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Management of
Peripheral Vascular
Disease
Dr Binaya Timilsina
BPKIHS
Nepal
Overview
• Definition
• Risk factors
• Work up : lab tests and imaging
• Treatment for chronic arterial insufficiency and ...
Definition
Peripheral artery occlusive disease or
peripheral arterial disease or
peripheral vascular disease
refers to the...
Risk factors for symptomatic peripheral
vascular disease.
EVALUATINGANDTREATINGTHEPATIENT
WITHPERIPHERALARTERIALDISEASE
• History and physical examination
• Testing and Imaging
• T...
Chronic Arterial Insufficiency
• Asymptomatic to gangrenous tissue loss
• Intermittent claudication: most common presentat...
Intermittent claudication
• Cramp-like pain felt in the muscles that is:
brought on by walking;
not present on taking th...
Thigh Claudication
60% Upper 2/3 Calf Claudication
Lower 1/3 Calf Claudication
Foot Claudication
30% Buttock & Hip Claudic...
Clinical Classification of
Intermittent claudication;
Critical limb ischaemia (CLI)
• Most severe form of PVD
• Can have acute or chronic presentation
• Chronic CLI is defined ...
Work up
• Lab tests
• Physiological tests like ankle brachial index
• Imaging
Doppler ultrasonography
Duplex ultrasonogr...
Lab Tests in PVD
• CBC: secondary polycythemia in smoker or elevated platelet in thrombotic
disease
• Renal function test:...
Ankle Brachial Index (ABI)
ABI
ABI Inferences
>1.3 Non compressible(arteriosclerotic)
1.00-1.29 Normal
0.91-0.99 Equivocal
0.41-0.90 Mild to moderate...
1) Segmental pressure
Bp cuffs at arm, upper thigh, above knee, below knee, and above ankle
Decrease in pressure of >20 mm...
3) Exercise testing
• Done in patients with claudication but pulses and ABI normal
• Patient able to walk in treadmill wit...
• Detection of blood velocity using ultrasonography
• Normal is triphasic: peak in systole, reversal of flow in
early dias...
Duplex Ultrasonography
• B mode imaging information about vessel wall and peak systolic
velocity (PSV)
• Ratio of PSV at s...
Angiography
• Used to be gold standard test for road mapping before surgery
• Safer in recent years due to fine 3-4 F cath...
CT Angiography
• Non invasive
• Still uses ionizing radiation and iodinated contrast agent
absence of flow in the right
• ...
MR Angiography
• Shift of imaging modality due to Gd-MRI
• Better for distal small and pedal vessels as compared to
angiog...
Ilio-femoralarterial diseasedetectedby
contrast-enhancedMR angiography
(A) Severe stenosis at the origin of the right supe...
Treatmentof Chronic arterialinsufficiency
• Risk factor modification
• Exercise therapy
• Drugs; Pentoxifyline, Cilostazol...
A. Risk factor modification
1. Smoking: cessation
2. Diabetes: each 1% rise in HbA1c associated with 28% risk for PVD.
<7%...
B. Exercise therapy
• Aids in improvement in pain free ambulation, working performance and
cardiac status
• Minimum 30-45 ...
D. Cilostazol:
Phosphodiesterase III inhibitors increases cAMP
Inhibits smooth muscle cell proliferation and contraction,
...
F. Intermittent pneumatic compression
Inflated for 2-3 seconds, rate 3 cycle/minute
G. Revascularization
Failed medical t...
Surgicalrepairoption for aortoiliacdisease
A. Endarterectomy
• Opening of diseased segment and removing plaque
• Indicatio...
C. Axillo-bifemoral bypass;
• Extra anatomic repair
• Comorbidities making difficult to undergo ABFB, and failed ABFB
• Pl...
D. Femoro-femoral bypass
In U/L iliac artery involvement
E. Obturator bypass
Graft between iliac artery and femoral artery...
Surgicalrepairoption for infrainguinal disease
• Autogenous grafts as great saphenous vein preferred
• Others: short saphe...
Endovascular approach
• Balloon angioplasty requires crossing the arterial
lesion transluminally with a guidewire and infl...
