INTERNAL    MEDICINE:Vascular Diseasesof the ExtremitiesnianderthalNOTES
VASCULAR DISEASES OF THE   EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Definition: stenosis or occlusion ...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-the highest prevalence of atheros...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:Pathology:-stenosis or occlusion a...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Primary sites of involvement:   1...
VASCULAR DISEASES OF THE     EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-S/Sx:  -50% are asymptomatic  -M...
VASCULAR DISEASES OF THE     EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-S/Sx:   -pts may complain of res...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Non-invasive Testing  *History an...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Non-invasive Testing  2. Ankle:Br...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Non-invasive Testing  4. Treadmil...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Non-invasive Testing  6. Other te...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Prognosis:  -influenced primarily...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Rx:  1. Risk factor modification ...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Rx:  3. ACE inhibitors – symptoma...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Rx:  7. Cilostazol – phosphodiest...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Rx:  *WARFARIN not used in patien...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Rx:  10. Revascularization      -...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersFIBROMUSCULAR DYSPLASIA:-Definition:  -hyperplastic disorder a...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersFIBROMUSCULAR DYSPLASIA:-Histologic classifications:  1. Intim...
VASCULAR DISEASES OF THE   EXTREMITIES – Arterial DisordersFIBROMUSCULAR DYSPLASIA:-S/Sx:  1. Claudication  2. Rest pain-T...
VASCULAR DISEASES OF THE   EXTREMITIES – Arterial DisordersFIBROMUSCULAR DYSPLASIA:-S/Sx:  1. Claudication  2. Rest pain-T...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersTHROMBOANGITIS OBLITERANS / BUERGER’S  DISEASE:-Definition:  -...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersTHROMBOANGITIS OBLITERANS / BUERGER’S  DISEASE:-Pathogenesis:...
VASCULAR DISEASES OF THE      EXTREMITIES – Arterial DisordersTHROMBOANGITIS OBLITERANS / BUERGER’S DISEASE:-S/Sx:   -TRIA...
VASCULAR DISEASES OF THE     EXTREMITIES – Arterial DisordersTHROMBOANGITIS OBLITERANS / BUERGER’S  DISEASE:-Dx:  -excisio...
VASCULAR DISEASES OF THE     EXTREMITIES – Arterial DisordersACUTE ARTERIAL OCCLUSION:-Definition:  -results in the sudden...
VASCULAR DISEASES OF THE     EXTREMITIES – Arterial DisordersACUTE ARTERIAL OCCLUSION:-EMBOLISM  -most common sources: hea...
VASCULAR DISEASES OF THE     EXTREMITIES – Arterial DisordersACUTE ARTERIAL OCCLUSION:-THROMBUS IN SITU  -occurs more freq...
VASCULAR DISEASES OF THE     EXTREMITIES – Arterial DisordersACUTE ARTERIAL OCCLUSION:-S/Sx:   -severe pain, paresthesia, ...
VASCULAR DISEASES OF THE     EXTREMITIES – Arterial DisordersACUTE ARTERIAL OCCLUSION:-Dx:  1. Arteriography      -useful ...
VASCULAR DISEASES OF THE    EXTREMITIES – Arterial DisordersACUTE ARTERIAL OCCLUSION:-Rx:  1. Heparin       -to prevent pr...
VASCULAR DISEASES OF THE     EXTREMITIES – Arterial DisordersATHEROEMBOLISM:-Definition:  -multiple small deposits of fibr...
