1. Peripheral Arterial Disease
Check the Pedal Pulse
Alaa Wafa . MD
Associate Professor of Internal Medicine
PGDIP DM Cardiff University UK
Diabetes & Endocrine Unit.
Mansoura University
2014
2. Amputation every 30 Seconds
Every 30 Sec. there is an Amputation
somewhere in the World
The global burden of diabetic foot disease. Lancet. Vol 366 November 12, 2005
4. Peripheral Arterial Disease
Progressive Atherosclerotic Partial
or Complete Obstruction
of one or more Arteries below the
Aortic Bifurcation
Academic
Definition
Robert S. et al.: Peripheral Arterial Disease Textbook. McGraw-Hill, USA. 2009.
PAD = PVD = PAOD = LEAD
ABI<0.9isHemodynamicDefinitionofPAD
5. Academic Definition of PAD.
Progressive Atherosclerotic Partial or Complete obstruction
of one or more Arteries below the Aortic Bifurcation
6. Prevalence of PAD by
Age Group
Eur J Vasc Endovasc Surg 2007; 33: S7
National Heart, Lung & Blood Institute, USA.
5% from adults > 50 years
20% from adults > 65 years
8. Intermittent Claudication
• Muscle discomfort may vary from patient to
other, resulting in different terms
• Pain
• Cramps
• Tightness
• Heaviness
• Burning
• Weakness
• Fatigue
• Collaterals acts as Stabilizing Factor
Robert S. et al.: Peripheral Arterial Disease Textbook. McGraw-Hill, USA. 2009.
9. Limitations of Symptomatic Diagnosis
Only 1 in 10 of these patients
has classical symptoms of
intermittent claudication (IC)
Diabetic Neuropathy
Sedentary Life
10. Stage Clinical Presentation
Stage I Asymptomatic
Stage II IIa: Mild Claudication
IIb: Severe Claudication
Stage III Rest Pain
Stage IV Tissue Loss (Ulceration and/or
Gangrene)
Fountain Classification of PAD
Stage III & IV: Critical Limb Ischemia
11. Fate of the Leg
Disabling Claudication or Pain at RestStabilized by
Collaterals
Norgen L. et al.: Intersociety Consensus for PAD (TASC II). Eur J Vasc Endovasc Surg Vol 33, Supplement 1, 2007.
5 Years
Deterioration
12. Fate of the Leg
Critical Limb
Ischemia
Norgen L. et al.: Intersociety Consensus for PAD (TASC II). Eur J Vasc Endovasc Surg Vol 33, Supplement 1, 2007.
Amputation
30%
Mortality
25%
14. Factors Magnifying Critical
Limb Ischemia incidence
Norgen L. et al.: Intersociety Consensus for PAD (TASC II). Eur J Vasc Endovasc Surg Vol 33, Supplement 1, 2007.
15. Diabetes
• Diabetes increases the risk of PAD by
4 Folds as well as Progression to CLI
• In diabetic Patients, every 1% increase
in A1C is accompanied by 26% increase in PAD
• Insulin Resistance is a Major Risk Factor for PAD
• Combined Early Large Vessels involvement with
Neuropathy leads to 10 times need for Major
Amputation (Aggressive Deterioration)
16. Diabetes
• More Severe & Longstanding Diabetes
is associated with more incidence of PAD
• Major Contributor are Advanced Glycated
End Products (AGEs)
– Combined excess Glucose with Collagen Fibers
– AGEs encourage Plaque Formation, Atherosclerosis &
increased trapping of LDL
17.
