Peripheral vascular disease
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Selected Vascular Diseases Describe the clinical features, diagnostic strategies, and management of the following conditions: - Peripheral Arterial Embolism - Peripheral Aterial Thrombosis - SMA Anurysm - Thoracic outlet syndrome
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Peripheral vascular disease
- 2. OBJECTIVE: Describe The Clinical Features, Diagnostic Strategies, And Management Of The Following Conditions: - Peripheral Arterial Embolism - Peripheral Arterial Thrombosis - SMA Aneurysm - Thoracic Outlet Syndrome
- 3. INTRODUCTION AND EPIDEMIOLOGY Acute limb ischemia results from a sudden decrease in blood supply to a limb, leading to tissue hypoperfusion and threatening limb viability. As time proceeds, cell death or irreversible tissue damage occurs. Without the presence of collateral vessels, peripheral nerves and skeletal muscle may suffer irreversible changes within 4 to 6 hours of vessel occlusion Risk Factor: Smoking and diabetes are the most important risk factors for peripheral arterial disease Additional risk factors include hyperlipidemia, hypertension, IV drug abuser, elevated blood homocysteine, and an elevated C-reactive protein level. Severity is linked to: Risk of myocardial infarction, ischemic stroke, and death from vascular disease Despite improvements in the management of peripheral arterial disease, current 1-year
- 4. WHAT TO DO ? 1) Good History taking 2) Focused Physical Examination 3) Diagnostics ( Laboratory and imaging) 4) Management
- 5. CLINICAL FEATURES (HX) • Pain (SOCRATES): Claudication cramp-like pain, ache, or tiredness that is brought on by exercise and relieved by rest Ischemic pain not relieved by rest or gravity, is not well localized, and can present as marked worsening of chronic pain • Associated Symptom: Pallor Pulseless Paralysis Paresthesias Poikilothermia + Risk factor assessment
- 6. CLINICAL FEATURES (PHYSICAL EX) • Palpation of the pulse volume • Finger pressure ( capillary refill ) = if there is reduced perfusion there will be delay in return of normal color • Burger’s sign • Allen test • Doppler ultrasound • Ankle brachial index
- 7. ANKLE BRACHIAL INDEX ABI > 0.9 → Normal ABI 0.7 – 0.9 → Mild ABI 0.7 – 0.5 → Moderate ABI < 0.5 → Severe (super emergent consultation)
- 9. ALLEN TEST AND BURGER’S SIGN
- 10. More than 2 week Symptoms started within 2 week Timing Gradual Relived by rest or gravity Sudden Not relived by rest or gravity Pain characteristics Absent Present Associated 5ps Present Not always Unless acute on top of chronic Sign of chronicity ( muscle atrophy, loss of hair, thickening of toenail, shiny skin, scaly skin ) Chronic limb Ischemia Acute limb ischemia
- 12. THE CLINICAL DISTINCTION BETWEEN THROMBOSIS AND EMBOLISM IN ANY GIVEN PATIENT IS NOT ALWAYS CLEAR Thrombosis most common cause of acute limb ischemia most often occurs in the presence of atherosclerosis more gradually Embolism Most arterial emboli originate from thrombus Most sudden onset
- 13. & Investigation
- 14. DIAGNOSTIC STRATEGIES L AB TEST Creatine Kinase, Myoglobin, And Serum Lactate Electrolytes And Glucose BUN And Creatinine Plus Urinalysis Cbc Prothrombin And Partial Thromboplastin Times Levels Of Cardiac Injury Markers And ECG IMAGING STUDY Doppler Us Vs Doplex Us X ray ? CT angiography MR Angiography Contrast Arteriography once suspected, consult a surgeon as soon as possible
- 17. MANAGEMENT
- 18. THE LONGER-TERM NONSURGICAL MANAGEMENT OF PERIPHERAL ARTERIAL DISEASE Combination of Smoking cessation, Structured exercise and Pharmacotherapy. Pharmacotherapy include: 1) Anti platelet therapy ( ASA or clopidogrel) 2) Cilostazol
- 19. DISPOSITION Admission Vs Discharge ?
