DR. ASHOK PRADHAN DU,TU

1. CHRONIC PERIPHERAL ARTERIAL
OCCLUSIVE DISEASE( LOWER LIMB)
DR ASHOK PRADHAN
2ND YR JR
UCMS,TH
BHAIRAHAWA, NEPAL

3. CHRONIC LOWER LIMB ISCHEMIA
DEFINITION :
• Increased limb ischemia for more than 2 weeks
• Gradual and progressive decrease in blood flow
• Decrease in tissue perfusion
ETIOLOGY :
– ATHEROSCLEROSIS
– THROMBOANGITIS OBLITERANS (BUERGER’S DISEASE)

4. RISK FACTORS
DEFINITIVE
• Hypercholesterolaemia
>200mg/dl
• Hyperlipidaemia LDL
>100mg/dl; HDL<35mg/dl
• Cigarette smoking
• Hypertension
• Diabetic mellitus
RELATIVE
• Ederly
• Male predominance
• Sedentary life
• Obesity
• Family history

5. Atherosclerosis
• Chronic, complex inflammatory condition of elastic and
muscular arteries, involving as systemic or segmental
• Lipid plaque forms inside the arterial wall, cause
narrowing and hardening of artery
Commonly involved arteries
Infrarenal part of abdominal aorta
– Iliofemoral artery
– Poplitial arteries

6. Pathophysiology
• Endothelial injury by any means
• LDL enters into the tunica intima
• Monocytes enters and release free radicles
causing oxidation of LDL
• Oxidized LDL activate monocytes to become
macrophages and engulf
• Vicious cycle goes on leading to foam cell
formation

7. Cont.
• PDGF(platelet derived growth factor) cause
the migration of smooth muscle cell over the
foam cell leading to plaque formtion
• Covered by endothelium and over time ca++
get deposited  narrowing and hardening of
artery
• Thus atherosclerosis contain core lipid,
smooth muscle cells, and macrophages.

8. Aortoiliac occlusive disease
• Infrarenal aorta and iliac arteries
• Types :
– Type 1: disease localised to distal abdominal aorta
and common iliac arteries
– Type 2: wide spread aortic and iliac disease
– Type 3: multiple level disease along with
infrainguinal diseases

9. TYPES OF AORTOILIAC OCCLUSIVE DISEASE

10. Thromboangiitis Obliterans
• Nonatherosclerotic inflammatory disorder
involving medium sized and distal vessels
• Seen in smoker and tobacco user
• Young and middle age
• Male predominant
• Autoimmune disease
• Cell mediated sensitivity
to type I & III collagen.

11. Pathogenesis
Smoking  nicotin  interfere with NO
release but release noradrenaline  vasospasm
and at the same time nicotine irritate wall leading
to inflammation oedema  thrombosis &
obliteration of vessels (both arteries and veins)
 segmental panarteritis with involvement of
nerve (obliteration of vasa nervosum) 
features of ischemia with pain

12. Cont..
• Compensatory peripheral vascular disease
• Decompensatory peripheral vascular disease
(critical limb ischemia)
– Pain
– Ulceration
– Gangrene
• Smoking index (SI>300)
• Pack year index(PYI>40)

13. Diabetic and PAD
• High blood sugar level is source of good culture
media for bacteria to grow infection
• Diabetic microangiopathy endothelium is independent of
insulin for glucose absorption and excess glucose within vessel wall lead to formation of
O-GLCNACInterfers with phosporylation of NO synthatase
• Diabetic neuropathy
• Glycosylated hemoglobin in blood defective
oxygen dissociation

14. Classification of Chronic limb ischemia
Fontaine classification Rutherford classification
Grade Clinical Feature
0 Asymptomatic
1 Mild claudication
2 Moderate claudication
3 Severe claudication
4 Ischemic Rest Pain
5 Minor tissue loss
6 Major tissue loss
Stage Clinical Features
I. Asymptomatic
II a Mild claudication
II b Moderate to severe
claudication
III Ischemic rest pain
IV Ulceration or
gangrene

15. Clinical features
• Pain
– Intermittent caludication
– Rest pain
• Parasthesia
• Pallor
• Diminished or absent pulse
• Thinning of skin
• Loss of subcutaneous fat
• Diminished hair/ brittle nail or shining of skin
• Ulcer or gangrene

16. Boyd’s classification of claudication
• Grade I: Patient developed pain on walking,
but if continues to walk, pain disappears. This
is due to washing away of substance P.
• Grade II: Pain persist on walking but can walk
with effort
• Grade III: Due to severe pain patient seeks rest

17. Level of Claudication According To Site
Of Obstruction

18. Differential Diagnosis Of Intermittent Claudication
condition Location of pain Characteristic
discomfort
Onset to exercise Effect of rest
Nerve root
compression
Rediates down
the leg, posterior
Sharp pain Soon after
exercise
Not relieved
quickly,(rest+)
Spinal stenosis Hip, thigh,
buttock
Motor weakness After standing or
walking
Releived by rest
arthritic Foot, arch Aching pain Variable degree
of exercise
Not quickly
relieved
Hip arthritis Hip, buttock,
thigh
Aching “ “
Venous
caludication
Entire leg Tight bursting
pain
After walking Subside slowly
Compartment
syndrome
Calf muscle “ After exercise Subside very
slowly