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INTERNAL MEDICINE - Vascular Diseases of the Extremities

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INTERNAL MEDICINE - Vascular Diseases of the Extremities

  1. 1. INTERNAL MEDICINE:Vascular Diseasesof the ExtremitiesnianderthalNOTES
  2. 2. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Definition: stenosis or occlusion in the aorta or arteries of the limbs-atherosclerosis is the leading cause of PAD in patients >40 years old-other causes: -thrombosis -embolism -vasculitis -fibromuscular dysplasia -entrapment -cystic adventitial disease -trauma
  3. 3. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-the highest prevalence of atherosclerotic PAD occurs in 60s-70s-Risk Factors: -cigarette smoking -hypercholesterolemia -DM -hypertension -hyperhomocysteinemia
  4. 4. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:Pathology:-stenosis or occlusion are usually LOCALIZED TO LARGE AND MEDIUM SIZED VESSELS-include the ff: 1. Atherosclerotic plaques w/ calcium deposition 2. Thinning of the media 3. Patchy destruction of muscle & elastic fibers 4. Fragmentation of the internal elastic lamina 5. Thrombi composed of platelets and fibrin
  5. 5. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Primary sites of involvement: 1. femoral and popliteal arteries 2. tibial and peroneal 3. abdominal aorta and iliac arteries*atherosclerotic lesions occur preferentially at :a.) arterial branch pointsb.) sites of increased turbulencec.) altered shear stressd.) site of intimal injury
  6. 6. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-S/Sx: -50% are asymptomatic -MOST COMMON SYMTPOM: INTERMITTENT CLAUDICATION -Definition: pain, ache, cramp, numbness or sense of fatigue in the muscles, occurs during exercise and relieved by rest, common in lower than upper extremities -the site of claudication is DISTAL to the location of the occlusive lesion e.g. calf claudication- femoral/popliteal lesion
  7. 7. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-S/Sx: -pts may complain of rest pain commonly at night when legs are horizontal and improve when legs are on dependent position -absent/decreased pulses distal to obstruction -bruits -muscle atrophy ISCHEMIC NEUROPATHY: -hairloss -numbness -thickened nails -hyporeflexia -smooth and shiny skin SEVERE ISCHEMIA: -decreased skin temperature -pallor/cyanosis -edema
  8. 8. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Non-invasive Testing *History and physical examination are often sufficient to establish the diagnosis of PAD 1. Arterial Pressure -placement of sphygmomanometric cuffs at the ankles and use of a Doppler device to auscultate or record blood flow from the dorsalis pedis and posterior tibial arteries -NORMAL arms and legs SBP are equal, but ANKLE PRESSURE may be slightly HIGHER DUE TO PULSE-WAVE AMPLIFICATION -SBP in ankle is DECREASED IN STENOSIS
  9. 9. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Non-invasive Testing 2. Ankle:Brachial Index -NORMAL: > 1.0 -PAD: < 1.0 -Severe ischemia: < 0.5 3. Duplex Ultrasonography -image and detect stenotic lesions in native arteries and bypass grafts
  10. 10. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Non-invasive Testing 4. Treadmill Testing / Stress test -allows physician to assess functional limitation objectively -decline in ABI immediately after exercise provides further support for the Dx of PAD 5. Magnetic Resonance Angiography, CT angiography, contrast angiography -not for routine testing but done prior to revascularization
  11. 11. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Non-invasive Testing 6. Other tests -segmental pressure measurements -pulse volume recordings -doppler flow velocity waveform analysis -transcutaneous oximetry
  12. 12. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Prognosis: -influenced primarily by coexistence of: 1. coronary artery disease 2. cerebrovascular disease -most is highest with the most severe PAD -It can be worse in patients who continue to smoke cigarette and those with DM
  13. 13. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Rx: 1. Risk factor modification and antiplatelet therapy should be intiated to improve cardiovascular outcomes 2. Cessation of cigarette smoking -counseling and adjunctive drug therapy with nicotine patch, bupropion or varenicline increases cessation rates and reduces recidivism
  14. 14. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Rx: 3. ACE inhibitors – symptomatic PAD 4. B-adrenergic blockers – HTN with coexistent CAD -reduce post revascularization complications 5. Statins NCEP – LDL cholesterol <100mg/dl 6. Clopidogrel -inhinits platelet aggregation via its effect on ADP-dependent platelet fibrinogen binding -more efficient than aspirin in decreasing M&M
  15. 15. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Rx: 7. Cilostazol – phosphodiesterase inhibitor with vasodilator and antiplatelet properties, increases claudication distance 8. Pentoxifylline – xanthine derivative; decreases blood viscosity to increase red cell flexibility, increasing blood flow to the microcirculation and enhancing tissue oxygenation