- 21. T H I R D M O S T C O M M O N V I S C E R A L A N E U R Y S M S . C A U S E S : 1 ) I N F E C T E D A N E U R Y S M S ( 6 0 % ) Cau sed by n on - h emoly t ic st rept ococci from lef t - sided bact er ial en docardit is. 2 ) AT H E R O S C L E R O S I S 3 ) T R A U M A PAT I E N T C H A R A C T E R I S T I C S : You n ger t h an 5 0 y ear s old Men an d women are affect ed equ ally.
- 22. CLINICAL FEATURES Intermittent upper abdominal pain consistent with abdominal angina. Fifty percent have a pulsatile abdominal mass on PE. Acute bacterial endocarditis ? DIAGNOSTIC Plain abdominal radiographs may show a calcified aneurysm. Angiography is necessary to confirm the diagnosis.
- 23. MANAGEMENT Underlying infectious process The surgical approach is difficult, varies with the condition of the patient, the shape of the aneurysm (saccular or fusiform) and the assessment of bowel viability. Need Vascular surgeon consultation :)
- 25. Thoracic outlet syndrome involves compression of the brachial plexus, subclavian vein, or subclavian artery at the superior aperture of the thorax. Divided into three type Neurologic Venous Arterial Depending on the predominant symptoms. Accounts for 95% 20 and 50 years Women Accounts for 4% 20 and 35 years Men Accounts for 1% Most serious Bimodal Men = Women
- 26. CLINICAL FEATURES Neurologic type: Compression of brachial plexus (C8,T1 ulnar) or (C5,C6C7 radial) Venous type: Venous engorgement and swelling of the affected extremity Arterial Type: Post-stenotic aneurysm formation
- 27. DIAGNOSTIC STRATEGIES Symptoms Physical Exam Provocative tests To reproduce symptoms and determine the cause ( EAST) Imaging test (x-ray, Ct scan, MRI, Arteriography) For abnormal anatomy or obstructed blood vessels Nerve conduction study for nerve function
- 28. EAST most reliable test in screening for thoracic outlet syndrome +ve test if: When patient unable to maintain elevation for 3-minute period Or When symptoms are induced
- 29. MANAGEMENT Neurogenic TOS - physical Therapy - medication: + pain relievers + muscle relaxants - surgery rarely indicated Vascular TOS - medication: + Anticoagulant + Thrombolytics ( clot dissolving) - surgery is common
- 30. REFRENCE
Editor's Notes
- History and physical is important to differentiate between the cause of the limb ischemia and its level and thus to manage it rapidly without having irreversible ischemia or reprofusion injury
- Pain alone may be the earliest symptom of ischemia, localized in the limb distal to the site of obstruction. Site: on the calf, on the buttocks and hip. it can be unilateral or bilateral ( if the embolism or thrombosis dislodged on the aortoiliac bifurcation ) Claudication = intermittent pressure Ischemic pain = severe, unrelenting pain aggravated by elevation and unrelieved by analgesics. Patients have prompt relief with any activity involving a standing position. Patients often sleep in a chair or with the leg dangling over the bed, if it is acute the patient will prescribe it as ( struck by sever shocking pain ).
- systematic assessment of the peripheral vascular system includes palpation of the pulse volume in the pairs of brachial, radial, femoral, posterior tibial, and dorsalis pedis arteries documented on a scale of 0 to 4+. Important to note, approximately 10% of the population does not have one of the dorsalis pedis pulses.8 Carotid arteries should be gently palpated one at a time.
- https://youtu.be/C4Utl1wkoio
- https://m.youtube.com/watch?v=Ba9wOF6Mb0c
- ALI pain: Pain over the distal forefoot waking the patient at night or requiring the patient to hang his or her feet over the bed is suggestive of severe arterial occlusion the pain of acute limb ischemia is not relieved by rest or gravity, is not well localized, and can present as marked worsening of chronic pain. CLI pain: intermittent claudication, which may progress to intermittent ischemic pain at rest. Claudication is a cramp-like pain, ache, or tiredness that is brought on by exercise and relieved by rest, similarly to angina in the heart. It is reproducible, resolves within 2 to 5 minutes of rest, and recurs at consistent walking distances.
