Peripheral Arterial Disease (seminar).pptx

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1. Presented by Cadets: Min Myat Maung Aung Kyaw Moe Aung Khaing Moe Aung Htoo Set Aung Bhone Myint Myat Aung Myin Htun Peripheral Arterial Disease (PAD)

2. Contents Blood supply of upper & lower limbs Peripheral Arterial Disease Investigation Management

3. Arteries of upper limb

4. Arteries of upper limb Right subclavian artery begins from brachiocephalic trunk (innominate artery). Left subclavian artery arises directly from arch of aorta.

5. Subclavian artery → Axillary artery → Brachial Artery Arteries of upper limb

6. Subclavian artery → Axillary artery → Brachial Artery Superficial palmar arch Deep palmar arch

7. Arteries of lower limb

8. Arteries of lower limb Abdominal aorta bifurcates into 2 common iliac arteries (LV 4). Common iliac artery External Internal Femoral Artery Pelvic organs

9. Arteries of lower limb Femoral Artery Superficial Deep (Profunda femoris artery) Collateral circulation around the knee joint Popliteal artery

10. Femoral Artery popliteal Anterior Tibial Posterior Tibial Medial + Lateral Planter Arteries Planter arterial arch

11. Femoral Artery popliteal Anterior Tibial Posterior Tibial Medial + Lateral Planter Arteries Planter arterial arch Dorsalis pedis Dorsal arterial arch

12. Arterial Diseases Stenosis due to trauma, atherosclerosis, emboli. In brain → TIA, stroke In limb → claudication and rest pain In abdomen → pain, bloody stool In kidneys → haematuria Aneurysm Arteritis Vessel abnormalities

13. Arterial stenosis & occlusion Caused by atherosclerosis, thromboembolism, result of trauma Produces symptoms and signs related to organ supplied by the artery Severity of symptoms is related to site of vessels occluded Stenosis or occlusion occur suddenly (acute) in previous normal artery Gradually (chronic) with progressive narrowing of artery over time In chronic, collateral circulation may develop.

14. Risk factors Smoking Diabetes Mellitus Hypertension Dyslipidaemia Obesity (BMI > 30) Previous History

15. Features of chronic arterial stenosis or occlusion in the leg Intermittent claudication Claudication distance Rest pain Ulceration and gangrene Colour, temperature, sensation and movement

16. Intermittent Claudication Result of anaerobic muscle metabolism Cramp-like pain in affected muscle Brought on by walking Not present on taking the first step Relieved by rest both in standing and sitting positions (usually within 5 minutes)

17. Claudication distance The distance that a person is able to walk without stopping varies only slightly from day to day. It is decreased by increasing the work demand & oxygen requirement of the muscle affected

18. Rest pain Increase disease progression>> decrease claudication distance Perfusion to leg may be severely compromised Anaerobic respiration occurs even at rest Exacerbated by lying down or elevation of the foot Due to gravitational effects on perfusion pressure in the foot Pain is worse at night Lessened by hanging the foot out of bed or by sleeping in the chair Pressure of the clothes may make pain worse

19. Ulceration & Gangrene Ulceration occurs with severe arterial insufficiency May present as painful erosion between toes Non healing ulcer on dorsum of the feet, shins and around the malleoli Superadded infection of gangrene make wet gangrene

20. Gangrene Refers to death of macroscopic portions of tissue which turn black because of the breakdown of haemoglobin and the formation of iron sulphide Usually affects the most distal part of a limb because of arterial obstruction(from thrombosis ,embolus or arteritis) There are two types of gangrene; Dry gangrene : occurs when the tissues are desiccated by gradual slowing of the bloodstream (atheromatous occlusion of arteries) Wet gangrene : occurs when superadded infection and putrefaction are present Crepitus may be palpated by gas forming organisms in Diabetic foot problems Should be considered surgical emergency with urgent tissue debridement or amputation required

21. Colour, temperature, sensation and movement In acute ischaemic, foot is cold, white, paralysed and insensate In chronic, ischaemic limbs tend to equilibrate with the surrounding temperature Chronic ischaemia does not produce paralysis & sensation is intact

