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Peripheral Vascular Disease

Mr Kamel Muhammad, MD, JBGS, MRCS (Ir)


Vascular & Endovascular SPR Registrar
The Countess of Chester NHS Foundation Trust

Tuesday, 30 October 2018


Review of Arterial Anatomy
What is Peripheral Vascular Disease?

• PVD: refers to diseases of blood vessels outside the heart and brain. It's
often a narrowing of vessels that carry blood to the legs, arms, stomach or
kidneys. There are two types of these circulation disorders:

1. Functional
2. Organic
What is Peripheral Vascular Disease?

1. Functional peripheral vascular diseases don't have an organic cause.


They don't involve defects in blood vessels' structure. They're usually short-
term effects related to "spasm" that may come and go.
Raynaud's disease is an example. It can be triggered by cold
temperatures, emotional stress, working with vibrating machinery or
smoking.
What is Peripheral Vascular Disease?

2. Organic peripheral vascular diseases are caused by structural changes


in the blood vessels, such as inflammation and tissue damage. Peripheral
artery disease is an example. It's caused by fatty build-ups in arteries that
block normal blood flow.
Scope & Prevalence
• PVD affects around 13% of the Western population who are more than 50 years
old.
• 14-18 million have PAD (in the US)
• 3x greater risk for diabetics over the age of 50
• 60% of patients with PVD will have IHD, and 30% have Cerebrovascular disease.
• Within 5 years of diagnosis, 25% of patients with intermittent claudication will die
from cardiovascular disease.
Mortality
• Life expectancy reduced 10 years in patients with PVD
• Mortality rate
• ~ 25% at 5 years
• ~ 50% at 10 years
• ~ 75% at 15 years
• 75% of deaths caused by cardiovascular events
PAD Risk Factors - NON-MODIFIABLE RISKS:

1. Age. The risk of limb loss due to PAD increases with age. People 65 or older are two to three times
more likely to have an amputation.
2. Gender. Men with PAD are twice as likely to undergo an amputation as women.
3. Race/ethnicity. Some racial and ethnic groups have a higher risk of amputation (i.e., African
Americans, Latino Americans, and Native Americans). This is because they are at increased risk for
diabetes and cardiovascular disease.
4. Family history of heart disease. A family history of cardiovascular disease is an indicator for risk
at developing PAD.
PAD Risk Factors - MODIFIABLE RISKS:

1. Cigarette smoking. Smoking is a major risk factor for PAD. Smokers may have 4X the risk of PAD than non-smokers.
2. Obesity. People with a BMI of 25 or higher are more likely to develop heart disease and stroke even if they have no other risk
factors.
3. Diabetes mellitus. Having diabetes puts individuals at greater risk of developing PAD as well as other cardiovascular diseases.
4. Physical inactivity. Physical activity increases the distance that people with PAD can walk without pain and also helps decrease
the risk of heart attack or stroke. Supervised exercise programs are one of the treatments for PAD patients.
5. High blood cholesterol. High cholesterol contributes to the build-up of plaque in the arteries, which can significantly reduce
the blood's flow. This condition is known as atherosclerosis. Managing cholesterol levels is essential to prevent or treat PAD.
6. High blood pressure. When blood pressure remains high, the lining of the artery walls becomes damaged. Many PAD patients
also have high blood pressure.
7. High levels of Homocysteine. This is an amino acid found in plasma (blood). Some recent studies show higher levels are
associated with PAD.
Causes of PVD
1. Atherosclerosis 2. Others
• Most common aetiology • Aneurysms (hereditary or acquired)
• Trauma / Radiation
• Closely associated with coronary artery disease
(CAD), cerebrovascular diseased (CVD), AAA, renal • Infection
artery stenosis, mesenteric ischemia, and their risk • Functional spasms (e.g., Raynaud syndrome)
factors • Vasculitis (e.g., Buerger's disease, aka
thromboangitis obliterans)
• Anatomic abnormalities (e.g., popliteal
entrapment syndrome in young pts)
Occlusive Arterial Disease Classification
• Arterial Insufficiency (2 types): b) Thrombosis is a blood clot that occludes a
vessel
1. Acute
• Embolic or an unstable atherosclerotic plaque • If detached it becomes an embolus
rupturing and creating a thrombosis or clot • Emboli usually come from the heart during
an MI or A-Fib, can come from other areas
• 80% in lower extremities
and attach itself (usually attaches at
• Definition/Clarification: bifurcations or narrowing areas)
a) Embolus is a foreign substance or blood clot • Creates loss of circulation to areas below it
(liquid, solid, or gas) transported by the blood or
lymphatic system ex. clot, air, fat.
• S/SX: 6 Ps (pulselessness, pallor, Perishing
cold, pain, paraesthesia, and paralysis)
Occlusive Arterial Disease Classification
2. Chronic b) Atherosclerosis
• Results in inhibited or total blockage of flow • Atherosclerosis is this build-up of plaque
• 2 types: • Result of calcium or cholesterol deposits
(plaque) inside the tunica intima
a) Arteriosclerosis
• Arteriosclerosis is part of the aging process
creates hardening of the arteries= less elastic
• Atheroma=thickening of tunica intima seen
with arteriosclerosis
Signs & Symptoms
• Pain. It occurs because the body is unable to deliver • Cool temperature of the foot and leg
enough blood to the feet.
• A sore on the foot that does not heal
• Decreased hair growth on the legs
• Fatigue in legs which may require may require patient
• Paleness of the leg or foot when elevated to stop and rest while walking.
• Blue/red discoloration of the foot when hanging • Slow or shuffled gait + having difficulty keeping up
down
with others.
• Absence of pulses in the foot
• Impotence may be a sign of iliac disease.
• Numbness, tingling, or pain in the foot, toes or leg
• Decreased ability to spread the toes and move the
foot
PAD Clinical Syndromes
Rutherford Classification

