peripheral vascular disease

peripheral vascular disease

1. Peripheral Vascular Disease

2. Definition Peripheral vascular disease  (PVD) is a blood circulation disorder that causes the blood vessels to narrow, block, or spasm outside the heart and brain. This can happen in arteries or veins Commonly used referring to peripheral arterial disease (PAD)

3. What Is The Peripheral Vascular System? The vessels not in chest , abdomen and brain These are the veins and arteries in the arms, hands, legs and feet

4. Difference Between PVD And PAD Peripheral Vascular Disease (PVD) There are problems altering the blood flow through both the arteries and veins. Peripheral Artery Disease (PAD) is a type of PVD have problems only with arterial blood flow

5. Diseases commonly found in peripheral vasculature

6. Atheroma Accumulation of degenerative materials in inner layer of arterial wall Materials: macrophage cell debris, containing lipid, Ca ++ & connective tissue What happened: intrude into lumen Where found: in atherosclerosis

7. Atheromatous plaque formation Accumulation between intima & media Atheroma don’t develop in veins Pathophysiology: Accumulation of fatty streak (macrophage takes up LDL and cholesterol) Foam cell formed Cell dies Content release Attracts more macrophage Creates extra cellular lipid core Peripheral calcification Plaque formation

8. Arterial stenosis and occlusion Cause: Atheroma Emboli Trauma Type: Acute Chronic

9. RISK FACTORS Positive family history of premature heart attacks or strokes Older than 50 years Male sex Overweight or obesity Inactive (sedentary) lifestyle Smoking Diabetes High blood pressure High cholesterol or LDL (the "bad cholesterol"), plus high triglycerides and low HDL

10. Chronic ischaemia Features: Intermittent claudication Rest pain Ulcer and gangrene Colour change Temperature Sensation & movement Capillary refill time Peripheral pulses

11. Intermittent claudication Claudication means cramp like pain in muscle during walking due to muscle ischaemia Not in the 1 st step (in osteoarthritis) Relieved by stand still/rest (in PLID posture change/rest) Commonly felt in calf Leriche’s syndrome : Buttock claudication + Impotency due to aorto -ileac obstruction

12. Grading of Intermittent claudication Grade 1: Pain goes away & patient continue walking (pain producing substances washed away by collaterals) Grade 2 Pain starts after some distance & can walk with pain Grade 3 When pain starts patient can't walk without taking rest

13. Rest pain Continuous pain occurs at rest throughout day and night due to severe ischaemia & felt in foot exacerbate by lying down or foot elevation Worse @ night due to decreased heart rate. Comfort by hanging the foot This pain is due to ischaemia of nerve ( crying of dying nerve )

14. Ulcer & gangrene Ulcer due to severe ischaemia Painful ulcer Site: between toes, around maleoli Black, mummified may be wet if infection occurs

15. Colour change of foot (a) elevation pallor and (b) dependent rubor

16. Relationship between occlusion site & Clinical features Aorto -iliac Claudication both buttock & thigh Leriche’s syndrome Absent femoral pulses Iliac Unilateral claudication in thigh/ calf Unilateral absent pulse Femoro-popliteal Distal obstructions

17. Stage of limb ischaemia: Fontainer’s staging Stage I: asymptomatic Stage II: Intermittent claudication Stage III: Rest pain IIIa : Rest pain + ABPI > 50 mm of Hg IIIb : Rest pain + ABPI < 50 mm of Hg Stage VI: Ulcer / Gangrene

18. Investigations For diagnosis Doppler USG Duplex scanning Angiography CT angiography MR angiography DSA For assessment CBC S. Lipid profile S. Creatinine Blood sugar S. Electrolite ECG CXR

19. Doppler USG Measured by Doppler USG Blood flow Site of stenosis Systolic pressure of small arteries ABPI

20. ABPI Ratio of systolic pressure @ ankle to arm Measured by Doppler USG Measured artery: dorsalis pedis , ant. tibial , & post. Tibial Value: Normal= 1 Claudication = < 0.9 Rest pain = < 0.5 Imminent necrosis = <0.3 Calcification = > 1

