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Peripheral Vascular Disease

Karthik Vamanan, MD
Asst. Prof. Dept. of Surgery
Vascular and Endovascular Surgery

Introduction
Vascular insufficiency

Acute
Chronic

Acute Ischemia
Etiology

Thrombosis
Embolism

Other causes
Causes of acute limb ischemia in

atherosclerotic patients

Thrombosis of an atherosclerotic stenotic


artery
Thrombosis of an arterial bypass graft
Embolism from heart, aneurysm, plaque, or
critical stenosis upstream (including
cholesterol or atherothrombotic)
Emboli secondary to endovascular procedures
Thrombosed aneurysm (especially popliteal
aneurysm)

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)

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

Clinical Presentation - Acute


Sudden onset of severe pain

May be silent
May reduce in intensity

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.

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

Differential
Conditions mimicking acute limb ischemia

Heart failure (especially if associated with


chronic occlusive disease)
Acute DVT
Acute compressive neuropathy
Other low flow states including vasopressor
therapy.

Investigation
PE

Non Invasive Laboratory


Angiography / MRA / CTA

DO NOT DELAY

Rx
Percutaneous

Thrombectomy
Thrombolysis

Open

Thrombectomy
Bypass
Fasciotomy?

Treatment

Treatment

Conclusions
Patients with acute limb ischemia face a 1-year

mortality of 10-20%
Treatment of occluded bypass grafts has a better
outcome than treatment of native arteries
Risk of major bleeding increases with thrombolysis
compared with surgical revascularization
Risk of a bleeding complication increases as
coagulopathy worsens (decreased fibrinogen,
prolonged PTT)
Risk of an intracranial bleed is approximately 1-2%
with thrombolysis
Lytic patients require fewer open surgical procedures

Treatment

Epidemiology- Chronic
Incidence between 500 and 1000 per million

population per year


20% of these patients die annually
5-year mortality = 70%

35% cardiovascular disease


9% non-cardiovascular disease

Risk Factors

Age
Family history
Trauma
Smoking
Diabetes
Hypertension - shear forces
Hypercholesterolemia
Hypercoagulable syndromes
Homocysteinemia

PAOD
Spectrum of disease

Asymptomatic Tissue Loss

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

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%

Claudication
Pathogenesis

Arterial obstruction proximal to affected


muscle beds
Limits the normal exercise-induced increase in
blood flow and produces transient muscle
ischemia during exercise

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

Claudication
History

Should be aimed at

Delineation of symptoms
Elimination of differential diagnoses
Presence of risk factors
Identification of other beds of atherosclerosis

Claudication
Specific History

Location of the pain or discomfort


Duration of the symptom
Whether it worsens or improves with time and
whether conservative therapy has had an
effect
Distance the patient can now walk before

experiencing the discomfort


being forced to stop

Claudication
Specific History

Elapsed time after exercise is stopped before


the pain is relieved
Type of rest or position of patient (standing at
rest, sitting, lying) necessary to relieve the
pain
Whether the pain returns after the same time
and distance if exercise is then resumed

Claudication
Differential Diagnosis

Nerve Root Compression


Arthritis and joint problems
DVT
%DNHUV&\VW
Chronic compartment syndrome
Neuropathy
Muscle strain

Critical Limb Ischemia


The TransAtlantic Inter-Society Consensus

(TASC) definition:

Persistent, recurring ischemic rest pain


requiring opiate analgesia for at least 2
weeks,
Ulceration or gangrene of the foot or toes,
AND ankle systolic pressure less than
50mmHg or toe systolic pressure less than
30mmHg (or absent pedal pulses in patients
with diabetes)

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

CLI
History

Prior and other history of vascular disease


Rule out other causes of pain and ulceration

Neuropathy
Venous disease
Infections

Physical Exam
Thorough physical

Peripheral sequelae of ischemia

Wasting
Thin skin
Hair loss
Thick nails

Physical Exam
Pulse exam

Palpate

Presence
Strength
Character

Auscultate

Bruits

Physical Exam
Patterns of Disease

Inflow
Outflow
Combination

H+P
Ischemic ulcers

located distally (on dorsum of foot/toes)


pain relieved by dependency, often occurring
at night
Irregular edge with poor granulation

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

Coexistent Cardiac Disease


20% previous myocardial infarction

7% previous congestive heart failure


4% previous arrhythmia
60% abnormal EKG

7% previous CVA

Investigation
NON-INVASIVE

ABI (ankle brachial index)


Segmental blood pressures
Toe pressures
Pulse volume recordings
Color flow Doppler
MRA

Ankle-Brachial Index

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

Segmental limb pressures

Segmental limb pressures

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

Toe Photoplethysmographic
Waveforms

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

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

Arterial Duplex Scan

MRA

Angiogram

Angiogram

Angiogram

Treatment
Goals

Relieve symptoms

Pain
Infection
Tissue loss

Preserve function
Preserve limb
Risk factor modification
Improve quality of life

Treatment
Medical Management

Risk modification

Statins
Diabetes management
Control hypertension
Cessation of smoking
Exercise

Treatment

Drug therapy

Antiplatelet therapy
Aspirin
Clopidrogel
Ticlopidine

Glycoprotein 11b/111a inhibitors???


Cilostazol

Oxypentifylline??
Pentoxyfylline

Antioxidants and chelation therapy???

Treatment
Endovascular management

Treatment
Surgical

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