This document defines peripheral artery disease and describes its causes and presentation. PAD is caused by a reduction of blood flow in the arteries due to stenosis or occlusion. Major causes include atherosclerosis, Buerger's disease, vasospastic disorders like Raynaud's, and vasculitis. Clinical features include trophic skin changes, absent pulses, and symptoms ranging from intermittent claudication to critical limb ischemia. Diagnosis involves imaging like Doppler and angiography. Treatment options include conservative management, endovascular procedures like angioplasty, and open surgeries like bypass grafts and amputation.

3. Definition:
It is the decrease in arterial blood supply to the
tissues due to partial or total occlusion of
arteries. Stenosis or occlusion produces
symptoms & signs that are related to the
tissues supplied by the artery. The severity of
symptoms is related to the size of the vessel
occluded & alternative routes (collaterals)
available for blood flow ,and adaptive limb
changes causing trophic changes.

4. Aetiology
1- Atherosclerosis
2- Buerger’s disease
3- Vasospastic disorders
• Primary (Raynaud’s disease)
• Secondary (Raynaud’s phenomenon)

5. 4- Vasculitis
 Takayasu disease
 Behcet disease
 Non-specific

6. Atherosclerosis
It is the process underlying the formation of
focal obstructions or plaques in large &
medium sized arteries. It is characterized by
the presence of focal intimal thickening,
these intimal elevations being made up of
accumulations of cholesterol rich & a
proliferation of connective tissue. An
essential component of atherogenesis is
inflammation involving monocytes /
macrophages, T lymphocytes & mast cells.

7. Predisposing factors:
1- Smoking
2- Diabetes mellitus
3- Hypercholesterolemia
4- Aging
5-Genetic

11. Atherosclerosis

12. Anatomical sites
At sites of arterial branching or tethering
- Aortoiliac disease.
- Femoropopliteal disease.
- Tibial disease

21. Development of collaterals

22. 0 ----------> Asymptomatic patient.
1 ----------> *
2 ----------> *
3 ----------> *
4 ----------> Rest pain.
5 ----------> Trophic changes &/or Minimal gangrene
requiring minor amputation.
6 ----------> Major gangrene requiring major amputation
above mid-tarsal with loss of foot function.
Intermittent claudication

23. Stages of chronic ischemia
Lafontain classification
1st: Asymtomatic.
2nd: Intermittent claudication.
3rd: Rest pain’ trophic changes, ulcers.
4th: Gangrene.

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27. Clinical features
General examination
Local examination
Signs:
1- Trophic changes.

29. Clinical features
General examination
Local examination
Signs:
1- Trophic changes.
2- Temperature changes
3- Color changes.

32. Clinical features
General examination
Local examination
Signs:
1- Trophic changes.
2- Temperature changes
3- Color changes.
4- Absence of pulses:

35. Clinical features
General examination
Local examination
Signs:
1- Trophic changes.
2- Temperature changes
3- Color changes.
4- Absence of pulses:
5- Special tests:
- Sluggish capillary circulation
- Buerger’s angle.

36. Buerger’s angle

37. Clinical features
General examination
Local examination
Signs:
1- Trophic changes.
2- Temperature changes
3- Color changes.
4- Absence of pulses:
5- Special tests:
- Sluggish capillary circulation
- Buerger’s angle.
- Harvey’s venous refilling time

38. 1- Laboratory investigations.
2- Imaging:
- Doppler flow study.

40. 1- Laboratory investigations:
2- Imaging:
- Doppler flow study.
• ABI
• Segmental pressure
- Duplex scanning

42. Duplex

44. 1- Laboratory investigations:
2- Imaging:
 - Doppler flow study.
ABI
Segmental pressure
 - Duplex scanning
 -Angiography

46. 1- Laboratory investigations:
2- Imaging:
- Doppler flow study.
• ABI
• Segmental pressure
- Duplex scanning
- Arteriography
Arteriography

47. Digital subtraction

48. Treatment:
1- Conservative
2- Endovascular
3- Open surgery

49. Conservative treatment:
1- Abstinence from smoking
2- Control of risk factors:
- DM
- Hypertension
- Hypercholesterolemia (statins / fibrates)
3- Foot Care
4- Medications:
- Vasoactive drugs ( Cilostazol-Naftidrufuryl
- Pentoxyfylline? )
-Anti-platelets (clopidogril – ASA )

