[03] pvd

7/21/2019 [03] PVD

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Peripheral Vascular

DiseaseAcute & Chronic Limb Ischemia

7/21/2019 [03] PVD


What is PVD?Definition:• Also known as PAD or PAOD

• Occlusi!e "isease of the arteries of

the lower e#tremit$

• %ost common cause:o Atherothrombosis

o Others: arteritis aneur$sm 'embolism

• (as both AC)*+ an" C(,O-IC P#

Pathoph$siolo.$:• Arterial narrowin. Decrease"

bloo" flow / Pain

• Pain results from an imbalance

between suppl$ an" "eman" of

bloo" flow that fails to satisf$

on.oin. metabolic re0uirements

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*he 1acts:2 *he pre!alence: 344 $ears is 2678947

9 678;67 of affecte" in"i!i"uals are as$mptomatic

< Pt=s with PVD alone ha!e the same relati!e risk of "eath from

car"io!ascular causes as those CAD or CVD

2 PVD pt=s / > more likel$ to "ie within 26 $ears than pt=s withoutthe "isease

9 *he ankle8brachial pressure in"e# @APIB is a simple nonin!asi!e

be"si"e tool for "ia.nosin. PAD an API E6F / "ia.nostic for PAD

2 Patients with PAD re0uire me"ical mana.ement to pre!ent futurecoronar$ an" cerebral !ascular e!ents

1. Prognosis at 1 yr in patient’s with Critical Limb Ischemia (rest pain):• Alive with two limbs !"#• Amp$tation %!#

• Car&iovasc$lar mortality %!#

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,isk 1actors:Typical Patient:• 'moer (%.!*+)

• ,iabetic (*-+)• ypertension• (# of ($percholesterolemiaGA1GI(DGCVA

• Age / 0" years.

• Age !" 2 years with a history o3 smoing or &iabetes.

• Age -" -2 with &iabetes an& at least one other ris 3actor 3or

atherosclerosis.

• Leg symptoms s$ggestive o3 cla$&ication with e+ertion orischemic pain at rest.

• Abnormal lower e+tremity p$lse e+amination.

• 4nown atherosclerosis at other sites (eg5 coronary5 caroti&5 or

renal artery &isease).

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Chronic PVD (istor$:

< Critical Htenosis / 367 impen"in. acute ischemic limb:

rest pain

ischemic ulceration

.an.rene

2. Other Symptom/Signs:• A b$rning or aching pain in the 3eet (especially at night)• Col& sin63eet• Increase& occ$rrence o3 in3ection• 7onhealing 8lcers

• Asymptomatic

1. INTERMITTENT CLAUDICATION

• Deri!e" from the Latin wor" Jto limp=• K,epro"ucible pain on e#ercise which is relie!e" b$ rest• Pain can also be repro"uce" b$ ele!atin. the le.• Km$ le.s .et sore at ni.ht an" feel better when I han. them o!er

the e".e of the be"

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9high Cla$&ication

60% 8pper %6* Cal3 Cla$&ication

Lower 16* Cal3 Cla$&ication

oot Cla$&ication

30% ;$ttoc < ip Cla$&ication

=Impotence > Leriche’s 'yn&rome

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DD# of Le. Pain2 Vascular

aB DV* @as for risk factorsB

bB PVD @clau"icationB

9 -eurospinal

aB Disc Disease

bB Hpinal Htenosis @Pseu"oclau"icationB

< -europathic

aB Diabetes

bB Chronic +tO( abuse

> %usculoskeletal

aB OA @!ariation with weather ' time of "a$B

bB Chronic compartment s$n"rome

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Ph$sical +#amination:E!min!tion: "h!t #o to:

Inspection

+#pose the skinan" look for:

• *hick Hhin$ Hkin• (air Loss• rittle -ails• Colour Chan.es @pallorB• )lcers• %uscle Wastin.

Palpation • *emperature @cool bilateralGunilateralB• Pulses: ?,e.ular ?AAA• Capillar$ ,efill• HensationG%o!ement

Auscultation • 1emoral ruits

Ankle rachialIn"e# @AIB

/ H$stolic P in ankle H$stolic P in brachial arter$

uer.er=s *est • +le!ate the le. to >4M an" look for pallor• Place the le. in a "epen"ent position F6M& look

for a re" flushe" foot before returnin. to normal

• Pallor at E96M / se!ere PAD

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Pictures:

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What "oes the AI mean?

A$I C%ini&!% Corre%!tion

36F -ormal Limb

646F Intermittent Clau"ication

E6> ,est Pain

E624 Nan.rene

CAUTION:Patient’s with ,iabetes ? @enal ail$re:

9hey have calci3ie& arterial walls which can 3alsely elevate their A;I.

