Peripheral arterial diseases diagnosis and treatment

By Dr Yar Jahan

1. Peripheral arterial disases By dr yarjhan

2. definition It generally refers to obstruction of arteries supplying the upper and lower extremities that when severe results in ischemia and potential tissue loss.

3. Chronic lower limb ischemia Acute lower limb ischemia Upper limb ischemia

4. It can present as Acute limb ischemia Chronic limb ischemia Acute on chronic limb ischemia(sudden worsening of symptoms who had long history of claudication suggesting thrombosis of crtically stenosed vessel)

5. Chronic limb ischemia Symptoms lasting for more than 2 weeks Causes Atherosclerosis Emboli (fat embolism ,air embolism,mycotic embolization) Burger disease Vasculitis Fibromuscular dysplasia Raynauds disease Trauma

6. Risk factor Modifiable Diabetes Hypertension Smoking Hyperlipedemia Non modifiable Old age Male Family history

7. Stages of limb ischemia Asymptomatic Intermittent claudication ( crampy pain in muscle brought by exercise or walking and relieved by rest) Ischemic rest pain (pain occurs at rest more at night ,patient hangs his legs down bed or chair to get relieved ) Critical limb ischemia ( persistant ischemic rest pain which requires analgesia greater than 2 weeks plus associatd with ulceration or gangrene )

8. Classification of chronic limb ischemia Fontaine classification Rutherford classification TASC classification

9. Fontaine classification stage interpretation Stage 1 asymptomatic Stage 2 Intermittent claudication Stage 3 Rest pain Stage 4 ulceration

10. Rutherford classification Grade category Clinical asymptomatic 1 1 Mild claudication 1 2 Moderate claudication 1 3 Severe claudication 2 4 Rest pain 3 5 Minor tissue loss 3 6 Major tissue loss

11. Level of arterial obstruction Aortoiliac occlusive disease(also known as inflow level) Femoropopliteal level Infrapopliteal level (also known as outflow level)

12. 1-Aortoiliac occlusive disease Atherolsclerosis causing chronic ischemia of distal aorta and iliac vessel Can be diffuse or isolated

13. Clinical features Triad of thigh claudication plus buttock claudication with absent femoral pulses Leriche syndrome (thigh plus buttock claudication plus impotence or erectile dysfunction ) Ischemic rest pain occurs when disease progressed futher Signs on examination Absent femoral pulses Pelvic bruit

14. Classification of aortoliac occlusive disease Based on atherosclerotic disease pattern TASC classification ( transatlantic intersociety consenus )( most coomonly used also give us treatment plan )

15. type Type 1 Type 2 Type 3 Distal aorta and common iliac vessel Diffuse occlusive diseas above inguinal ligament Diffuse occlusive disease involving both above and below inguinal ligament incidence 10 per 25 per 65 per

16. Tasc classification

17. Investigations General All baseline ( cbc rft lft bsr serum electrolyte ecg echocardiogram chest xray ) Thigh brachial pressure index (less than 0.8 ) Radiological ( non invasive) Doppler and duplex scan (for diagnosis ,shows monophasic waveform plus peak systolic velocity geater than 2.5 ) Ct angiogram (diagnosis ,level of obstruction,to know about collateral ,type of obstruction) Mr angiogram

18. Invasive test Angiography (can be diagnostic and therapeutic ) Digital subtraction angiography (better view e liminate other structures only vascular system identified,smaller details can be identified ) Additional tests for cause hbaic , lipid profile,uric acid echocardiography,carotid doppler

19. Management 1-control of risk factor 2-medical treatment 3-surgical intervention

20. Medical treatment Antiplatelet ( aspirin , clopidogrel ) Lipid lowering drugs(statin) Vasodilator ( ticlopidine,cilostazole eg pletaal ) B complex Painkiller

21. Surgical interventions 1-open bypass procedure 2-open endartectecomy ( rarely done now a days) 3-endovascular treatment NOTE Tasc a and b endovascular treatment preferred Tasc c and d open technique is prefered

22. Indication of surgical option Failure of medical therapy Patient who are symptomatic Patient with more distal lesion are unlikely to benefit from medical therapy

23. 1-Bypass procedure 1-aortobifemoral bypass(most commonly performed ,symptomatic improvement more than 80 per) 2-axillobifemoal bypass(limb saving procedure , can be done in local in emergency setting) 3-ileofemoral bypass(for unilateral disease) 4-obturator bypass(sepsis ,neoplasm ,malignancy)(anastomosis between external iliac or common iliac to superficial femoral artery)

24. Choice of material for graft Synthetic ( dacron ,PTFE) Natural (internal mammary ,long saphenous vein reversed or in situ,umblical vein graft) Note saphenous vein graft is best for infrapopliteal bypass procedure .

