Leiriches syndrome(aortoiliac disease)claudication of the buttocks and thighs,absent or decreased femoral pulses,impotence
Introduces by reneefontaine
The right hip extensors concentrically contract to extend the hip the knee extensors eccentrically contract to allow the knee to bendthe knee extensors contract concentrically to extend the knee and straighten the leg late part where the hip flexors contract eccentrically to control the movement of the pelvis by the action of the right ankle plantar flexors (posterior calf compartment muscles, the most important of which are the gastrocnemius and soleus). Functionally, these muscles contract concentrically and accelerate the trunk forward and upward over the left leg
Main brought by exercise not rest or standing long time,doesnotvary.cramping,tightnessbuttocks,calf,thigh stops after restPain at feet or toes at night
In normal patients, the feet quickly turn pink. If, more slowly, they turn red like a cooked lobster, suspect ischemia.One leg at a time. With the patient supine, empty the superficial veins by 'milking' the leg in the distal to proximal direction. Now press with your thumb over the saphenofemoral junction (4 cm below and 4 cm lateral to the pubic tubercle) and ask the patient to stand while you maintain pressure. If the leg veins now refill rapidly, the incompentence is located below the saphenofemoral junction, and vice versa
Bun-blood urea nitrogen
ABI=0.9 and 1.2lesser than 0.9 indicates arterial disease. greater than 1.3 is also calcification of the walls of the arteries and incompressible vessels, reflecting severe peripheral vascular disease.<30-20mmhg-critical limb ischemia
MR angio-arteriesCt-with contrast dyes
Smokers have up to a tenfold increase between two and four times increased Dyslipidemia (high low density lipoprotein [LDL] cholesterol, low high density lipoprotein [HDL] cholesterol) - elevation of total cholesterol, LDL cholesterol, and triglyceride levels each have been correlated with accelerated PAD
Periphral Arterial Disease
Peripheral Vascular Disease- Legs By, Kriti Chakrabarty, 6th year
Overview• Commonly referred to as peripheral arterial disease (PAD) or peripheral artery occlusive disease (PAOD),• A disease of the peripheral blood vessels Characterized by narrowing and hardening of the arteries that supply the legs and feet• The decreased blood flow results in nerve and tissue damage to the extremities
Incidence • PVD is a very common disorder • Most common in men over 50 years of age.
Epidemiology• The prevalence of peripheral vascular disease in the general population is 12– 14%, affecting up to 20% of those over 70,70%–80% of affected individuals are asymptomatic; only a minority ever require revascularization or amputation. Peripheral vascular disease affects 1 in 3 diabetics over the age of 50.• The incidence of symptomatic PVD increases with age, from about 0.3% per year for men aged 40–55 years to about 1% per year for men aged over 75 years. The prevalence of PVD varies considerably depending on how PAD is defined, and the age of the population being studied
In India• A population-based study in South India reported a prevalence of PAD of 6.3% amongst diabetics compared to 3.2% in the whole population.• This contrasts with a population- based study from the United States which reported the PAD prevalence to be 22% in its diabetic cohort as compared to 3% in people with normal glucose tolerance
Onset• PVD has a gradual onset• Initially asymptomatic until secondary complications develop such as:Claudication - pain, weakness, numbness, or cramping in muscles after walking or exercise.
• Sores, wounds, or ulcers that heal slowly or not at all
Noticeable change in color (blueness or paleness) or temperature (coolness) when compared to the other limbDiminished hair and nail growth on affected limb and digits.When peripheral artery disease becomes severe, you may have:Impotence(Leiriche syndrome)Pain and cramps at night
The 5 P’s• Pulselessness• Paralysis• Paraesthesia• Pain• Pallor
Classification• Peripheral artery occlusive disease is commonly divided in the Fontaine stages:1. Mild pain when walking (claudication), incomplete blood vessel obstruction;2. Severe pain when walking relatively short distances (intermittent claudication), stage IIa : pain triggered by walking "after a distance of >150 m stage II-b after <150 m3. Rest pain, mostly in the feet, increasing when the limb is raised;4. Biological tissue loss (gangrene) and difficulty walking.
A more recent classification by Rutherford consists of three grades and six categories • Mild claudication • Moderate claudication • Severe claudication • Ischemic pain at rest • Minor tissue loss • Major tissue loss
Pathophysiology:• PVD, also known as arteriosclerosis obliterans, is primarily the result of atherosclerosis. The atheroma consists of a core of cholesterol joined to proteins with a fibrous intravascular covering.• Vascular disease may manifest acutely when thrombi, emboli, or acute trauma compromises perfusion.