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In!esti.ations:

77 I7BA'IB:

,$ple+ 8ltraso$n& normal is triphasic biphasic monophasic absent

;L, 9'9':

1. ;68C6omocysteine Levels

%. Coag$lation 't$&ies

*. asting Lipi&s an& asting Dl$cose

-. ;A1C

E7 9 IFAD:

1. 9o image G to intervene%. Pt’s with &isabling symptoms where revasc$larisation is consi&ere&

*. 9o acc$rately &epict anatomy o3 stenosis an& plan 3or PCI or '$rgery

-. 'ometimes in pt’s with &iscrepancy in h+ an& clinical 3in&ings

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A7DID@APH:

7oninvasive:• C9 Angiogram• F@ Angiogram

Invasive:• ,igital '$btraction Angiography

Dol& 'tan&ar&

Intervention at the same time

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*ar"us et par!us / small amplitu"e ' slow risin. pulse

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C9 Angiography ,igital '$btraction Angiography

Value of angiographyValue of angiography

Localies the obstr$ction

Bis$alie the arterial tree < &istal

r$no33

Can &iagnose an embol$s:

Sharp cutoff, reversed meniscus or clotsilhouette

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*reatment:1. RIS' (ACTOR MODI(ICATION:

aB Hmokin. CessationbB ,i.orous HL control

cB P re"uction

"B Lipi" Lowerin. *herap$

). MEDICAL MANA*EMENT:aB Antiplatelet therap$ e.

AspirinGClopi"o.rel

bB Phospho"iesterase Inhibitor e.

Cilostaol

cB 1oot Care

2. E+ERCISE:aB Clau"ication e#ercise

rehabilitation pro.ram

bB >46mins <# weekl$ for 29 weeks

cB months later '4mins walkin.

time @before painB

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PCIGHur.er$:Indication!Conideration:•Poor response to e+ercise rehabilitation ? pharmacologic therapy.

•'igni3icantly &isable& by cla$&ication5 poor JL•9he patient is able to bene3it 3rom an improvement in cla$&ication•9he in&ivi&$al’s anticipate& nat$ral h+ an& prognosis•Forphology o3 the lesion (low ris ? high probabilty o3 operation

s$ccess)

PCI:• Angioplasty an& 'tenting•'ho$l& be o33ere& 3irst to patients with signi3icant comorbi&ities who are

not e+pecte& to live more than 1% years

"ypa #urgery:•@everse the sapheno$s vein 3or 3emoropopliteal bypass•'ynthetic prosthesis 3or aortoiliac or ilio3emoral bypass•thers G iliac en&arterectomy < thrombolysis•Current Cochrane review = not enough evidence for Bypass>PCI

A$putation: Last @esort

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Home $pass Options:

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%r presents with an acutel$

painful le.:

ou ha!e ha" a bus$ "a$ in the +D an" the ne#t

patient to see is:

%r 8 a 6 $r ol" .entleman with a !er$ painful le.

(e tells $ou that he woke up this mornin. with an

e#cruciatin. pain in his left le. an" has ne!er felt

this pain before

? +mbolism @A1G,ecent InfarctGAnuer$smB

? *hrombosis of nati!e !essel or .raft

?*rauma

%)H* ,)L+ O)* AC)*+ LI% IHC(+%IA

h h f f

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What are the features of an

acute ischemic limb?

,+%+%+, *(+ P=H:

1. ,AIN

1. ,ALLOR

1. ,ULSELESNESS

1. ,ERIS-IN* COLD ,OI'ILOT-ERMIA

1. ,ARAST-ESIAS

1. ,ARAL0SIS

i+e&mottling <

cyanosis

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(istor$ & +#am 1in"in.s(rther -:• Hmokes 96ci.sG"a$ for <6 $ears

• > months of Jle. cramps= in O*( le.s• 9< weeks of intermittent chest palpitations• (as not seen a Dr in the last month

E!min!tion:

• Inspection:o LLL: below the knee is paleGcool

• Palpation:o Irre.ularl$ irre.ular pulseo LLL Capillar$ return is slu..isho -o pulses palpable below L femoral arter$

o All pulses palpable but appear re"uce" in , le.o -ormal Hensation ' %o!ement bilaterall$

Impression60yo male with a L Acute Ischemic limb on the background of heavy

smoking, untreated AF and symptomatic P!"

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What will $ou "o now?

2 CALL *(+ VAHC)LA, ,+NIH*,A,

9 O,D+, I-V+H*INA*IO-H

aB 1+

bB +)C

cB Coa.ulation Htu"ies"B Nroup an" (ol"

eB 29 Lea" +CN

fB Chest ,

< I-I*A*+ AC)*+ %A-AN+%+-*:

aB Anal.esiabB Commence IV heparin

cB Call ,a"iolo.$ for An.io.raph$ if limb still !iable

"B Discuss with re.istrar:

iB *hrombotic cause ?cathetar in"uce" thrombol$sis

iiB +mbolic cause ?embolectom$

iiiB All other measures not possible $passGAmputation

'imple meas$res to improve

e+isting per3$sion:

• 4eep the 3oot &epen&ant

• Avoi& press$re over the heel

• Avoi& e+tremes o3 temperat$re(cold induces vasospasm)

• Fa+im$m tiss$e o+ygenation

(oygen inhalation)

• Correct hypotension

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%r =s Complication An.io.ram is "one in ra"iolo.$ Hhows acute thrombosis of L popliteal arter$

Cathetar in"uce" urokinase an" heparin infusion is starte"

K. *- ho$rs later

'evere cal3 pain in the reper3$se& limb

All p$lses are presentLeg is swollen5 tense an& ??? ten&er

&P&'U#ION IN(U)*@estore& bloo& 3low can lea& to $nwante& local ? systemic e33ects

1) Easho$t GoFetabolic Aci&osisoyperalemiao A@ (myoglobin$ria)o7oncar&iac AP

%) Compartment 'yn&rome GoFay nee& 3asciotomy

[03] pvd

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