50. 1- Critical ischemia
2- Severe incapacitating claudication
Indications for intervention:
Treatment:

51. Treatment:
Endovascular surgery
• Percutaneous transluminal angioplasty (PTA).
• Intravascular stents , and covered stents.
•Catheter directed thrombolysis.
•Mechanical atherectomy catheters.
•Excimer laser.
•Drug eluting baloons and stents. (paclitaxel)

52.  It is controlled fracture of the atheromatous
plaque ,and pushing it to the periphery of the
artery by the balloon inflation, thus creating a
space in the artery center.

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60.  Limitations of endovascular
 High re-occlusion rate in long
lesions.
 Guide wire can fail to cross
highly calcific chronic total
occlusion (CTO).
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63.  Closure of the tract of an arterio-venous fistula.
 Sealing of a large perforation if it happens in a
large artery during angioplasty which does not
respond to balloon inflation for a few minutes.

65. Endovascular techniques

66.  Progression of the original disease .
Prevention by controling the risk factors and immuno
modulation of autoimmune diseases
 Intimal hyperplasia
Reaction to mechanical manipulations or barotrauma to the
wall of an artery that causes migration of myoepithelial cells
from the media to the sub-intima with proliferation that
causes sub-intimal tissue growth with narrowing of the
arterial wall .
Prevention by drug eluting balloons or stents.

67. Treatment:
Open surgical techniques
• Thromboendarterectomy.
• Bypass surgery:
Aortobifemoral bypass
Femoropopliteal bypass
Femoro or popliteo-distal bypass
 Reversed saphenous vein graft.
 In-situ saphenous vein graft.
 Synthetyic graft.
• Sympathectomy.
• Amputation.

75. Treatment:
Open surgical techniques
• Thromboendarterectomy.
• Bypass surgery:
Aortobifemoral bypass
Femoropopliteal bypass
Femoro or popliteo-distal bypass
 Reversed saphenous vein graft.
 In-situ saphenous vein graft.
 Synthetyic graft.
• Sympathectomy.
• Amputation.

80. Thromb-angitis obliterans
(Buerger’s disease)

81. Aetiology:
1- It affects mostly males.
2- Age: between 20 and 40 years.
3- Heavy Smokers.
4-Progressive course with periods of
remissions but not to baseline.

85. Clinical features:
1.Usually Young male
2. Heavy smoker
3. Migratory thrombophlebitis
4. ± Raynaud’s phenomenon

86. Observe
*Affection
from distal to
proximal.
*Pruning of
tibial vessels
and foot arch.

88. Treatment:
1. Smoking must be stopped
2. Vasoactive drugs
3. Sympathectomy
4. Amputation

89. Vasospastic disorders:
Raynaud’s disease

90. Aetiology:
1. Sensitivity of the small arteries to
cold.
2. Increased sympathetic tone.
3. Psychological instability.
4. The presence of cold agglutinins.

91. Diagnosis:
1. Bilateral
2. Young females
3. Attacks are precipitated by exposure to cold
4. Attacks consist of: Pallor ,Cyanosis,Redness
5. Radial and ulnar pulses are preserved
6. No major gangrene.

93. Treatment:
1. Avoid coldness.
2. Vasodilator drugs.
3. Calcium channel antagonists.
4. Surgery: cervico-dorsal sympathectomy.

94. Raynaud’s phenomenon

95. Definition:
Raynaud’s disease accompanying organic
diseases including:
1. Collagen disorders.
2. Thoracic outlet syndrome e.g.
cervical rib.
3. Occupations: vibrating tools
laborers.
4. Drugs: ergotamines.

97. Treatment:
1. Of the original disease.
2. Vasodilators may be used.
3. Sympathectomy may be used to tide
the patient over the acute crisis.

98.  Usually affects the aortic arch and its major
branches.
 The pulseles disease.
 Common in the far east.
 Severe forms can affect all the Aortic branches.
 Depostion of firm rubbery material in the
subintima. Autoimmune.
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