Dr Asso Amin (MRCP-UK)

Anatomy Abdominal Aorta divides to 2 Common Iliac arteries at L4 Common iliac artery divides to external and internal iliac

arteries External Iliac artery passes downwards on the medial aspect

of psoas muscle to the inguinal ligaments. As it enters the thigh it becomes the common femoral artery Divides into superficial and deep iliac artery Superficial femoral artery passes on the medial aspect of the

femur in middle third of thigh Enters the adductor canal and becomes the popliteal artery

after it exits the inferior aspect of the canal Anterior tibial and posterior tibial

PathophysiologyAtheroslerotic lesion.Non Atherosclerotic causes of PAD 1. Acute arterial disease2. vasospam3. radiation4. takayasu’s disease5. Buergers disease6. fibromascular dysplesia 7. compartment syndrome

Epidemiology PAD is defined as an ABPI of less than 0.90 in either

leg . 10% , raising to 15-20% over the age of 70. affects 27

Million people in Europe and North America. NHANES ,PAD presents in 0.9% aged 40-49 , and 15%

above 70 . PARTNERS , 7000 patients over 70 or 50-69 with DM or

current smoker.PAD has 6 fold increase risk of death from CVD than

without PAD

Major risk factors-: 1. Age ,sex and ethnicity

2. Smoking .Edinburgh Artery Study

3. Diabetes meta-analysis of 13 studies found that 1% increase of Hb1ac increase risk of PAD by 26% . Also faster progression and 10 times more likely to need major amputation.

4. Hypertension and Hyperlipidaemia . Framingham Heart Study

5. CKD

Clinical Presentation A symptomatic :- Progression to other stages less than 20% PAD reports typical features The role of treatment.

Claudication Critical Limb Ischemia –Chronic Acute Limb Ischemia

Diagnostic Evaluation Physical examination Ankle Brachial Index and Toe brachial Index Normal values 0.9-1.3 Mild Obstruction 0.7-0.9 Moderate Obstruction 0.5-0.7 Severe Obstruction <0.5 ABI threshold of 0.9 has 95% sensitivity and 100%

specificity False positive in non compressible vessels ,should be

suspected when ABPI is more than 1.3 or systolic BP lower is higher by 20mmHg or 20%

Non compressible vessel expected in DM, and CKD

Diagnostic Evaluation Segmental Pressure Measurements Continuous wave Doppler Treadmill Exercise Testing with ABI Vascular treadmill testing –less intense( Gardner –Skinner

Bruce Control or Hiatt protocols) ECG at same time Symptoms or protocol completion limited After completion –supine position and record at 1 min

interval Alternative 6 min walk or paedal plantar flexion test .

Diabetic foot Toolkit Assessment

Vascular Doppler with Continuous Wave form

Diagnostic Evaluation Duplex USS Sensitivity 90% , specificity 95%

Computed Tomographic Angiogram (CTA) location and stenosis severity.

MRA Contrast Angiogram

Screening for a symptomatic patients patient age above 70 years patient between 50-70 and CVD risk

factors patient below 50 with diabetes& CVD

risk factors

Screening is done by symptoms and ABI

Critical Limb Ischemia Evaluation Conformation of diagnosis Localizing the lesion Assessment for need for revascularization Assessment for operative risk ( Lee’s Revised

operative risk assessment)

History and examination Hematological and Biochemical Hb1AC%,Lipid,GUE Ankle/Toe pressure index Lower limb vascular imaging Duplex scan of carotid artery ( high risk) Coronary assessment

Management Supervised exercise programs Cilostazol:- Phosphodiesterase enzyme inhibitor that

increase C-Amp . Has antiplatelets and vasodilator effect Seven RCT ( improve walking distance by 40-60%) ,100mg

BD

SE headache, flushing, dizziness, CI :- HF

Anti-platelets :- Antithrombotic trialists meta analysis on 135000 patients ,

shows reduction of vascular death by 22% Reduce risk of PAD progression CHARISMA STUDY

Management Anti-Hypertensive Improve endothelial function and CVD mortality Ramipril reduce risk of CVD in PAD by 25% . Recommended

for both symptomatic and a symptomatic ?? B- blockers

Lipid Lowering agent- Traget LDL of less than 130mg/dl , Treatment of DM Smoking cessation L-Carnitine – 2 multicentre study ,700 patients , improve

walking distance

Surgical Management Pre-operative risk assessment and Risk

reduction.( Goldmans and Destky&Lee Revised risk)