Abdulrahman Al-Muammar, MD, FRCSC King Saud University College of Medicine.
Peripheral Arterial Disease Mohammed Al-Omran, MD, MSc, FRCSC Assistant Professor & Consultant...
-
Upload
osborn-gibson -
Category
Documents
-
view
218 -
download
0
Transcript of Peripheral Arterial Disease Mohammed Al-Omran, MD, MSc, FRCSC Assistant Professor & Consultant...
Peripheral Arterial Peripheral Arterial DiseaseDisease
Mohammed Al-OmranMohammed Al-Omran, , MD, MSc, MD, MSc, FRCSCFRCSC
Assistant Professor & ConsultantAssistant Professor & ConsultantVascular Surgery Vascular Surgery
King Saud UniversityKing Saud University
What is Peripheral What is Peripheral Arterial Disease?Arterial Disease?
PAD=POAD=PVDPAD=POAD=PVD Arteriosclerotic occlusive Arteriosclerotic occlusive
disease of aortoiliac and/or disease of aortoiliac and/or femoropopliteal arterial systemfemoropopliteal arterial system
What are the risk factors What are the risk factors for PAD?for PAD?
Non-Modifiable Risk Factors:Non-Modifiable Risk Factors: Male genderMale gender Advanced ageAdvanced age Family historyFamily history
Modifiable Risk Factors:Modifiable Risk Factors: Major Major SmokingSmoking HypertensionHypertension DiabetesDiabetes HyperlipidemiaHyperlipidemia
MinorMinor HomocystenemiaHomocystenemia ObesityObesity Hypercoaguable stateHypercoaguable state Physical inactivityPhysical inactivity
PathogenesisPathogenesis
PathogenesisPathogenesis
How do patients with PAD How do patients with PAD present?present?
AsymptomaticAsymptomatic
SymptomaticSymptomatic
•Intermittent Intermittent claudicationclaudication•Critical Limb IschemiaCritical Limb Ischemia Pain at restPain at rest Tissue lossTissue loss GangreneGangrene
How do patients with PAD How do patients with PAD present?present?
How do we diagnose How do we diagnose PAD?PAD?
SymptomaticSymptomatic
AsymptomaticAsymptomatic
ABI measurementABI measurement Non-invasive tests (arterial Non-invasive tests (arterial duplex, duplex, CTA, MRA)CTA, MRA) Invasive test (Conventional Invasive test (Conventional angiogram)angiogram) ABI ABI measurementmeasurement
HistoryHistoryPhysical ExaminationPhysical Examination
How do we diagnose How do we diagnose PAD?PAD?
Symptomatic 10%
Asymptomatic 90%
Ankle Brachial IndexAnkle Brachial Index
ABI= Ankle SBP(PT or DP)/ Highest Arm SBP
Ankle Brachial IndexAnkle Brachial Index
ABI valueABI value IndicatesIndicates
<0.9<0.9 AbnormalAbnormal
0.8- 0.90.8- 0.9 Mild PADMild PAD
0.5- 0.80.5- 0.8 Moderate PADModerate PAD
<0.5<0.5 Severe PADSevere PAD
<0.25<0.25 Very Severe PADVery Severe PAD
The ABI has limited use in evaluating calcified vessels that are not compressible as in Diabetics
InvestigationsInvestigations
InvestigationsInvestigations
Why it is important to Why it is important to recognize patients with recognize patients with
PAD?PAD? PAD is a marker of PAD is a marker of
systemic systemic atherosclerosis atherosclerosis
Patients with Patients with either symptomatic either symptomatic or asymptomatic or asymptomatic PAD generally PAD generally have widespread have widespread arterial diseasearterial disease
Why it is important to Why it is important to recognize patients with recognize patients with
PAD?PAD? Coexisting vascular Disease:Coexisting vascular Disease:
CADCAD-- 35 % to 92%-- 35 % to 92%
CVDCVD-- 25 % to 50%-- 25 % to 50%
Why it is important to Why it is important to recognize patients with recognize patients with
PAD?PAD? Cause of death:Cause of death: CADCAD– 40%-60%– 40%-60% CVDCVD– 10%-20% – 10%-20% NNon-cardiovascularon-cardiovascular causescauses----
Only 20% to 30 %Only 20% to 30 % Patients with PAD have a Patients with PAD have a 6 fold6 fold
increased risk of cardiovascular increased risk of cardiovascular disease mortality compared to disease mortality compared to patients without PADpatients without PAD
Natural HistoryNatural History
Weitz JI et al, Circulation 1996; 94: 3026-49.
