2. Peripheral Vaskular Disease - Dr. Muzakkir, Sp.jp

7/26/2019 2. Peripheral Vaskular Disease - Dr. Muzakkir, Sp.jp

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Peripheral Vascular Disease

Karthik Vamanan, MD

Asst. Prof. Dept. of SurgeryVascular and Endovascular Surgery


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Introduction

Vascular insufficiency

Acute

Chronic


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Acute Ischemia

Etiology

Thrombosis

Embolism


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Other causes

Causes of acute limb ischemia inatherosclerotic patients

Thrombosis of an atherosclerotic stenoticartery

Thrombosis of an arterial bypass graft

Embolism from heart, aneurysm, plaque, orcritical stenosis upstream (includingcholesterol or atherothrombotic)

Emboli secondary to endovascular procedures

Thrombosed aneurysm (especially poplitealaneurysm)


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Other causes

Non atherosclerotic, non embolic causes of acute

limb ischemia

Arterial trauma (especially iatrogenic)

Aortic/arterial dissection

Arteritis with thrombosis (eg, giant cell arteritis,

thromboangiitis obliterans)

Spontaneous thrombosis associated with a

hypercoagulable state

Popliteal cyst with thrombosis

Popliteal entrapment with thrombosis

Vasospasm with thrombosis (e.g. ergotism)


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Epidemiology - Acute

Incidence = 14/100,000

12% of operative load in vascular surgery

units

Mortality rate = 25%

Morbidity rate = 20% Jivegard et al. Acute limb ischemia due to arterial

embolism or thrombosis. J. Cardiovasc Surg 29:32-36,1988


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Clinical Presentation - Acute

Sudden onset of severe pain

May be silent

May reduce in intensity


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H + P

Ask about onset

Look for previous symptoms of arterial

disease like claudication and rest pain.

Risk factors for atherosclerosis.

Embolic sources - ?

History of previous embolic episodes.


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H + P

Pain

On passive extension of ischemic muscle

Paresthesias and paralysis

Diabetes?

Paresthesias first, then sensory, motor last.

Pallor

Level of demarcation

Cap refill

Venous filling Poikilothermia

Pulseless


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Differential

Conditions mimicking acute limb ischemia

Heart failure (especially if associated with

chronic occlusive disease)

Acute DVTAcute compressive neuropathy

Other low flow states including vasopressor

therapy.


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Investigation

PE

Non Invasive Laboratory

Angiography / MRA / CTA

DO NOT DELAY


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Rx

Percutaneous

Thrombectomy

Thrombolysis

Open

Thrombectomy

Bypass

Fasciotomy?


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Treatment


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Treatment


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Conclusions

Patients with acute limb ischemia face a 1-yearmortality of 10-20%

Treatment of occluded bypass grafts has a betteroutcome than treatment of native arteries

Risk of major bleeding increases with thrombolysiscompared with surgical revascularization

Risk of a bleeding complication increases ascoagulopathy worsens (decreased fibrinogen,prolonged PTT)

Risk of an intracranial bleed is approximately 1-2%with thrombolysis

Lytic patients require fewer open surgical procedures


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Treatment


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Epidemiology- Chronic

Incidence between 500 and 1000 per millionpopulation per year

20% of these patients die annually

5-year mortality = 70% 35% cardiovascular disease

9% non-cardiovascular disease


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Risk Factors

Age

Family history

Trauma

Smoking Diabetes

Hypertension - shear forces

Hypercholesterolemia

Hypercoagulable syndromes

Homocysteinemia


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PAOD

Spectrum of disease

Asymptomatic Tissue Loss


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Claudication

Intermittent claudication is lower extremity

muscular pain in the calves (less frequently

the buttocks or thighs) induced by exercise

and relieved with short periods of rest We know that for every person with

claudication, there are at least four people

with similar disease without symptoms


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Claudication

Natural History

Associated with favorable outcome

1 in 4 have worsening symptoms

1-7% limb loss at 5-10 yrs Less favorable natural history if

ABIs low

Continues to smoke

Poorly controlled DM

Mortality rate at 5 years is 50%


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Claudication

Pathogenesis

Arterial obstruction proximal to affectedmuscle beds

Limits the normal exercise-induced increase inblood flow and produces transient muscle