- ——————— Embolism: foreign body (bloos clot) carried out by the blood to a site distant from its origin Thromboembolism: Most arterial emboli (85%) originate from thrombus formation in the heart. Left ventricular thrombus formation resulting from myocardial infarction accounts for 60% to 70% of arterial emboli. Atrial thrombi associated with mitral stenosis and rheumatic heart disease account for only 5% to 10% of arterial emboli.2 Coexisting atrial fibrillation, often without mitral stenosis, is present in 60% to 75% of patients with peripheral arterial embolic events because atrial fibrillation itself predisposes patients to intracardiac clotting
- تنتنالي تقول انه الثرومبوسيس اكثر بينما روزن يقول فيفتي فيفتي Embolism: Sudden loss of a pulse is the hallmark If arterial embolism is suspected, the physical examination should be directed toward identifying its source (a left ventricular mural thrombus [prior myocardial infarction] or a left atrial thrombus [mitral valve disease]). Coexistent atrial fibrillation is common Because acute arterial embolism usually occurs in patients without significant peripheral atherosclerosis or well- developed collateral circulation, it usually manifests as sudden limb-threatening ischemia. Patients describe a sensation of the leg’s being “struck” by a severe shocking pain. Thrombosis: Physical findings of in situ thrombosis are often accompanied by evidence of atherosclerotic occlusive disease. thrombosis is almost always superimposed on a complicated atherosclerotic lesion but can be caused by vasculitis or trauma. In situ thrombosis usually occurs with long-standing peripheral atherosclerosis and well-developed collateral circulation, often seen sub-acutely with non–limb-threatening ischemia
- Why lab? 1- Following restoration of blood flow, reperfusion injury can occur and may manifest as compartment syndrome, rhabdomyolysis, or metabolic derangements. Often, hyperkalemia, myoglobinemia, metabolic acidosis, and an elevation in creatine kinase level exist. The extent of reperfusion injury depends on the duration and location of the arterial blockage, the amount of collateral flow, and the previous health of the involved limb. Approximately one third of all deaths from occlusive arterial disease are secondary to metabolic complications after revascularization. 2- to roll out underlying source —————— markers of cellular ischemia or injury (e.g., creatine kinase, myoglobin, and serum lactate), assess the metabolic status (electrolytes and glucose), Renal function (BUN and creatinine plus urinalysis) Potential anemia and infection (CBC) bleeding tendency (prothrombin and partial thromboplastin times). Levels of cardiac injury markers and ECG may identify triggers including infarction or rhythm change ———— - Doppler voice with waveform analysis - Doplex bidirectional image 2D with or without color and voice, very accurate for detecting complete or incomplete arterial obstruction. Sensitivity declines for localization of thromboembolic occlusion at or below the calf level, we can perform POCUS - Contrast arteriogarphy is the definitive study CT angio useful to differentiate between Thrombosis vs Embolism, most readily available study in the ED X ray no role unless you think of DDx ————————— The selection of most timely and appropriate imaging technique is best a joint decision between the ED physician, vascular surgeon, and/or interventional radiologist.
- We said before that the early sign of limb ischemia is the pain So ? What is the the sign that we are afraid of ? 1- sensory loss Preservation of light touch on skin testing is a good guide to tissue viability. “Presence of sensitivity to light touch is the best guide to viability of the tissue” 2- paralysis Paralysis represents severe muscle and neural ischemia, which may be irreversible. Involuntary muscle contracture with “woody” hardness represents irreversible ischemia
- Limb viability is dependent on the effectiveness of collateral circulation, and no arbitrary time period can exclude treatment options despite the common belief that “treatment must occur in 4 to 6 hours.”