25. Endovascular treatment Ballonic dilation Stent placement

26. 2-infrainguinal( femoropopliteal occlusive disease plus infrapopliteal occlusive disease) Symptoms lasting from more than 2 weeks Risk factors and causes are same as of aorto -iliac occlusive disease

27. Symptoms Asymptomatic Intermittent claudication of thigh, leg and foot Discoloration of leg and foot Ulceration

28. Management Control of risk factors Medical treatment Surgical intervention Endovascular Procedure Bypass procedure Endartectomy (limited role not performed now days)

29. Endovascular Procedure Indications: Short segment occlusion Non-calcified Tasc classification type a and b Below popliteal results are not good (Vessel diameter is low) Types: Percuataneous Transluminal balloon angioplasty Subintimal angioplasty Stenting Stent graft Mechanical atherectomy Laser atherectomy

30. Bypass Procedure Indications: Multifocal long segment Below the popliteal level

31. Options: For SFA Occlusion femoropopliteal bypass is performed (Using PTFE or Saphenous vein)(Anastomosis between common femoral and popliteal artery) For Popliteal or tibial vessel then options are femoral to posterior tibial bypass (Between common femoral artery and posterior tibial artery) Femoroperoneal bypass Common femoral to anterior tibial bypass SFA anastomosis to dorsalis pedis artery

32. Complications of Bypass Graft stenosis Limb swelling (Due to damage to lymphatic vessels) Wound infection

33. Acute limb ischemia Sudden occlusion to blood flow within 14 days of onst of symptom .

34. Causes Embolism Thrombosis Traumatic Ischemia Intra-arterial drug injection Aortic dissection Extensive Ilio -femoral DVT ( Phlegmasia Cerula Dolens )

35. Clinical Features (6P’s) Pain Pulseless Pallor Poikilothermia Paresthesia Paralysis

36. Classification According to viability Rutherford Classification

37. Viability Classification Feature Viable Threatened Irreversible Clinical description Not immediately threatened Salvagable if treated Major tissue loss, amputation is necessary Capillary return Intact Intact but slow Absent Muscle weakness None Mild Paralysis Sensory Loss None Mild Profound anesthesia Doppler Finding Audible Inaudible Inaudible

38. Rutherford Classification Grade 1: Viable (No sensory or motor loss and on Doppler arterial and venous, both signals normal) Grade 2a: Marginally threatened (Minimal sensory with no motor loss on Doppler arterial signal inaudible, venous audible) Grade 2 b: Immediately threatened (sensory loss, mild motor loss, on Doppler, arterial inaudible, venous can be audible) Grade 3: (Irreversible)(Sensory loss, motor loss, on Doppler, arterial and venous both inaudible)

39. Investigations General Investigations: All baselines Serum LDH, Lactate, ABGs and CPK Levels Imaging Non invasive Doppler and Duplex (Diagnosis, localizes and identifies cause) CT angiogram and MR Angiogram (Not done in acute setting, helps in diagnosis, calcifications can be seen)

40. Invasive: Angiography Digital Subtraction angiography (Newer technique, helps in diagnosis plus intervention at same time, best when previously open surgery is done) To Know the cause: Echo Abdominal angiogram (If we are suspecting aneurysm) Lipid profile Carotid Doppler

41. Management Avoidance of risk factors Medical Surgical intervention (According to the source) Embolectomy thrombolytic therapy revascularization procedure

42. Avoidance of risk factors Stop smoking Control diabetes, hypertension Statins for dyslipidemia

43. Medical Place the patient in reverse trendelenberg position Analgesic/painkiller IV fluids for dehydration Oxygen inhalation Anticoagulants (Heparin or warfarin, inj Clexane )

