Chronic peripheral vascular disease

Chronic peripheral vascular disease (Ischaemia(

Assistant prof. Dr.Abdulameer M. Hussein

Objective

To understand the chronic peripheral arterial disease, definition ,causes, clinical features and management.

Chronic peripheral vasculardisease (Ischaemia)

Peripheral vascular disease (PVD), also known as peripheral arterial disease (PAD) or peripheral artery occlusive disease (PAOD), which can result from Atherosclerosis. inflammatory processes leading to stenosisDiabetes Mellitus.Burger’s diseaseSLE, Rheumatoid arthritis Arteriopathy ( pulseless disease = Takayasu’s disease )

PATHOGENESIS

“atherosclerosis is a chronic inflammatory response of the arterial wall initiated by injury to the endothelium”

Atherosclerosis is a slow, complex disease in which fatty substances, cholesterol, cellular waste products, calcium, and other substances build up – called plaque - in the inner lining of an artery.Arteriosclerotic vascular disease is a condition where the arteries become narrowed and hardened due to an excessive build up of plaque around the artery wall. The disease disrupts the flow of blood around the body, posing serious cardiovascular complications

Risk Factors For Atherosclerosis 

Major Risk factor
A) constitutional Age Sex Genetic Familial B) Acquired Hyperlipidemia Hypertension Cigarette smoking Diabetes mellitus


Minor Risk factors
Environmental influence Obesity Hormone estrogen def Physical inactivity Stress Infection(C. pneumonia CMV) Homocystin urea Alcohol

Complications of atherosclerosis1- Narrowing of vascular lumen … chronic ischemia.2- Superimposed thrombosis … acute ischemia.3- Ulceration with liberation of fatty core … acute ischemia, fat emboli, DIC.4- Pressure atrophy of the media with fibrosis….weakening of the wall …. Aneurysmal dilatation.5- Dystrophic calcification.

Major manifestations of atherothrombosis include

Cerebrovascular disease Coronary artery disease Renal artery stenosis Visceral arterial disease Peripheral arterial disease Intermittent claudication Critical limb ischemia


Prevalence and IncidenceThe prevalence of peripheral vascular disease in people aged over 55 years is 10 – 25% and increases with age. 70 – 80% of affected individuals are asymptomatic. Only a minority requires revascularization or amputation.

Patients have a decreased quality of life due to a reduction in walking distance and speed leading to immobility Ranges in severity from intermittent claudication to limb ischemia Can present with buttock, thigh, calf or foot claudication singly or in combination Diminished pulses with occasional bruits over stenotic lesions Poor wound healing, unilateral cool extremity, shiny skin, hair loss, and nail changes
Clinical Presentation

Only 1 in 10 patients with PAD has classical symptoms of intermittent claudication

1 in 5 people over 65has PAD† † ABI<0.9

Claudication

literally 'limping' (Latin), is a medical term usually referring to impairment in walking, or pain, discomfort or tiredness in the legs that occurs during walking and is relieved by rest.

Claudication

FootOcclusive disease of the tibial and peroneal vesselsCalf Cramping in upper 2/3 usually due to SFA stenosisThighUsually occlusion of the common femoral arteryButtock and HipAortoiliac occlusive disease (Lariche’s syndrome)

Classification I: mild pain on walking ("claudication) II: severe pain on walking relatively shorter distances (intermittent claudication) III: rest pain . IV: tissue loss (gangrene).

Natural History of PAD

Associated with significant mortality because of association with coronary and cerebrovascular events including death, MI, and stroke 6x more likely to die within 10 yrs than patients without PAD 5 yr mortality rate in pts with claudication is about 30% Continued use of smoking results in a two fold risk of mortality

Evaluation

Inspection -hair -capillary refill -cyanosis/rubor -edema -nails -foot architecture/callouses -cellulitis -ulcers -gangrene

Palpation

Sitting Supine

Findings Suggestive of PVD

Decreased Pulses -Femoral -Popliteal -Dorsalis Pedis -Posterior Tibial Muscle atrophy/hair loss/nail changes Dependent Rubor Ulcers/Gangrene

Evidence of poor wound healing in the area where the blood flow is restricted Decreased blood pressure in an affected limb Whooshing sounds (bruits) over the arteries, heard with a stethoscope Signs of a pulsating bulge (aneurysm) in the abdomen or behind the knee


Diagnosis Ankle brachial pressure index (ABPI/ABI) which is a measure of the fall in blood pressure in the arteries supplying the legs. A reduced ABPI (less than 0.9) is consistent with PVD. Values of ABPI below 0.8 indicate moderate disease and below 0.5 severe disease. Doppler ultrasound Angiography Computerized tomography (CT) scanners provide direct imaging of the arterial system as an alternative to angiography.

TREATMENT

Dependent on the severity of the disease, the following steps can be taken

Conservative measures

Anti-platelet agents Diabetic control Smoking cessation Anti-hypertensives Statin therapy Weight reduction Exercise rehabilitation Revascularization/PTCA/stenting

Intervention therapy

Indications for intervention (PTA) Persistent limiting claudication that prevents patient from performing daily activities Rest pain Tissue loss Patients who are poor surgical candidates Long term success of PTA depends on site and length of the lesion Limited to focal, short segment occlusions No significant difference in outcome between PTA or surgery

Angioplasty (PTA or percutaneous transluminal angioplasty) can be done on solitary lesions in large arteries, such as the femoral artery. Plaque excision, in which the plaque is scraped off of the inside of the vessel wall.

Surgical therapy

Lesions might be better treated surgically if: Long segments Multi focal stenosis Eccentric, calcified lesions

We may do Bypass grafting. Sympathectomy . Amputation

BURGER’S DISEASE It is called Thrombo angitis oblitrans because histologically was characterized by thrombosis in both arteries and veins, and were associated with marked inflammatory response which may lead to complete obstruction it affect medium and small vessel , usually femoral and brachial arteries are not involved.

Clinical features It begins in young adult life between 20 -35 years Associated with smoking especially early smoking Exacerbation with smoking Remission with stop smoking Cold sensitivity Intermittent claudication Rest pain Pale & cold Numbness and Paraesthesia Diminish pulses May be gangrene

Thromboangitis Obliterans

TREATMENT Conservative treatment Surgical treatment Sympathectomy Amputation when gangrene develop

RAYNAUD’S DISEASE Is a disease characterized by episodic attacks of vasospasm causing closure of the small sized arteries and arteriole of the distal part of the extremity in response to cold exposure or emotional stimuli, it usually affect upper limb arteries

Pathology The condition is attributed to abnormal sensitivity in the direct response of the artery to cold. When cooled these vessels go into spasm and as a result the part become pale, then the decrease in the blood flow lead to accumulation of metabolite in the capillaries so the capillaries dilated and become filled with deoxygenated blood so the part become swollen and dusky.

As the attack passes off the arteries relax, oxygenated blood returns into the capillaries so hands become red with burning pain. Later oblitrative changes occur leading to ischemic changes of the tips of the fingers

Raynauds’ Disease

Clinical Features Burning pain in the fingers. Color changes ( pallor, cyanosis and redness). Normal peripheral pulses. Later ulceration and gangrenous changes.

TREATMENTAvoid the causative factors Operative treatment – Dorsal sympathectomy

THANK YOU