequate control of diabetes. (f) Control of thrombosing tendencies with longterm anticoagULANTS

18. 2. Measures to Increase Circulation (a) Walking – The patient should be instructed to walk slowly up to the point of claudication several times a day. (b) Warm environment – Hot bag to abdomen may cause vasodilation in lower limbs. Blood flow can often be stimulated by placing a thermostatically controlled heating unit over the lower extremities; the temperature within the box should not exceed 90°F. The source of heat is usually in the form of electric light bulbs. Heat must never be applied directly to ischaemic extremities.

19. (c) Active vascular exercise – Buerger’s exercise – Legs are elevated to 60° and kept in that position for 2–3 minutes until blanching occurs. Then dangle legs for 5 minutes till maximal flushing is seen. Then keep legs in horizontal position for 5 minutes. Contraindicated if infection or open wound.

20. (d) Passive vascular exercise – (i) “ Suction pressure treatment” – Alternate high and low pressure is produced in a hermetically sealed boot ( Pavex boot). (ii) Saunder’s oscillating bed for extremely old and debilitated patients in place of postural exercise. (iii) Intermittent venous occlusion – With a sphygmomanometer, the pressure is raised to about 60 mm Hg. For 2 minutes and released for 4 minutes, the process being repeated for half an hour.

21. (e) Other measures – to alter flow properties of blood such as haemodilution , defibrination , plasma exchange and haemorheological drugs.

22. B. Interventional treatment Revascularization - Procedures – (a) Percutaneous re-opening procedures– ( i ) Percutaneous transluminal angioplasty – is widely used for critical stenosis or occlusion. (ii) Local fibrinolytic therapy – as alternative or additional procedure to PTA, particularly if suggestion of recent thrombosis and it can be combined with thrombectomy. Streptokinase 6000 units/ hr directly into the occlusion, with repeat arteriography after 6–12 hours. If significant improvement, treatment may be continued for 12–24 hours, with repeat arteriograms every 12 houRS .

23. C. Reconstructive arterial surgery (limb salvage): –– Indications – (a) Presence of severe claudication interfering with everyday work. (b) Critical leg ischaemia with rest pain or impaired skin and tissue viability and non-healing ulcers. –– Procedure – Bypassing of occluded segment – Reconstructions above groin (aorto-iliac segment) give better results than those below the groin ( femoro -popliteal segment). More distal bypasses to calf arteries only as alternative to major amputation

24. Vasculopathy of specific aetiology - Non-atherosclerotic (VSE-NA) in young patient. PAD may be the first presentation of connective tissue disease (CTD) or thrombophilic state, younger age of onset, fever, wt. loss, multiple limb involvement, anaemia , high ESR, proteinuria and RBCs in urine all point to CTD, upper limb involvement being more common.

25. THROMBOANGIITIS OBLITERANS (BUERGER’S DISEASE) Inflammatory occlusive disorder involving small and medium-sized arteries and veins in distal upper and lower extremities, usually in males in age group 25–40. Heavy cigarette smoking is a predisposing factor. Increased incidence of HLAB 5 and A-9 ANTIGENS.

26. Clinical Features Migratory superficial thrombophlebitis – Red painful areas on dorsum of foot particularly in region of ankle or lower leg and occasionally lower arm; often a vein 2 to 4 inches in length is involved. Slight malaise and little rise of temperature may be present. Lasts for 10 to 12 days and is followed by a brownish pigmentation.

27. Pain – One of the earliest symptoms, varies in intensity from mild to excruciating pain and often appears for the first time after exposure to cold. Intermittent claudication occurs in almost all patients and is confined not only to calves but also occurs in feet. It is cramp-like and often occurs after progressively shorter intervals and lasts longer after cessation of activity.

28. (b)Rest pain may be due to impending trophic disturbances. (C)Involvement of nerves causes sharp, shooting, lancinating pains in the whole extremity. Occasionally pain is relieved by keeping the leg down. Patient sits on edge of bed holding the involved foot, which is crossed over the healthy leg, in his hand.

