perepheral arterial disease

Peripheral arterial disease Zahid Bahli Trust assistant Surgeon 04/03/20 :

Peripheral arterial disease Zahid Bahli Trust assistant Surgeon 04/03/20

Definition:

Definition Patients with compromised blood flow to the extremities as a consequence of peripheral artery disease (PAD) . Intermittent claudication (derived from the Latin word for limp) is defined as a reproducible discomfort of a defined group of muscles that is induced by exercise and relieved with rest. This disorder results from an imbalance between supply and demand of blood flow that fails to satisfy ongoing metabolic requirements.

Clinical Manifestation:

Clinical Manifestation Although many diseases can cause intermittent claudication, the vast majority of patients with claudication suffer from PAD.

Prevalence:

Prevalence 27 million affected individuals 413,000 hospital discharges of patients with chronic PAD per year with 88,000 hospitalizations involving lower extremity arteriography and 28,000 discharges for embolectomy or thrombectomy of lower limb arteries.

Risk Factors:

Risk Factors The risk factors that favor the development of peripheral artery disease (ie,hyperlipidemia, smoking, hypertension, diabetes) are similar to those that promote the development of coronary atherosclerosis

Clinical presentation:

Clinical presentation

Clinical Presentation:

Clinical Presentation Asymptomatic — 20 to 50 percent Atypical leg pain — 40 to 50 percent Classic claudication — 10 to 35 percent Critical limb ischemia — 1 to 2 percent

Symptomatic Disease:

Symptomatic Disease Among symptomatic patients, the perception of claudication can vary from severe, debilitating discomfort at rest to a bothersome pain of seemingly little consequence. The severity of symptoms of claudication depends upon the degree of stenosis, the collateral circulation, and the vigor of exercise.

Distribution:

Distribution Buttock and hip — aortoiliac disease Thigh — aortoiliac or common femoral artery Upper two-thirds of the calf — superficial femoral artery Lower one-third of the calf — popliteal artery Foot claudication — tibial or peroneal artery

Diagnosis:

Diagnosis Good history Clinical examination Bedside test- Ankle Brachial Pressure Index (ABPI).

Ankle Brachial Pressure index (APBI):

Ankle Brachial Pressure index (APBI) ABPI (leg)= P(leg)/P(arm) ABPI value under 0.5 - Severe arterial disease ABPI value between 0.5 to 0.8 - Moderate arterial disease ABPI value between 0.8 to 0.9 - Slight arterial problem ABPI value between 0.9 to 0.10 - Acceptable and normal ABPI value between 1.0 to 1.2 - Normal range ABPI value more than 1.2 – presumed marker of vascular stiffness.

Major differential diagnosis of intermittent claudication:

Major differential diagnosis of intermittent claudication Condition Location of pain or discomfort Character- istics of discomfort Onset relative to exercise Effect of rest Effect of body position Other features Intermittent claudication Buttock, thigh, or calf muscles and rarely the foot Cramping, aching, fatigue, weakness, or frank pain After same degree of exercise Quickly relieved None Reproducible Nerve root compression (such as herniated disc) Radiates down leg, usually posteriorly Sharp lancinating pain Soon, if not immediately after onset Not quickly relieved (also often present at at rest) Relief may be aided by adjusting back position History of back problems Spinal stenosis Hip, thigh buttocks (follows dermatome) Motor weakness more prominent than pain After walking or standing for same length of time Relieved by stopping only if position changed Relief by lumbar spine flexion (sitting or stooping forward) Frequent history of back problems, provoked by intraabdominal pressure Hip arthritis Hip, thigh, buttocks Aching discomfort, usually localized to hip and gluteal region After variable degree of exercise Not quickly relieved (and may be present at rest) More comfortable sitting, weight taken off legs Variable, may relate to activity level, weather changes Arthritic, inflammatory processes Foot, arch Aching pain After variable degree of exercise Not quickly relieved (and may be present at rest) May be relieved by not bearing weight Variable, may relate to activity level Venous claudication Entire leg, but usually worse in thigh and groin Tight, bursting pain After walking Subsides slowly Relief speeded by elevation History of iliofemoral deep vein thrombosis, signs of venous congestion, edema

Investigations:

Investigations Duplex ultrasound CT angiogram/MR angiogram Formal angiography/angioplasty Other relevant investigation related to underlying condition like Diabetes

Treatment :

Treatment Once the diagnosis is established, Risk factor modification, Exercise, Pharmacology Percutaneous intervention Surgery.

What does exercise do:

What does exercise do Improved endothelial dysfunction via increases in nitric oxide synthase and prostacyclin. Reduced local inflammation that is induced by muscle ischemia by decreasing free radicals. Increased exercise pain tolerance. Induction of vascular angiogenesis. Improved muscle metabolism by favorable effects on muscle metabolism and other pathways. Reductions in blood viscosity and red cell aggregation.

No smoking:

No smoking warning consequences

Loose weight:

Loose weight

Pharmacological treatment:

Pharmacological treatment Pharmacologic therapy of claudication is aimed at symptomatic relief or slowing the progression of the natural disease. A number of drugs have been evaluated but, as will be seen, the evidence of benefit is convincing only for antiplatelet agents, usually aspirin , and cilostazol . Statins and antihypertensive .

Statins and precautions:

Statins and precautions To be taken at night. Deranged liver function tests- LFTs to be checked before and at 3 month after starting Avoid grapefruit- affects absorption . Generalised muscle pains-immediate medical attention and CK estimation for rhabdomyolysis.

Surgical/interventional options:

Surgical/interventional options PTA (percutaneous transluminal angioplasty). ENDARTERECTOMY AND PATCH REPAIR BYPASS SURGERY

Worsening clinical situation and priorities:

Worsening clinical situation and priorities Limb salvage. Pain control often -require opioids Treatment of infection/wet gangrene Wound healing

Critical ischemia:

Critical ischemia Limb-threatening ischemia occurs when arterial blood flow is insufficient to meet the metabolic demands of resting muscle or tissue; it is the most common indication for lower extremity arterial reconstruction. It has been estimated that limb-threatening ischemia occurs in 1 to 2 percent of patients with peripheral arterial disease (PAD) who are 50 years of age or older

Sometime….:

Sometime…. We are not always winning the battle…..

Amputation:

Amputation Ancient surgery stump

Questions Thanks:

Questions Thanks