21. Duplex scanning Combination of Doppler study & B mood USG Gives idea about- Stenosis Visual impression of small vessel Turbulence Velocity of flow Changes in direction of flow

22. Angiography Invasive & indicated when intervention is think about Using Sheldinger technique Usually through femoral artery Advantages Visualization of artery, site of occlusion, collaterals seen Disadvantages Bleeding, haematoma, thrombosis, embolism Arterial dissection, false aneurism

23. Angiography CT Angiography MR Angiography

24. DSA (Digital subtraction angiography)

25. Treatment Nonsurgical General Drugs Interventional Surgical

26. Non surgical treatment General Stop smoking Walk within limit of disability Dietary advice to loss weight Care of ischaemic foot, avoid trauma

27. Non surgical treatment Drugs Pentoxiphylin  ↓ blood viscosity , improve circulation; 400 mg bd. Cilostazole  inhibit platelet aggregation; 100mg bd Analgesic Low dose aspirin Clopidogrel Anti HTN Anti DM Statin  lipid lowering Antibiotics Anti platelet; 75 mg daily

28. Interventional treatment PTA: Percuteneoans transluminal angioplasty By balloon Catheter Via femoral artery Fluoroscopic guidance Suitable for short segment, < 5 cm

29. Transluminal stenting Self expanding metallic stent Suitable for long segment; > 5 cm PTA failure

30. Surgical treatment Indication: Severe symptom Angioplasty failed/not possible Option: Bypass graft Natural Saphanous (long/short) graft Arm vein graft Synthetic Dacron PTFE End arterectomy Lumber sympathetectomy Amputation

31. Surgical treatment Natural Graft Synthetic graft

32. End arterectomy

33. Lumber sympathetectomy

34. Amputation

35. Critical Limb Ischaemia Def: Critical limb ischaemia is a late sign of progressive limb ischaemia, characterized by- Rest pain; requiring regular analgesic >2 weeks Ulcer due to arterial insufficiency Gangrene Systolic pressure of limb < 50 mm of Hg Management: same as chronic limb ischaemia

36. Acute occlusive condition Causes Emboli Thrombi Trauma

37. Embolus An embolus is a body that is foreign to the blood stream & which may lodge into blood vessel & cause obstruction. Type Thrombo -embolic Lt. atrium  fibrillation/MI/ endocarditis Aneurism Atherosclerotic plaque Fat Air Infective Parasitic Malignant

38. Site of acute arterial occlusion Limbs Brain - middle cerebral artery Retina – central retinal artery  Amourosis fugux Gut Kidney

39. Symptoms Sudden, severe onset of constant pain/numbness May have H/O cardiac disease May have H/O trauma/ arterial catheterization May have H/O arterial graft

40. Signs 5P Pain, pallor, paralysis, pulselessness & parasthesia Limb is cold, tender, swollen Toe cannot be moved If occlusion is > 6 hours  irreversible damage occurs & line of demarcation may present

41. Immediate management It is a surgical emergency, so if a patient have a H/O cardiac disease with acute limb ischaemic features immediate management should be done So the M x is: 5000 U of heparin I/V To reduce extension of thrombi To maintain patency of vessel Analgesic

42. Investigation In treating acute limb ischaemia (ALI) TIME is everything in worst case ALI may progress to critical limb ischaemia So the choice of INV. Is Colour Doppler study Evaluates lesion into 3 categories Viable Threatened Irreversible

43. Surgical management Embolectomy Rx of choice Under LA By Fogarty balloon catheter Intra arterial thrombolysis With tissue plasminogen activator Or streptokinase/ urokinase

44. Intra arterial thrombolysis….cont. Injected into clot via catheter Success achieved within 24 hours Regular angiogram should be done Contraindication Recent stroke Bleeding diathesis Pregnancy Age> 80 After managing ALI total evaluation of the cause should be attempted & managed accordingly

45. Thank You All