29. 3. Raynaud’s phenomenon (RP) – Raynaud’s phenomenon refers to reversible spasm of peripheral arterioles in response to cold or stress. RP is usually seen in distal digits but may involve nose, ears and tongue. It is characterised by triphasic response: –– Phase 1: Pallor due to vasoconstriction of precapillary muscular arterioles. –– Phase 2: Cyanosis due to venous pooling and deoxygenation of venous blood. –– Phase 3: Erythema because of hyperaemia . It is associated with throbbing.

30. Raynaud’s phenomenon should be distinguished from Raynaud’s disease which is occurrence of vasospasm primarily with no association with another illness (Primary Raynaud’s). RP is secondary to other conditions, most commonly an autoimmune disease (Secondary Raynaud’s).

31. Clinical Stages 1. Premonitory stage – Often unnoticed by the patient. Characterised by attacks of recurrent phlebitis, swelling of feet, loss of hair on the legs and formation of tender nodules in skin. The stage may last from 2 to 7 years.

32. 2. Stage of claudication – Severe, cramping pains on walking which disappear after short rest and recur when the walk is resumed. 3. Stage of rest pain – Pain comes in paroxysms even at rest, is increased by elevation and relieved temporarily by lowering of the extremity. 4. Stage of trophic changes and gangrene – Pain constant and excruciating, vesicles on great toe followed by ulcers or fissures. Gangrene dry or moist spreading upwards.

33. Investigations Arteriography – Smooth, tapering distal segmental vessels and fine network of collateral vessels. Excision biopsy – of involved vessels confirms diagnosis. Management No specific treatment. Abstinence from tobacco. Arterial by-pass of larger vessels in selected cases and also debridement depending on symptoms and severity of ischaemia. Amputation if other measures fail.

34. RAYNAUD’S SYNDROME AND PHENOMENON It is characterized by sequential development of white, numb ‘dead fingers’ (digital ischaemia), cyanosis, rubor of fingers (and toes) on exposure to cold, and subsequent flushing phase due to rewarming.

35. Classification: of Raynaud’s phenomenon Primary or Idiopathic (Raynaud’s Disease) No underlying cause. Occurs usually in females between 15 to 20 years of age. Family history common. Never progresses to ulceration.

36. Management (1) Warm clothing and avoidance of exposure to cold (2) Drugs – (a) Adrenergic blocking agents. (b) Reserpine reduces pain and promotes ulcer healing. (c) Calcium antagonists Nifedipine or Diltiazem. (d) Prazosin. (3) Surgical sympathectomy – if failure to respond to drugs, but effect transient

37. Persistent digital ischaemia – Ischaemia of a digit or digits may last for days or weeks. Patients are usually middle age or elderly, often hypertensive. The cause is not obvious but may be due to occlusion of the digital artery by atheroma. At times polycythaemia vera or dysproteinaemia is the cause, or, in young subjects, a cervical rib may be responsible. Treatment – Spontaneous recovery is usual but for severe ischaemia reflex heating, analgesics and dextran infusion, and antibiotics for infection. Amputation along line of demarcation if gangrene occurs.

38. Cold injury – Freezing of tissues in hands and feet leading to frost bite can occur following prolonged exposure to cold. There is usually redness, blistering, infection and superficial gangrene of the digits of hands and feet. Treatment – Reflex heating, antibiotics and analgesics and dextran infusion. Deep tissues are usually preserved and skin gangrene separates out leaving a shrunken digit beneath.

39. Acrocyanosis – Reddish or bluish discolouration of hands and feet on exposure to cold occurring mostly in young women. It is thought to be due to arteriolar spasm with dilatation of venules in the skin. It may coexist with Raynaud’s phenomenon.

40. When the hand or foot is warm, the skin becomes bright pink. Acrocyanosis may also be seen in elderly patients with cardiac disease and in neurological disorders such as stroke, poliomyelitis and multiple sclerosis. Treatment – Limbs must be kept warm. Sympathectomy may be necessary in patients with severe coldness and chilblains

41. Livedo reticularis – occurs usually in young women. There is blotchy mottling and discolouration of feet and legs. It is likely to be due to patchy arteriolar vasospasm in the skin. A secondary form may occur in patients with polyarteritis nodosa or polycythaemia vera. It is as a rule localised to digits or feet and the condition may progress to gangrene.

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