19. Rest pain
• Continuous and aching
• Due to ischemic change in somatic nerve
• Cry of the dying nerves and worse at night
• Aggravated by elevation of limb above the
level of heart
• Relived by hanging the leg below the level of
heart
• Most distal part-tip of toes

20. Examination
• Buerger’s postural test
• Capillary filling time
• Harvey’s sign
• Fuchsig’s test

21. Cont..
• Ankle brachial pressure index
• Segmental pressure measurement
• Trademill exercise- to unmask the preliminary
stage of arterial occlusion (disappearing
pulse)(due to exercise increase in vasodilation and collateral circulation
coz decrease in pulse)

22. Interpretation Of ABI
ABI INTERPRETATION
>1.3 Noncompressible
1-1.29 Normal
0.91-0.99 Boderline
0.41-0.9 Mild to moderate PAD
0.0-0.3 Severe PAD

23. Investigation
• Routine blood examination
• Blood sugar
• HbA1C
• Serum creatinine
• Blood lipid
• Urine for sugar
• Straight x- rays

24. Cont..
• Doppler scan/ Duplex imaging- Doppler shift
• Angiography(sodium ditrizoate)
– Retrograde transfemoral seldinger angiography
• Free flush arteriography
• Selective angiography
– Direct aortic angiogram
– Digital subtraction angiogram
– CT Angiogram/ MR Angiogram

25. Doppler
• Normal doppler arterial waveform
demonstrates triphasic flow  sharp systolic
upstroke,reversal of flow in early diastole and
low amplitude forward flow throughout
diastole
• With the obstructive disease the initial feature
systolic upstroke is lost and reversal of flow
component ie diastolic phase and further
multiphasic flow

26. Angiography

27. Digital Subtraction Angiography
• Digital subtraction angiography is a type of
fluoroscopy technique used in interventional
radiology to clearly visualize blood vessels in
bone and dense soft tissue environment.
• It is simple technique by which bone structure
images plus opacified vessels are cancelled or
subtracted from a film by computerized
system,giving unobscured image of vessel

28. DSA OF RIGHT COMMON ILIAC ARTERY

29. Baseline digital substraction angiography of (a and b) the popliteal
region and (c) leg demonstrates abrubt thromboembolic occlusion of
the popliteal artery (large white arrow in a). Typical corkscrew collateral
arteries (small white arrows in b and c) and occlusion of the run-off
vessels in concordance with Buerger's disease before intervention.

30. CT ANGIOGRAPHY
ADVANTAGE
• Depiction of entire artery with ability to
appreciate thrombus and calcification
• Thin slice of 0.625 mm allows three
dimensional reconstruction of vessels

31. Genreal Treatment
Stop smoking
Change in lifestyle
• Healthy eating habits
• Reduction of weight
• Exercise
Buerger’s position and exercise
Care of foot

32. Medical Therapy
Disorder Pharmacological agent Purpose for PAD
reduction
Dyslipidemia Statin
Gemfibrozil
Target LDL<100mg/dl
PAD pts with low HDL
and high TG
Hypertension Beta blocker
ACE inhibitor
Decrease risk of
cardiovascular events
Diabetics Insulin therapy or Oral
hypoglycemic agent
Proper foot care
HbA1C <7%
Atherosclerosis Aspirin
Clopidogrel
Cilostazol
Reduce the chance of
vascular events

33. Surgery
• Percutaneous transluminal balloon angioplasty
Indication-(stenosis less than 5cm)
– Conventional
– Subintimal
• Endarterectomy
• Indication- ( segmental block of artery)
– Open
– Semiclosed
– Wiely’s eversion endarterectomy
• Femoroplasty/Profundaplasty (segmental block)

34. Cont..
• Reverse saphenous vein graft –segmental block, femoropoplitial block
• Insitu saphenous vein graft – segmental block, femoropoplitial block
• Arterial graft( involvement of long segment)
• Lumber sympathectomy – for healing purpose of ulceration
• Chemical sympathctomy( caudal block)
• Omentoplasty –for healing puropse
• Amputation - gangrene

35. Conventional method of PTA

38. FEMORAL ENDARTERECTOMY(open method)

39. Bifurcated Dacron patch for simultaneous superficial femoroplasty and
profundoplasty

41. he artery.
The Y-shaped graft creates a bypass for blood to travel around the blocked section of the artery.
Bypass surgery is preferred for people who have many areas of blockage or a long, continuous
blockage in the arteries of the abdomen and/or the pelvis.

42. Cont..
• Lumber sympathectomy – abolish vasomotor
activity  vasodilation improve circulation
• Omentoplasty – rich in blood supply and heals
ulcers
• Amputation – depends upon extent of
gangrene, site of block and amount of
collaterals