- Acute critical limb ischemia is a time-sensitive diagnosis; once suspected, consult a surgeon as soon as possible, even while obtaining diagnostic imaging —————- heparin prevents clot extension(prpagation), recurrent embolization, venous thrombosis, microthrombi distal to the obstruction, and reocclusion after reperfusion. Direct thrombin inhibitors, such as lepirudin or argatroban, are an alternative treatment option when heparin-induced thrombocytopenia with thrombosis is of concern. No absolutely contraindications to heparin there is only relative !! Relative contraindications include recent neurosurgery (especially within 2 weeks), major surgery within 48 hours, childbirth within 24 hours, a known bleeding diathesis, thrombocytopenia, a potentially hemorrhagic lesion, an —————
- The longer-term nonsurgical management of peripheral arterial disease focuses on the combination of smoking cessation, structured exercise, and pharmacotherapy. Antiplatelet therapy with either aspirin (75 to 100 milligrams daily) or clopidogrel (75 milligrams daily) can reduce mortality from cardiovascular causes in patients with peripheral arterial disease. Dual antiplatelet therapy is not initially recommended.19 The American College of Cardiology/American Heart Association 2016 guidelines include cilostazol, a phosphodiesterase inhibitor, as a Class I recommendation for the treatment of intermittent claudication. Pentoxifylline is no longer recommended.19,20
- روزن يقول كنسلت الفاسكولار لهم كلهم وهو يقرر تنتنالي تختلف وتقولPatients with acute or worsening chronic ischemia require observation, hospital admission, or immediate transfer to a center with vascular surgery capability. Patients with chronic peripheral arterial disease without an immediate threat to limb viability + absent other acute illness can be discharged home to follow up with a vascular surgeon or primary care physician. Instruct patients to return immediately for worsening of symptoms (especially pain) and to start aspirin (81 milligrams daily after first dose of 325 milligrams if there are no contraindications).
- Pupmed: “Aneurysms of the superior mesenteric artery (SMA) are an uncommon but lethal entity, which must be treated expeditiously to avoid mortality and high incidence of ischemic small bowel complications”.
- 1- Compression of the brachial plexus causes the neurologic type accounts for approximately 95% between the ages of 20 and 50 years women predominating 2- Compression or thrombosis of the subclavian vein 4% of all cases. It occurs most often in men 20 to 35 years old 3- arterial type of thoracic outlet syndrome is rare occurring in approximately 1% of all cases most serious of the three types. Men and women are equally affected in a bimodal age distribution of young adults (from cervical rib compression) and patients older than age 50 (from localized atherosclerosis
- most often affects the lower two nerve roots, eighth cervical (C8) and first thoracic (T1), producing pain and paresthesias in the ulnar nerve distribution. The second most common pattern is the upper three nerve roots of the brachial plexus (C5, C6, and C7), with symptoms referable to the neck, ear, upper chest, upper back, and outer arm in the radial nerve distribution ——— progresses to intimal damage and subclavian vein thrombosis, with venous engorgement and swelling of the affected extremity
- most reliable test in screening for thoracic outlet syndrome is the elevated arm stress test (EAST) A blood pressure difference between the two arms is a reliable indication of arterial involvement. The blood pressure in the affected arm is lower. Doppler ultrasonography may be helpful in demonstrating comparatively reduced pressure over the pairs of radial, ulnar, and brachial arteries. The supraclavicular area should be auscultated bilaterally for subclavian bruits Arteriography is recommended with (1) obliteration of radial pulse on the EAST, (2) blood pressure 20 mm Hg less than that of the opposite asymptomatic limb, (3) possible subclavian steno- sis or aneurysm (bruit or abnormal supraclavicular pulsation), and (4) evidence of peripheral emboli in the upper extremity.44 Venography is indicated for edema of the hand or arm, unilateral cyanosis, or a prominent venous pattern of the arm, shoulder, or chest
- DispositionThe correct diagnosis of thoracic outlet syndrome can be achieved in more than 90% of patients with a careful history, physical examination, and bedside testing alone.44 Neurologic, orthopedic, or vascular surgery consultation is indicated according to the pathologic condition