Endovascular approach Vs Surgical
• Published papers favor either of approaches
• TASC II recommends angioplasty over surg...
Therapeutic angiogenesis
• Gene transfer by use of 4000mg naked plasmid DNA encoding VEGF
injected directly in ischemic li...
Amputation
• Recommended in
Severe symptoms not amenable to or
failed revascularization
Gangrenous tissue/ nonfunctional...
Buerger’sdisease /Thromboangitisobliterans
• Non-atherosclerotic vascular disease characterized by
absence or minimal pre...
•OLIN criteria for Diagnosis
1. Age younger than 45 years
2. Current or recent history of tobacco use
3. Presence of dista...
Color duplex ultrasonography in TAO
• Occlusion of distal calf or pedal arteries
• Occlusion of forearm, palmar arch or di...
Treatment of Buerger’s disease
• Tobacco cessation
• Explanation advice
• Drugs
• Direct arterial surgery
• Sympathectomy
...
Treatment
A. Tobacco cessation
Only proven preventing guideline
B. Explanation advice
Adjustment of lifestyle
Exercise and...
C. Drugs
• Prostaglandins: prostacyclin or PGI2 (iloprost) 40 times
antiplatelet and vasodilator effect as compared to PGE...
D. Direct arterial surgery
• Revascularization surgery rarely feasible
• Arterialization of veins by creating AV fistula b...
E. Sympathectomy
• Objectives
Causes vasodilatation by decreasing sympathetic vasomotor tone
Abolish pain impulses carri...
Methods
1. Surgical sympathectomy
Lumbar sympathectomy
• Open sympathectomy by extraperitoneal approach
• In unilateral su...
Drawbacksof Lumbarsympathectomy
• Is a temporary procedure, effect rarely lasts beyond 6 months. Reasons are
Technical fa...
Cervicalsympathectomy
• T1(lower portion of stellate ganglion), T2 and T3 removed
• Approaches
Supraclavicular route
Axi...
2. Chemical sympathectomy
• 5ml of phenol solution in water(1:16) injected beside bodies of 2nd and 4th
vertebrae
• Contra...
F. Omental transposition
• Rich vascular supply which directly improves tissue perfusion
• Causes neovascularization
• Inc...
Steps
• Midline incision
• Omentum mobilized
• Subfascial tunneling from inferior end of incision
to inguinal incision and...
Complications and outcomes
• Complications: gastric devascularization and necrosis, paralytic
ileus, gastric hemorrhage, o...
Raynaud’sphenomenon
• Excessively reduced blood flow in response to cold or emotional stress,
causing discoloration of the...
ClinicalManifestations
• Usually bilateral –(both arms or feet are affected)
• Pallor, coldness, numbness, cutaneous cyano...
Management
• Aimed at prevention
• Person is advised to protect against exposure to cold
• Quit smoking
• Drug therapy – c...
Acute limb ischemia
• Acute onset of extremity pain with absent pulses
• Cause either emboli or trauma
• Bounding water ha...
Embolectomy (and thrombectomy)
• Local or general anesthesia
• The artery (usually the femoral), exposed and held
in sling...
Intra-arterial thrombolysis
• 5F catheter passed into occluded vessel, left embedded in clot and
thrombolysis by tissue pl...
SUMMARY
Intermittentclaudicationtreatment algorithmAlgorithm in management of PVD
Treatment plan in CLI
THANK YOU
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Management of peripheral vascular disease Dr Binaya Timilsina

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Management of peripheral vascular disease Dr Binaya Timilsina

  1. 1. Management of Peripheral Vascular Disease Dr Binaya Timilsina BPKIHS Nepal
  2. 2. Overview • Definition • Risk factors • Work up : lab tests and imaging • Treatment for chronic arterial insufficiency and acute limb ischemia • Summary
  3. 3. Definition Peripheral artery occlusive disease or peripheral arterial disease or peripheral vascular disease refers to the obstruction or deterioration of arteries other than those supplying the heart and within the brain.
  4. 4. Risk factors for symptomatic peripheral vascular disease.