18. Diabetic Vascular Complications
All patients with diabetes are at risk of developing several chronic
complications, categorized as microvascular and macrovascular1,2
Diabetic
Retinopathy
Microvascular Complications Macrovascular Complications
Diabetic
Nephropathy
Diabetic
Neuropathy
Stroke
Peripheral
Vascular Disease
Heart
Disease
1. Fowler. Clinical Diabetes 2008;26(2):77-82.
2. http://www.who.int/diabetesactiononline/diabetes/basics/en/index3.html
DPNP
19. Diabetic Peripheral Neuropathic Pain:
A Frequent and Debilitating Complication
10%-20% of patients with diabetic peripheral neuropathy
develop pain1
This pain broadly interferes with daily functioning and quality
of life1-4
• General activity
• Walking
• Energy level
• Social activities
• Ability to sleep
• Change in mood, feelings of depression and anxiety
• Overall enjoyment of life
1. Argoff et al. Mayo Clin Proc 2006;81(4 Suppl):S3-11.
2. Boulton. Clin Diabetes 2005;23:9-15.
DPNP 3. Galer et al. Diabetes Res Clin Pract 2000;47(2):123-8.
4. Gore et al. J Pain Symptom Manage 2005;30(4):374-85.
20. Diabetic Neuropathy: Clinical Presentation
Large-fiber
Neuropathy
Small-fiber
Neuropathy
Proximal Motor
Neuropathy
Acute
Mononeuropathies Pressure Palsies
Sensory loss: 0+++
(touch, vibration)
Pain: ++++
Tendon reflex:
N
Motor deficit: 0+++
Sensory loss: 0+
(thermal, allodynia)
Pain: ++++
Tendon reflex: N
Motor deficit: 0
Sensory loss: 0+
Pain: ++++
Tendon reflex:
Proximal motor deficit:
++++
Sensory loss: 0+
Pain: ++++
Tendon reflex: N
Motor deficit:
++++
Sensory loss in nerve
distribution: ++++
Pain: +++
Tendon reflex: N
Motor deficit: ++++
III VI
Truncal
Ulnar
Lateral
popliteal
Median
Reprinted from: Vinik et al. Diabetologia 2000;43(8):957-73.DPNP
23. 1. HISTORY
HISTORY
Duration of
diabetes
Quality of
glycemic
control
Complications
and
comorbidities
Patient foot specific
medical history
Initial
wounding
event
History of
recurrent
wounds
Previous
wound
healing
Prior
diagnostic
testing
Prior treatment
and response
Social
history
26. Signs-
loss of vibratory and position sense
loss of deep tendon reflexes
trophic ulceration
foot drop
muscle atrophy
excessive callus formation
Semmes-Weinstein filament
Biothesiometer
Pulsation of dorsalis pedis artery and
posterior tibial artery
Bruit at iliac or femoral arteries
Skin atrophy
Loss of pedal hair growth
Toe cyanosis
Ulceration or ischemic necrosis
Pallor and rubor after 1-2 minutes of
elevation above heart level
History of claudication
ASSESSMENT OF
NEUROPATHY
ASSESSMENT OF PERIPHERAL
ARTERIAL DISEASE
38. Role of Serotonin in PAD
Serotonin
5-HT2
5 Hydroxytryptamine-2
100% stored in Platelets
•Promotes Platelets Aggregation
•Thrombus Formation
•Augments Aggregating Factors
•RBCs Aggregation (Rouleaux)
•Increase Blood Viscosity
•Direct Vasoconstriction
•Collaterals: Serotonin Sensitive
•Serotonin Sensitivity is defined by
Hyper-reactivity to Serotonin
(increased by Age, Hypertension, ischemia
Atherosclerosis Hypercholesterolemia)
39. Naftidrofuryl Multi Modes of Action
5-HT2
↑ Platelets aggregation
↑ Vasoconstriction
↑ RBCs Rigidity
41. Global Guideline for the Management of
PAD (TASC II).
Inter-Society Consensus for the Management of
Peripheral Arterial Disease
42. Pharmacotherapy
A. Drugs with evidence of clinical utility in claudication
(Grade A)
Blood
Platelets
RBCsV. Smooth
Muscles
5-HT
Naftidrofuryl is the only
available specific Serotonin
S2 - receptor blocker on
blood platelets and
vascular smooth muscles
Global Guideline for the Management of
PAD (TASC II).
10