22. Muscle group affected by claudication is classically one anatomical level below the level of arterial disease Relationship of clinical findings to site of disease Aortoiliac obstruction Claudication in both buttocks, thighs, and claves Femoral and distal pulses absent in both limbs. Bruit over the aortoiliac region Impotence ( Leriche ) Iliac obstruction Unilateral claudication in the thigh and calf and sometimes the buttock Bruit over the iliac region Unilateral absence of femoral and distal pulses Femoropopliteal obstruction Unilateral claudication in the calf Femoral pulse palpable with absent unilateral distal pulses Distal obstruction Femoral and popliteal pulses palpable Ankle pulses absent Claudication in calf and foot

23. Other sides of atheromatous occlusive diseases Carotid stenosis – TIA Subclavian artery stenosis – claudication in arm Mesenteric artery occlusive disease Renal artery stenosis

24. Physical Examination Inspection Patient position – lying comfortable, hanging down the foot Colour changes Red – vasodilation of microcirculation due to ischaemia White – advanced ischaemia Blue – excess deoxygenated blood Black - gnagrene

25. Trophic changes Loss of hair Shining of skin Lost of digits Ulceration gangrene

26. Buerger’s angle Lift the leg until it becomes white The angle between the horizontal and leg is Buerger’s angle Less than 20 degree indicates severe ischaemia Drop the leg over the side of bed leads to purple or red colour due to reactive hyperaemia

27. Buerger’s angle Lift the leg until it becomes white The angle between the horizontal and leg is Buerger’s angle Less than 20 degree indicates severe ischaemia Drop the leg over the side of bed leads to purple or red colour due to reactive hyperaemia

28. Palpation Temperature Capillary refill time Pulses – femoral artery, popliteal artery, anterior tibial artery, posterior tibial artery, dorsalis pedis artery ABPI

29. Investigation Doppler ultrasound blood flow detection Hand-held Doppler ultrasound probe (assessment of occlusive arterial disease) Ankle-brachial pressure index (APBI) : ratio of systolic pressure at the ankle to that in the arm Resting ABPI = 1 Below 0.9 → arterial obstruction (claudication) Below 0.5 → rest pain, below 0.3 → imminent necrosis

30. Duplex scanning Major non-invasive technique uses B-mode ultrasound to provide an image of vessels.

31. Angiography Invasive and only appropriate if intervention is being contemplated. Injection of radio-opaque dye into the arterial tree by a percutaneous catheter method ( Seldinger technique) Hazards: bleeding, haematoma, false aneurysm formation, thrombosis, arterial dissection, distal embolization, renal dysfunction and allergic reaction. Digital subtraction angiography (DSA) is now standard technique.

32. General Investigation FBC, Blood Glucose, Lipid profile, serum urea & electrolytes (to exclude anaemia, diabetes, renal disease and lipid abnormalities) ECG (left ventricular hypertrophy, coronary ischaemia, rhythm abnormalities)

33. Treatment of arterial stenosis or occlusive Non – surgical management Claudication a structured exercise programme – at least 2 hours per week for 3 months Smoking cessation Control DM, hypertension, dyslipidaemia Control body weight Buerger’s exercise

34. Drugs Medication may be required for diseases associated with arterial disorders (hypertension, DM, dyslipidaemia) Antiplatelets (clopidogrel, asparin ) Avoid beta blockers Percutaneous transluminal angioplasty and stenting

35. Operation for arterial stenosis or occlusion Sites of disease and types of operation Aortoiliac occlusion – aortofemoral bypass (Dacron graft) If only iliac system is occluded – iliofemoral of femorofemoral crossover graft Superficial femoral artery disease – femoropopliteal bypass Occlusion beyond popliteal artery into tibial vessels – femorodistal bypass

36. Acute arterial occlusion Sudden occlusion of an artery is usually caused by an embolus Embolic occlusion An embolus is an object that has become lodged in a vessel causing obstruction having been carried in the blood stream from another site Sources – Lt atrial in AF, Lt ventricular mural thrombus following MI, vegetation on heart valve in infective endocarditis, thrombi in aneurysm or atherosclerotic plaques Emboli may lodge in any organ and cause ischaemic symptoms

37. Other forms of embolism Infective emboli of bacteria or an infected clot Parasitic emboli ( ova of Taenia echinococcus ) Air embolism Therapeutic embolism ( use to arrest of haemorrhage )

38. Clinical features of acute limb ischaemia An emergency that requires immediate treatment Ischaemia beyond 6 hrs is usually irreversible & result in limb loss Presented with pain, pallor, paralysis, loss of pulsation, cold and paraesthesia

39. Treatment Immediate administration of 5000U of heparin IV Pain control Embolectomy and thrombolysis

40. Thank U