  5. 5. EVALUATINGANDTREATINGTHEPATIENT WITHPERIPHERALARTERIALDISEASE • History and physical examination • Testing and Imaging • Treatment • Characterizing the pain divides PVD into Chronic arterial insufficiency Acute arterial occlusion
  6. 6. Chronic Arterial Insufficiency • Asymptomatic to gangrenous tissue loss • Intermittent claudication: most common presentation Features of chronic lower limb arterial stenosis or occlusion • Intermittent claudication • Rest pain • Dependent rubor • Ulceration • Gangrene • Arterial pulsation diminished or absent • Arterial bruit • Slow capillary refilling
  7. 7. Intermittent claudication • Cramp-like pain felt in the muscles that is: brought on by walking; not present on taking the first step (unlike osteoarthritis); relieved by standing still (unlike nerve compression from a lumbar intervertebral disc prolapse or osteoarthritis of the spine or spinal stenosis)
  8. 8. Thigh Claudication 60% Upper 2/3 Calf Claudication Lower 1/3 Calf Claudication Foot Claudication 30% Buttock & Hip Claudication ±Impotence – Leriche’s Syndrome Sites of Intermittent claudication
  9. 9. Clinical Classification of Intermittent claudication;
  10. 10. Critical limb ischaemia (CLI) • Most severe form of PVD • Can have acute or chronic presentation • Chronic CLI is defined as >2 weeks of rest pain, ulcer or tissue loss and characterized by Ankle–brachial index ≤ 0.4 Ankle systolic pressure ≤ 50 mmHg Toe systolic pressure ≤ 30 mmHg
  11. 11. Work up • Lab tests • Physiological tests like ankle brachial index • Imaging Doppler ultrasonography Duplex ultrasonography Angiography CT angiography MR angiography
  12. 12. Lab Tests in PVD • CBC: secondary polycythemia in smoker or elevated platelet in thrombotic disease • Renal function test: elevated in DM,HTN. No contrast study if deranged • Lipid profile: hyperlipidemia • FBS and HbA1c: • ECG: • ESR: elevated in collagen vascular disease • CRP: marker of worsening PVD • Hypercoagulable state and Homocysteine: prothrombin time, partial thromboplastin time, thrombin time, lupus anticoagulant, anti-cardiolipin antibody, activated protein C resistance, factor V Leiden
  13. 13. Ankle Brachial Index (ABI)
  14. 14. ABI ABI Inferences >1.3 Non compressible(arteriosclerotic) 1.00-1.29 Normal 0.91-0.99 Equivocal 0.41-0.90 Mild to moderate PVD 0.31-0.40 Rest pain <0.30 Impending gangrene
  15. 15. 1) Segmental pressure Bp cuffs at arm, upper thigh, above knee, below knee, and above ankle Decrease in pressure of >20 mmHg in comparison to above level indicates occlusion 2) Digital pressure measurement Mini cuff at toe base and pressure by manometer Toe brachial index(TBI) >0.7 with pressure > 50 mmHg indicative of preserved flow Done if ABI>1.3 or pedal arch vessel involvement suspected ABI
  16. 16. 3) Exercise testing • Done in patients with claudication but pulses and ABI normal • Patient able to walk in treadmill without symptoms or decrease in ABI : PVD ruled out • Drop in ABI of 0.2 or in ankle pressure of 20 mmHg which do not return to pre exercise level within 3 min suggest PVD ABI
  17. 17. • Detection of blood velocity using ultrasonography • Normal is triphasic: peak in systole, reversal of flow in early diastole and forward diastolic flow • Earliest change: loss of reversal of flow so biphasic • As obstruction increases widening of diastolic peak occurs and flow monophasic Doppler Ultrasonography
  18. 18. Duplex Ultrasonography • B mode imaging information about vessel wall and peak systolic velocity (PSV) • Ratio of PSV at stenosis to proximal segment of 2 denotes 50% obstruction and 4 -70% • Non invasive, cheap has largely replaced routine use of conventional arteriography
  19. 19. Angiography • Used to be gold standard test for road mapping before surgery • Safer in recent years due to fine 3-4 F catheters • Hematoma, arterial spasm, sub intimal dissection, infection, pseudoaneurysm, AV fistula and embolization • Slowly being replaced by CTA and MRA
  20. 20. CT Angiography • Non invasive • Still uses ionizing radiation and iodinated contrast agent absence of flow in the right • common iliac artery • (white arrow)
  21. 21. MR Angiography • Shift of imaging modality due to Gd-MRI • Better for distal small and pedal vessels as compared to angiography • Sensitivity 81% and specificity 92% • Gd worsens CKD patients and precipitates nephrogenic systemic fibrosis
  22. 22. Ilio-femoralarterial diseasedetectedby contrast-enhancedMR angiography (A) Severe stenosis at the origin of the right superficial femoral artery (arrow) also involving the origin of the profunda femoris artery. (B) Long-segment occlusion of the left superficial femoral artery (arrowhead) and bilateral significant stenosis of the profunda femoris arteries (arrows).