Dx:• Patient History-HTN ,DM , Family history , pain?• Physical Examination:Habitus , Constitution of the person ,Discoloration , Mass of muscle , Hair and nail growth on the limb area , TemperatureAusculatation: Over the precordium and the affected limb of region.• A whooshing sound with the stethoscope over the artery (arterial bruits)• Decreased blood pressure in the affected limb• Weak or absent pulses in the limb
Physical Assessment• Femoral pulses: check above the inguinal fold• Popliteal pulse is behind the knee• Doralis Pedis is on the top of the foot and the posterior tibial pulse in on the medial aspect of the ankle
Buergers test -You can illicit elevation pallorby elevating the leg while the patient is on theexam table. The skin becomes very pale. Havethe patient sit up and you see the leg go frompale to hyperemic as depictedBrodie-Trendelenburg Test (assessment ofvalvular competence if varicose veins)
DDx:• Aneurysm, Abdominal• Ankle Injury, Soft Tissue• Back Pain, Mechanical• Deep Venous Thrombosis and Thrombophlebitis• Lumbar (Intervertebral) Disk Disorders• Venous disease• Trauma, Peripheral Vascular Injuries
Lab Studies• Routine blood tests generally are indicated in the evaluation of patients with suspected serious compromise of vascular flow to an extremity.• CBC, BUN, creatinine, and electrolytes studies help evaluate factors that might lead to worsening of peripheral perfusion..• Lipid Profile, Coagulation etc
• An ECG may be obtained to look for evidence of dysrhythmia, chamber enlargement, or MI.• Elevated levels of inflammatory blood markers such as D dimer, C-reactive protein, interleukin 6, and homocysteine have been linked to decreased lower extremity tolerance of exercise
Imaging Studies• Doppler ultrasound exam of an extremity-to determine flow status. Lower extremities are evaluated over the femoral, popliteal, dorsalis pedis, and posterior tibial arteries. Note the presence of Doppler signal and the quality of the signal (ie, monophasic, biphasic, triphasic)• Magnetic resonance angiography or CT angiography• Modern multislice computerized tomography (CT) scanners provide direct imaging of the arterial system as an alternative to angiography
Other tests• Blood pressure measured in the arms and legs for comparison (ankle/brachial index, or ABI)• Treadmill test-to confirm PAD• Transcutaneous oximetry affords assessment of impaired flow secondary to both microvascular and macrovascular disruption.
• Angiography of the arteries in the legs (arteriography)
Risk factors• Smoking.• Diabetes mellitus• Dyslipidemia• Hypertension• Risk of PAD also increases in individuals who are over the age of 50,• male,• obese, or• with a family history of vascular disease, heart attack, or stroke.• Other risk factors which are being studied include levels of various inflammatory mediators such as C- reactive protein, homocysteine
Treatment• Emergency-ABC, Heparin• Lifestyle Changes• Smoking cessation• Management of diabetes-feet• Management of hypertension.• Management of cholesterol, and medication with antiplatelet drugs. Medication with aspirin, clopidogrel and statins, which reduce clot formation and cholesterol levels, respectively• Regular exercise for those with claudication helps open up alternative small vessels (collateral flow)
Cont.• Cilostazol or pentoxifylline treatment to relieve symptoms of claudication.• Treatment with other drugs or vitamins are unsupported by clinical evidence, "but trials evaluating the effect of folate and vitamin B-12 on hyperhomocysteinaemia, a putative vascular risk factor, are near completion".
Revascularization• After a trial of the best medical treatment outline above, if symptoms remain unacceptable, patients may be referred to a vascular or endovascular surgeon.• Angioplasty (PTA or percutaneous transluminal angioplasty) can be done on solitary lesions in large arteries, such as the femoral artery, but angioplasty may not have sustained benefits.• Plaque excision, in which the plaque is scraped off of the inside of the vessel wall.
• Occasionally, bypass grafting is needed to circumvent a seriously stenosed area of the arterial vasculature. Generally, the saphenous vein is used, although artificial (Gore-Tex) material is often used for large tracts when the veins are of lesser quality.• Rarely, sympathectomy is used - removing the nerves that make arteries contract, effectively leading to vasodilatation.• When gangrene of toes has set in, amputation is often a last resort to stop infected dying tissues from causing septicemia.• Arterial thrombosis or embolism has a dismal prognosis, but is occasionally treated successfully with thrombolysis.
Guidelines• Several different guideline standards have been developed, including:• TASC II Guidelines• ACC/AHA Guidelines
Prognosis• Individuals with PAD have an "exceptionally elevated risk for cardiovascular events and the majority will eventually die of a cardiac or cerebrovascular etiology";• prognosis is correlated with the severity of the PAD as measured by the Ankle brachial pressure index (ABPI). Large-vessel PAD increases mortality from cardiovascular disease significantly. PAD carries a greater than "20% risk of a coronary event in 10 years".• There is a low risk that an individual with claudication will develop severe ischemia and require amputation, but the risk of death from coronary events is three to four times higher than matched controls without claudication. [• Of patients with intermittent claudication, only "7% will undergo lower extremity bypass surgery, 4% major amputations, and 16% worsening claudication", but stroke and heart attack events are elevated, and the "5- year mortality rate is estimated to be 30% (versus 10% in controls)"