ischemia during exercise


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Claudication

Clinical Presentation

Usually classic like the definition

Symptoms range from severe pain and

cramps to fatigue on exertion Level will depend on level of disease

Initially may not be consistently reproducible


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Claudication

History

Should be aimed at

Delineation of symptoms

Elimination of differential diagnoses Presence of risk factors

Identification of other beds of atherosclerosis


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Claudication

Specific History

Location of the pain or discomfort

Duration of the symptom

Whether it worsens or improves with time andwhether conservative therapy has had an

effect

Distance the patient can now walk before

experiencing the discomfort

being forced to stop


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Claudication

Specific History

Elapsed time after exercise is stopped before

the pain is relieved

Type of rest or position of patient (standing atrest, sitting, lying) necessary to relieve the

pain

Whether the pain returns after the same time

and distance if exercise is then resumed


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Claudication

Differential Diagnosis

Nerve Root Compression

Arthritis and joint problems

DVT

Chronic compartment syndrome

Neuropathy Muscle strain


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Critical Limb Ischemia

The TransAtlantic Inter-Society Consensus(TASC) definition:

Persistent, recurring ischemic rest painrequiring opiate analgesia for at least 2weeks,

Ulceration or gangrene of the foot or toes,

AND ankle systolic pressure less than50mmHg or toe systolic pressure less than

30mmHg (or absent pedal pulses in patientswith diabetes)


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CLI

Natural History

Rarely antecedent history of claudication

Most (if not all) patients with CLI will progress

to limb loss Mortality rate at 5 years is 70%

Prognosis worse if

DM

Smoking

Occlusive Disease below the knee


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CLI

History

Prior and other history of vascular disease

Rule out other causes of pain and ulceration

Neuropathy Venous disease

Infections


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Physical Exam

Thorough physical

Peripheral sequelae of ischemia

Wasting

Thin skin

Hair loss

Thick nails


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Physical Exam

Pulse exam

Palpate

Presence

Strength Character

Auscultate

Bruits


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Physical Exam

Patterns of Disease

Inflow

Outflow

Combination


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H + P

Ischemic ulcers

located distally (on dorsum of foot/toes)

pain relieved by dependency, often occurring

at night Irregular edge with poor granulation


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H + P

Other Ulcers

Neurotropic

Located at pressure points (under calluses, plantar

aspect of 1st/5th MP joints)

Painless

Punched out with deep sinus

Stasis

Located over medial malleolus or lower third of leg

May have mild pain relieved by elevation Shallow, irregular shape, rounded edges, granulating

base


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Coexistent Cardiac Disease

20% previous myocardial infarction

7% previous congestive heart failure

4% previous arrhythmia

60% abnormal EKG

7% previous CVA


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Investigation

NON-INVASIVE

ABI (ankle brachial index)

Segmental blood pressures

Toe pressures Pulse volume recordings

Color flow Doppler

MRA


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Ankle-Brachial Index


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Ankle-Brachial Index

Ankle SBP/Brachial SBP

normal is 0.9-1

single level occlusion > 0.5

multi level occlusion < 0.5 claudication 0.6 to 0.9

rest pain 0.3

Calcification can alter results


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Segmental limb pressures


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Segmental limb pressures


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Toe Pressures

Measured with cuff around digit and PPG

(photo-plethysmography) monitor

Not as likely affected by calcification of

arteries Normal: 60 to 80% of ankle or brachial

T Ph l h hi


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Toe Photoplethysmographic

Waveforms


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Pulse Volume Recording

Pneumatic cuffs measure the momentary

volume changes with each pulse.

Normal:

sharp systolic peak prominent reflected wave

Not affected by calcified vessels


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Arterial Duplex Scan

Duplex visualization

Color imaging of luminal flow

Velocity measurement of flow

increased velocity at stenosis

decreased velocity distal to stenosis

spectral broadening (turbulence


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Arterial Duplex Scan


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MRA


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Angiogram


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Angiogram


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Angiogram


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Treatment

Goals

Relieve symptoms

Pain

Infection Tissue loss

Preserve function

Preserve limb

Risk factor modification

Improve quality of life


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Treatment

Medical Management

Risk modification

Statins

Diabetes management Control hypertension

Cessation of smoking

Exercise


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Treatment

Drug therapy

Antiplatelet therapy

Aspirin

Clopidrogel

Ticlopidine

Glycoprotein 11b/111a inhibitors???

Cilostazol

Oxypentifylline??

Pentoxyfylline

Antioxidants and chelation therapy???


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Treatment

Endovascular management


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Treatment

Surgical


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2. Peripheral Vaskular Disease - Dr. Muzakkir, Sp.jp

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Transcript of 2. Peripheral Vaskular Disease - Dr. Muzakkir, Sp.jp