  23. 23. Treatmentof Chronic arterialinsufficiency • Risk factor modification • Exercise therapy • Drugs; Pentoxifyline, Cilostazole, Naftidrofuryl • Intermittent pneumatic compression • Revascularization by Open surgery or endovascularization • Therapeutic angiogenesis
  24. 24. A. Risk factor modification 1. Smoking: cessation 2. Diabetes: each 1% rise in HbA1c associated with 28% risk for PVD. <7% treatment goal 3. Hypertension goal bp <140/90 and <130/80 if DM and renal insufficiency ACE inhibitors 4. Hyperlipidemia: diet modification Statins, niacin or fibrates 5. Antiplatelet therapy Aspirin 75-325 mg/day or clopidrogel 75mg/day or both
  25. 25. B. Exercise therapy • Aids in improvement in pain free ambulation, working performance and cardiac status • Minimum 30-45 min/session, 3-4 times/week, for at least 12 weeks C. Pentoxifylline • Xanthine derivative • Rheolytic effects on RBC wall deformability and flexibility thus reducing viscosity and improving oxygen delivery, decreases platelet aggregation • Dose; 400 mg TDS (max 1800mg/day)
  26. 26. D. Cilostazol: Phosphodiesterase III inhibitors increases cAMP Inhibits smooth muscle cell proliferation and contraction, Inhibits platelet aggregation Decreases TG and increases HDL Dose; 50mg/day X 1 wk then 50 mg BD X 1 week then 100mg BD E. Naftidrofuryl : Serotonin antagonist, promotes vasodilatation
  27. 27. F. Intermittent pneumatic compression Inflated for 2-3 seconds, rate 3 cycle/minute G. Revascularization Failed medical therapy Severe claudication If a proximal stenotic lesion is present Revascularization by open surgery or endovascular technique
  28. 28. Surgicalrepairoption for aortoiliacdisease A. Endarterectomy • Opening of diseased segment and removing plaque • Indications: in infected cases, small vessels not amenable for endovascular or graft repair, in impotence B. Aorto Bifemoral Bypass (ABFB) • Using PTFE grafts or Dacron grafts (knitted/woven), iliac, distal aortic segment and proximal femoral segment can be bypassed by placing graft between infrarenal aorta and B/L femoral • End to end anastomosis better • Patency are 90% at 5 yrs and 75-85% at 10 yrs
  29. 29. C. Axillo-bifemoral bypass; • Extra anatomic repair • Comorbidities making difficult to undergo ABFB, and failed ABFB • Placing a subcutaneous graft between axillary artery and ipsilateral femoral artery • Opposite limb vascularized by femoro-femoral bypass
  30. 30. D. Femoro-femoral bypass In U/L iliac artery involvement E. Obturator bypass Graft between iliac artery and femoral artery through obturator membrane in infected or distorted groin anatomy
  31. 31. Surgicalrepairoption for infrainguinal disease • Autogenous grafts as great saphenous vein preferred • Others: short saphenous vein, cephalic or basilic vein • Cryopreserved cadaveric veins prone to thrombosis • Very low success rate in below knee bypass if synthetic grafts (PTFE or Daccron) used
  32. 32. Endovascular approach • Balloon angioplasty requires crossing the arterial lesion transluminally with a guidewire and inflating a balloon advanced over the wire at the lesion. • Considered successful if residual stenosis <30%
  33. 33. Endovascular approach Vs Surgical • Published papers favor either of approaches • TASC II recommends angioplasty over surgery • BASIL trial favors surgical group Endovascular approach Surgical approach Shorter hospital stay Less morbidity Less interference with daily life Low patency rates Longer perioperative stay, More complications like bowel, ureteric injury and impotence Superior patency rates
  34. 34. Therapeutic angiogenesis • Gene transfer by use of 4000mg naked plasmid DNA encoding VEGF injected directly in ischemic limbs • Others are Stem cells, Autologous progenitor cells, Growth factors such as basic fibroblast growth factor (bFGF), and Transcription factors such as hypoxia-inducible factor-1 • Used in CLI patients who lack options for endovascular or surgical revascularization