Natural HistoryNatural History
Annual risk :Annual risk :
- Mortality - Mortality 6.8%6.8%
- MI - MI 2.0%2.0% - Intervention - Intervention
1.0%1.0% - Amputation - Amputation
0.4%0.4%
Ouriel K, Lancet 2001; 358: 1257-64.
Worldwide Causes of Worldwide Causes of DeathDeath
Goals of treating patients Goals of treating patients with PADwith PAD
Relief symptomsRelief symptoms Improve quality of lifeImprove quality of life Limb salvageLimb salvage Prolong survival Prolong survival
Risk Factors Modification
Improve Lower Limb Circulation
Strategies in treating Strategies in treating patients with PADpatients with PAD
Risk Factors Modification• Diet and weight controlDiet and weight control• Exercise Exercise • Hypertension controlHypertension control• Diabetes controlDiabetes control• Lipid controlLipid control• Smoking CessationSmoking Cessation
Strategies in treating Strategies in treating patients with PADpatients with PAD
Improve Lower Limb Circulation• Conservative (Exercise Program)Conservative (Exercise Program)• Intervention ( Revascularization)Intervention ( Revascularization) - Angioplasty +/- Stenting- Angioplasty +/- Stenting - Surgical Bypass - Surgical Bypass
Strategies in treating Strategies in treating patients with PADpatients with PAD
Percutanous Transluminal Percutanous Transluminal AngioplpastyAngioplpasty
PTAPTA
Surgical BypassSurgical Bypass
Acute Limb Acute Limb IschemiaIschemia
What is an Acute Limb What is an Acute Limb Ischemia?Ischemia?
Sudden decrease or worsening in Sudden decrease or worsening in the limb perfusion causing a the limb perfusion causing a potential threat to the limb viability potential threat to the limb viability resulting from a sudden obstruction resulting from a sudden obstruction of the arterial system of the arterial system
What are the causes of acute What are the causes of acute arterial occlusion ?arterial occlusion ?
EmbolusEmbolus ThrombosisThrombosis OthersOthers
TraumaTrauma
IatrogenicIatrogenic
Arterial dissectionArterial dissection
What is the possible source for What is the possible source for an embolus? an embolus?
Spontaneous (80%) Cardiac source arrhythmias, MI, prosthetic valve, endocarditis
Non-Cardiac source Proximal AS plaque, Proximal Aneurysm,
Paradoxical emboli
Iatrogenic (20%) Angiographic manipulation Surgical manipulation
What are the common sites for What are the common sites for embolus lodgment in the arterial embolus lodgment in the arterial
tree?tree?
How do patients with acute How do patients with acute limb ischemia present?limb ischemia present?
Sudden onset of diffuse and poorly Sudden onset of diffuse and poorly localized leg pain localized leg pain
6 Ps6 Ps Paresthesias Paresthesias Pain Pain Poikilothermia (coolness) Poikilothermia (coolness) Pallor Pallor Pulselessness Pulselessness ParalysisParalysis
InvestigationsInvestigations
Acute Limb Ischemia is aAcute Limb Ischemia is a
CLINICAL DIAGNOSISCLINICAL DIAGNOSIS If time allows, especially if If time allows, especially if
atherosclerotic thrombosis is atherosclerotic thrombosis is suggested, preoperative suggested, preoperative angiographyangiography is often wise is often wise
Goal of treating patients Goal of treating patients with Acute Limb Ischemiawith Acute Limb Ischemia
Rapid restoration of adequate Rapid restoration of adequate arterial perfusion without the arterial perfusion without the development of morbid local development of morbid local or systemic complicationsor systemic complications
TreatmentTreatment
EMEGENCY (Golden time is 6 EMEGENCY (Golden time is 6 hours)hours)
ABCABC
IV Heparin (anticoagulation)IV Heparin (anticoagulation)
Rapid surgical Rapid surgical thromboembolectomythromboembolectomy
+/ - surgical bypass+/ - surgical bypass
+/- thrombolytic therapy+/- thrombolytic therapy
+/- primary amputation+/- primary amputation
Surgical Thrmboemblectomy Surgical Thrmboemblectomy ProcedureProcedure
ThrombolysisThrombolysis
What do we worry about What do we worry about after revascularization?after revascularization?
Reperfusion InjuryReperfusion Injury Local Local Compartment SyndromeCompartment Syndrome Systemic Systemic HyperkalemiaHyperkalemia AcidosisAcidosis MyoglobulinuriaMyoglobulinuria
Compartment SyndromeCompartment Syndrome
Thank YouThank You
Mohammed Al-Omran, Mohammed Al-Omran, MD, MSc, FRCSCMD, MSc, FRCSCAssistant Professor & ConsultantAssistant Professor & Consultant
Vascular Surgery Vascular Surgery King Saud University King Saud University