  16. 16. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Rx: *WARFARIN not used in patients with CHRONIC PAD 9. Supportive measures -meticulous care of feet -shock blocks under the head of the bed and canopy over the feet -exercise regularly and at progressively more strenuous levels (30-45 min session, 3-5 times/wk for 12 weeks) -advise to walk until near maximum caludication discomfort occurs, then resting until the symptoms resolve before resuming ambulation
  17. 17. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersPERIPHERAL ARTERIAL DISEASE:-Rx: 10. Revascularization -indicated for pts with disabling, progressive, or severe symptoms of intermittent claudication despite medical therapy or those with critical limb ischemia
  18. 18. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersFIBROMUSCULAR DYSPLASIA:-Definition: -hyperplastic disorder affecting medium-sized and small arteries -common in FEMALES -usually involves RENAL and CAROTID arteries but can affect extremity vessels, most common are the ILIAC ARTERIES - “string of beads”” appearance
  19. 19. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersFIBROMUSCULAR DYSPLASIA:-Histologic classifications: 1. Intimal Fibroplasia 2. Adventitial Hyperplasia 3. Medial Dysplasia a. medial fibroplasia -MOST COMMON b. perimedial fibroplasia c. medial hyperplasia
  20. 20. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersFIBROMUSCULAR DYSPLASIA:-S/Sx: 1. Claudication 2. Rest pain-Tx: 1. Percutaneous Transluminal angiography (PTA) 2. Surgical reconstruction
  21. 21. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersFIBROMUSCULAR DYSPLASIA:-S/Sx: 1. Claudication 2. Rest pain-Tx: 1. Percutaneous Transluminal angiography (PTA) 2. Surgical reconstruction
  22. 22. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersTHROMBOANGITIS OBLITERANS / BUERGER’S DISEASE:-Definition: -an inflammatory occlusive vascular disorder involving small and medium-sized arteries and veins in the distal upper and lower extremities -common in men <40 years -with definite relation to cigarette smoking
  23. 23. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersTHROMBOANGITIS OBLITERANS / BUERGER’S DISEASE:-Pathogenesis:INITIAL STAGE: polymorphonuclear leukocytes infiltrate arterial and venous wallsinternal elastic lamina is preserved but inflammatory thrombus developsMononuclear cells, fibroblasts and giants cells replace the neutrophilsLATER STAGES: Perivascular fibrosis, organized thrombus, recanalization
  24. 24. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersTHROMBOANGITIS OBLITERANS / BUERGER’S DISEASE:-S/Sx: -TRIAD 1. Claudication of affected extremity -affects distal vessels (calves, forearms) 2. Raynaud’s phenomenon 3. Migratory superficial vein thrombophlebitis -trophic nail changes -reduces/absent pulses on ulna, radius, tibia -smooth, tapering segmental lesions in the distal vessels -collateral vessels at site of occlusio
  25. 25. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersTHROMBOANGITIS OBLITERANS / BUERGER’S DISEASE:-Dx: -excisional biopsy and pathologic examination of the involved vessel-Rx: -no specific treatment EXCEPT ABSTENTATION FROM TOBACCO
  26. 26. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersACUTE ARTERIAL OCCLUSION:-Definition: -results in the sudden cessation of blood flow to an extremity -TWO PRINCIPAL CAUSES: 1. embolism 2. thrombus in situ -paradoxically, may originate from a venous thrombus that entered the systemic circulation via a patent foramen ovale or septal defect
  27. 27. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersACUTE ARTERIAL OCCLUSION:-EMBOLISM -most common sources: heart, aorta, large arteries -emboli tend to lodge at vessel bifurcation because the vessel caliber decreases at these sites -in the lower extremities, emboli lodge more frequently in femoral A, iliac A, aorta, popliteal A and tibioperoneal A.
  28. 28. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersACUTE ARTERIAL OCCLUSION:-THROMBUS IN SITU -occurs more frequently in atherosclerotic vessels at the site of an atherosclerotic plaque or aneurysm and in arterial bypass grafts -may complicate arterial punctures and placement of catheters -associated with polycythemia and hypercoagulable disorders
  29. 29. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersACUTE ARTERIAL OCCLUSION:-S/Sx: -severe pain, paresthesia, numbness, coldness develop in the involved extremity within 1 hour -paralysis may happen in severe ischemia -loss of pulses distal to occlusion -pallor/cyanosis -hyporeflexia/areflexia -weakness and muscle stiffening
  30. 30. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersACUTE ARTERIAL OCCLUSION:-Dx: 1. Arteriography -useful in confirming Dx and demonstrating location and extent of occlusion
  31. 31. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersACUTE ARTERIAL OCCLUSION:-Rx: 1. Heparin -to prevent propagation of clot 2. Throboembolectomy/Arterial bypass procedure 3. Intraarterial thrombolytic therapy with recombinant tissue plasminogen activator or urokinase*meticulous observation for hemorrhagic complications is required during intraarterial thrombolytic therapy
  32. 32. VASCULAR DISEASES OF THE EXTREMITIES – Arterial DisordersATHEROEMBOLISM:-Definition: -multiple small deposits of fibrin, platelets, and cholesterol debris embolize from proximal atherosclerotic lesions or aneurysmal sites

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