  35. 35. Amputation • Recommended in Severe symptoms not amenable to or failed revascularization Gangrenous tissue/ nonfunctional Life threatening infection • 25% patient of CLI require amputation/yr and 25% die within 1 yr due to cardiovascular involvement
  36. 36. Buerger’sdisease /Thromboangitisobliterans • Non-atherosclerotic vascular disease characterized by absence or minimal presence of atheromas, segmental recurring and progressive vascular inflammation, vasoocclusive phenomenon and thrombosis of small and medium arteries and veins of hands and feet. • Lack of unanimous diagnostic criteria: is a disease of exclusion
  37. 37. •OLIN criteria for Diagnosis 1. Age younger than 45 years 2. Current or recent history of tobacco use 3. Presence of distal extremity ischemia (indicated by claudication, rest pain, ischemic ulcers, gangrene) documented by non invasive vascular testing 4. Exclusion of autoimmune dis, hypercoagulable states and diabetes 5. Exclusion of proximal source of emboli by ECHO and arteriography 6. Consistent arteriographic findings in the clinically involved and non involved limbs
  38. 38. Color duplex ultrasonography in TAO • Occlusion of distal calf or pedal arteries • Occlusion of forearm, palmar arch or digital arteries • Normal appearing arteries proximal to lesion • Serpigineous or corkscrew collaterals at the site of occlusion • Intact vessel wall in the level of thrombotic occlusion often free of calcification
  39. 39. Treatment of Buerger’s disease • Tobacco cessation • Explanation advice • Drugs • Direct arterial surgery • Sympathectomy • Omental transposition • Amputation
  40. 40. Treatment A. Tobacco cessation Only proven preventing guideline B. Explanation advice Adjustment of lifestyle Exercise and diet Care of feet Heel raise Analgesics and position
  41. 41. C. Drugs • Prostaglandins: prostacyclin or PGI2 (iloprost) 40 times antiplatelet and vasodilator effect as compared to PGE1 • Intra-arterial thrombolytic therapy Intra-arterial streptokinase (bolus 10,000 U f/b 5000 units per hour • Trental(pentoxyfiline) • Praxiline: niftidrofuryl oxalate • Aspirin
  42. 42. D. Direct arterial surgery • Revascularization surgery rarely feasible • Arterialization of veins by creating AV fistula between artery proximal to site of block and adjacent vein
  43. 43. E. Sympathectomy • Objectives Causes vasodilatation by decreasing sympathetic vasomotor tone Abolish pain impulses carried by sympathetic fibres • Contraindicated in intermittent claudication by stealing blood from ischemic muscles to skin • Nakata et al reported ulcer healing in 58% and relief of rest pain in 64%
  44. 44. Methods 1. Surgical sympathectomy Lumbar sympathectomy • Open sympathectomy by extraperitoneal approach • In unilateral surgeries, sympathetic ganglia,L1, L2, L3 and sometimes L4 removed • In bilateral cases L1 of one side preserved to avoid retrograde ejaculation • Transperitoneal approach rarely used • Laparascopic via retroperitoneal route has replaced others
  45. 45. Drawbacksof Lumbarsympathectomy • Is a temporary procedure, effect rarely lasts beyond 6 months. Reasons are Technical failure to identify lumbar chain (mistaken with lymphatic chain, genitofemoral nerve, ureter, psoas sheath, psoas minor) Cross connections of chain from opposite chain Regeneration from cut ends Hypersensitivity of end organ receptors to circulating adrenalins
  46. 46. Cervicalsympathectomy • T1(lower portion of stellate ganglion), T2 and T3 removed • Approaches Supraclavicular route Axillary route Posterior approach Transthoracic laparoscopic approach now standard treatment of choice