“Critical Limb Ischemia”


• Amputation rate 10-40%
• 3x MI, Stroke, Vascular
Death (c/w claudicants)
• Implies chronicity
Evaluation of PVD
• History
• Physical Examination
• Vascular Tests
History
• History—the most important aspect of the diagnostic evaluation
of PAD
• Location of symptoms
• Description of discomfort
• Exacerbating/ameliorating characteristics
• Reproducible symptoms
Physical Examination

• The physical examination is integral to the diagnosis of PVD.


Specifically evaluating a patient’s pulses, palpating for aneurysms,
auscultating for bruits, blood pressure measurement in the extremities,
evaluation of temperature, colour, sensation, and motion of the legs,
and presence of skin breakdown, ulceration or overt gangrene can in
making the diagnosis.
Physical Examination
• Absent or diminished femoral or pedal pulses (especially after exercising the limb)
• Arterial bruits
• Hair loss
• Poor nail growth (brittle nails)
• Dry, scaly, atrophic skin
• Dependent rubor (reddish, blue colour in dependent position).
• Pallor with leg elevation after 1 minute at 60 degrees (normal colour should return in 10 to 15 seconds; longer than 40
seconds indicates sever ischemia) – aka Buerger's test

• Ischemic tissue ulceration (punched-out, painful, with little bleeding), gangrene.


Physical Examination - Ankle-Brachial Index

• Simple, painless, accurate, highly reproducible examination


• Clinically useful
• Identifies patients with PAD
• Major indicator of premature MI, CVA, mortality
• Indications
• Any patient with suspicion for PAD
• Any patient at risk of PAD
• Age 50 or greater with history of DM or tobacco use
• Age 70 or greater regardless of risk factors
Physical Examination - Ankle-Brachial Index

• How to perform
• Patient resting supine for 5-10 minutes
• Continuous wave, hand-held Doppler
• Measure systolic BP in both arms
• Higher value is DENOMINATOR of ABI
• Measure systolic BP in DP and PT
• Higher value is NUMERATOR of ABI
Physical Examination - Ankle-Brachial Index
Vascular Tests – Diagnosis of PAD
• Non-invasive techniques • Invasive techniques
• ABI (Ankle/Brachial Index) • Peripheral Angiograms
• Exercise Test • CT Angiograms
• Segmental Pressures • MR Angiograms
• Segmental Volume Plethysmography
• Duplex Ultrasonography
• CT Angiogram
• MRA (Magnetic Resonance Arteriography)
• Carotid Doppler identifies patients who are at
risk for stroke
• Vascular ultrasound
Non-invasive Diagnostic testing:
Duplex ultrasound
• Can accurately localize and quantify lesions.
• Can differentiate between stenosis and occlusions, measure flow
velocities in bypass grafts.
• Requires experienced technician.
Non-invasive Diagnostic testing:
CT Angiogram
• CT: cross sectional images of soft tissue & volume changes
• If patient has renal disease, patient should be hydrated (IV or oral) 12 hrs. before
procedure
• Monitor urinary output post procedure
• Evaluate for iodine or shellfish allergies
• Premedicate -steroids & histamine blockers
Invasive Diagnostic testing:
Contrast Angiography
• Gold standard evaluation of lower extremity ischemia
• Appropriate patient:
• No contraindication (allergy, AKI, risk of cholesterol emboli)
• Expected to undergo revascularization
• Study is from aorta down, bilaterally
• CT or MR angiography can also be used
PAD Intervention Options
• Medical • Surgery
• Risk Factor Modification • Bypass Grafts
• Exercise Therapy
• Drug Therapy • Amputation
• Endarterectomy
• Endovascular Therapy
• Peripheral Transluminal Therapy
• Peripheral Stenting
• Angioplasty
• Laser
• Cryoplasty
• Atherectomy
• Thrombolic Therapy (adjunctive)
Medical - Risk Factor Modification
• Tobacco cessation
• Exercise
• Weight reduction
• Pharmacologic intervention
• Hypercholesterolemia
• Hypertension
• Diabetes
Medical - Risk Factor Modification
• Smoking
• Complete cessation
• Diabetes mellitus
• HbA1c <7.0%, treat other risk factors
• Dyslipidemia
• LDL <100 mg/dL, modify HDL and TG
• Hypertension
• BP <140/90 or <130/80 in diabetes
• ACE inhibitors
• Antiplatelet therapy
• Aspirin or clopidogrel
Medical therapy for Intermittent Claudication
• Symptom/Limb • Life
• Tobacco cessation • Tobacco cessation
• Foot care • Control of DM
• Control of DM • Reduction in cholesterol
• Reduction in cholesterol • Reduction in BP
• Antiplatelet agents • Antiplatelet agents
• Exercise • Exercise
• Cilostazol
• Angiogenesis
• Gingko biloba
Endovascular Interventions
• Percutaneous transluminal angioplasty (PTA)
• Stenting
• Thrombolysis
Surgical Interventions
• Bypass grafts
• Amputation

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