44. Embolectomy Through Fogarty Catheter As long as the limb is viable (Grade 1 or Grade 2a) After embolectomy , fasciotomy must be done For lower limb, femoral artery and transpopliteal embolectomy can be done

45. Thrombus Thrombolytic therapy or Revascularization procedure Can be given systemically or percutaneous catheter directed thrombolysis Indications: Class I and Class IIa , viable tissue, thrombus after angioplasty, native vessel occlusion

46. Contraindications of thrombolysis Absolute: CVA within 2 months Active bleeding within 10 days Intracranial trauma within 3 months Intracranial surgery within last 3 months Malignancy (Intracranial) Metastasis

47. Relative: CPR within last 10 days Major non-vascular surgery or trauma within last 10 days Uncontrolled hypertension (>180/110) Intracranial tumor Recent eye surgery Minor Contraindications: Liver failure Pregnancy

48. Agent for thrombolysis SK, Urokinase , TPA Complications after thrombolysis: Bleeding Embolisation Compartment syndrome

49. Revascularisation Procedure Thrombectomy (Open or endovascular approach) By pass procedure (For acute on chronic limb ischemia)

50. Complication of revasculaization procedure Reperfusion injury Compartment syndrome

51. Amputations If gangrene develops, then go for amputation

52. Thromoboangitis obliterans (burger disease) Common in young , middle age, males, smokers Moe common in lower limbs Non atherosclerotic inflammatory disorder of mdium sized and distal vessel with cell mediated hypersensitivity to type 1 and 3 collagen. Segmntal,progressive,occlusive ,inflammatory disease of small and medium sized vessel that presents as Raynaud phenomenon with microabcesses,along with giant cell infiltration with skip lesions.

53. Classification Type 1 upper limb, rare Type 2 involving legs infrapopliteal Type 3 femoropopliteal Type 4 aortoiliofemoral Type 5 generalized

54. Clinical features Intermittent claudication Rest pain Ulceration gangrene Absent pulses

55. Investigation Doppler and duplex Usg abdomen(to rule aneurysm) Angiogram (gold standard)(corkscrew appearance du to dilation of vasa vasorum,inverted tree appearance,vasopasm ) biopsy

56. Management Conservative Medical management Surgical intervention

57. Conservative Stop smoking Burger position (head end raised foot lowered) Care of foot(avoid trauma,dryness of foot,wear socks with foot wear)

58. Medical manageement Antiplatlet Statin Vasodilator Painkiller Genetic therapy( intramsuscular injection of VEGF to promote angiogenesis)

59. Surgical intervention Sympathectomy (injecting xylocaine or phenol in L2,3,4 vertebrae ) pofundoplasty (to open collaterals and improve perfusion,localized stenosis) amputation

60. Raynaud phenomenon Episodic attack of small arteries and arterioles of distal extermites in response to cold or emotional stimuli. Types 1-Raynaud syndrome (due to underlying collagn disorder like scleroderma and rheumatoid arthritis) 2-Raynaud disease (idiopathic causes)

61. Clinical features Female patient when exposed to cold suffers Raynaud phenomenon (initially pale ,then cyanosis ,then redness of extremites occurs).

62. Treatment Avoid predisposing factor such as cold Medical management ( pentoxiphyline,aspirin,calcium chnnel blocker,ace inhibitor,nitrates ) Cervical sympathectomy

63. Upper limb ischemia Causes Atherosclerosis causing chronic limb ischemia Emboli causing acute limb ischemia Raynaud disease Thoracic outlet syndrome Thromoangitis obliterans Trauma Vasculitis Diseases (scleroderma ,CREST syndrome) Drugs

64. Symptoms Upper limb claudiction Weakness Ulceration gangrene

65. Investigation General investigation Cbc lft rft bsr ecg lipid profile Radiological Xray neck (to rule out cervical rib) Doppler and duplex Ct mr angiogram Ct scan neck chest

66. Management Medical management is same Surgical management

67. E mbolus Brachial embolectomy

68. Chronic ischemia Endovascular approach Bypass procedure( aortosubclavian bypass,subclavian axillry bypass)