  47. 47. 2. Chemical sympathectomy • 5ml of phenol solution in water(1:16) injected beside bodies of 2nd and 4th vertebrae • Contraindicated in patients on anticoagulants • Preferably under fluoroscopic or ultrasound guidance pt on lateral position on local anesthesia
  48. 48. F. Omental transposition • Rich vascular supply which directly improves tissue perfusion • Causes neovascularization • Increases lymphatic drainage • Based on arterial arcade formed by anastomosis of right and left gastroepiploic artery
  49. 49. Steps • Midline incision • Omentum mobilized • Subfascial tunneling from inferior end of incision to inguinal incision and again to upper third of thigh • 3-4 transverse incisions over the medial aspect of the thigh and leg and subfascial tunnel made and omental pedicle advanced • Distal end of the pedicle is fixed to the gastrocnemius with atraumatic 2-0 chromic catgut
  50. 50. Complications and outcomes • Complications: gastric devascularization and necrosis, paralytic ileus, gastric hemorrhage, omental necrosis, and wound infection • Singh et al reported healing in 88%, decrease in rest pain in 72%, increase in claudication distance in 96%
  51. 51. Raynaud’sphenomenon • Excessively reduced blood flow in response to cold or emotional stress, causing discoloration of the fingers, toes, and occasionally other areas • Raynaud's disease (also known as primary Raynaud's phenomenon), where the cause is unknown • Raynaud's syndrome (secondary Raynaud's phenomenon), caused by a known primary disease, most commonly connective tissue disorders such as SLE, Sjogrens disease, Rheumatoid arthritis, Multiple sclerosis • Hyperactivation of sympathetic nervous system causing extreme vasoconstriction of the peripheral blood vessels, leading to tissue hypoxia
  52. 52. ClinicalManifestations • Usually bilateral –(both arms or feet are affected) • Pallor, coldness, numbness, cutaneous cyanosis and pain • With longstanding or prolonged Raynaud’s disease – ulcerations can develop on the fingertips and toes
  53. 53. Management • Aimed at prevention • Person is advised to protect against exposure to cold • Quit smoking • Drug therapy – calcium channel blockers, vascular smooth muscle relaxants, vasodilators – to promote circulation and reduce pain • Botox • Sympathectomy to relieve symptoms in the early stage of advanced ischemia • If ulceration/gangrene occur, the area may need to be amputated
  54. 54. Acute limb ischemia • Acute onset of extremity pain with absent pulses • Cause either emboli or trauma • Bounding water hammer pulses proximal to occlusion • Revascularization within 6 hours critical to avoid limb loss • Emergent arterial imaging include duplex ultrasound, CTA, MRA and invasive angiogram • Heparin bolus 100 U/kg followed by IV heparin infusion 15U/kg/hour with goal PTT 60-80 sec • Two methods of treatment: Embolectomy and Intra-arterial thrombolysis
  55. 55. Embolectomy (and thrombectomy) • Local or general anesthesia • The artery (usually the femoral), exposed and held in slings. • Longitudinal or transverse incision, the clot removed, together with the embolus with Fogarthy balloon catheter • The catheter introduced both proximally and distally • Procedure repeated until bleeding occurs
  56. 56. Intra-arterial thrombolysis • 5F catheter passed into occluded vessel, left embedded in clot and thrombolysis by tissue plasminogen activator 5mg bolus with mechanical pulse spray/ suctioning with catheter • The method abandoned if no progression of dissolution of clot with time (>24 hours)
  57. 57. SUMMARY
  58. 58. Intermittentclaudicationtreatment algorithmAlgorithm in management of PVD
  59. 59. Treatment plan in CLI
  60. 60. THANK YOU

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