Lower limb peripheral vascular disease includes arterial, venous, and lymphatic disorders such as atherosclerotic peripheral arterial disease, deep vein thrombosis, chronic venous insufficiency, and lymphedema. Symptoms range from asymptomatic to intermittent claudication, critical limb ischemia, and acute limb ischemia. Evaluation involves assessing risk factors, examining pulses and skin changes, and vascular testing like ankle-brachial index. Management focuses on risk factor modification, exercise, wound care, pain management, and surgical or endovascular revascularization when needed to prevent limb loss.
Clinical examination notes based on TU/KU curriculum of MBBS in nepal. Hope this will be very much helpful in step wise approach to you people especially during exam time.
Knee pain is an extremely common complaint, and there are many causes.
Family physicians, Orthopedic surgeons and internist, Pediatricians and other doctors frequently encounter patients with knee pain.
PERIPHERAL ARTERIAL DISEASES- INTRODUCTION- Limb Ischemia
Dear Viewers,
Greetings from “Surgical Educator”
Today I am uploading an introductory video on “Peripheral Arterial Diseases”. In this video I have discussed the surgical anatomy, modes of presentation, symptoms, signs, investigations and a diagnostic algorithm of Peripheral Arterial Diseases. In the subsequent three videos I will discuss about chronic lower limb ischemia, acute lower limb ischemia and upper limb ischemia. I hope you will enjoy these series of teaching videos. You can watch these videos in the following links:
surgicaleducator.blogspot.com
youtube/c/surgicaleducator
Thank you for watching the video.
Clinical examination notes based on TU/KU curriculum of MBBS in nepal. Hope this will be very much helpful in step wise approach to you people especially during exam time.
Knee pain is an extremely common complaint, and there are many causes.
Family physicians, Orthopedic surgeons and internist, Pediatricians and other doctors frequently encounter patients with knee pain.
PERIPHERAL ARTERIAL DISEASES- INTRODUCTION- Limb Ischemia
Dear Viewers,
Greetings from “Surgical Educator”
Today I am uploading an introductory video on “Peripheral Arterial Diseases”. In this video I have discussed the surgical anatomy, modes of presentation, symptoms, signs, investigations and a diagnostic algorithm of Peripheral Arterial Diseases. In the subsequent three videos I will discuss about chronic lower limb ischemia, acute lower limb ischemia and upper limb ischemia. I hope you will enjoy these series of teaching videos. You can watch these videos in the following links:
surgicaleducator.blogspot.com
youtube/c/surgicaleducator
Thank you for watching the video.
This presentation is a comprehensive summary about all aspects of back pain. Back pain is one of the most common orthopaedic morbidity or orthopedic disability. Sciatica and lumbar disc diseases are common cause of spinal disability. Back pain are divided into Red flags, green flags and yellow flags for quick clinical screening. both treatment, prevention aspects are covered. Spinal anatomy and Biomechanics are covered. Epidemiology and role of various types of spine surgery, microdiscectomy, endoscopic spine surgery are also described.
PROCTOLOGY AND USE OF LASER SURGERY.
CLINICAL EXAMINATION
RELEVANCE OF PR AND PROCTOSCOPY
HAEMORRHOIDS
FISTULA ANO
PILONIDAL SINUS
FISSURE
ROLE OF LASER SURGERY
PER RECTAL EXAMINATION
PROCTOSCOPY
This presentation is a comprehensive summary about all aspects of back pain. Back pain is one of the most common orthopaedic morbidity or orthopedic disability. Sciatica and lumbar disc diseases are common cause of spinal disability. Back pain are divided into Red flags, green flags and yellow flags for quick clinical screening. both treatment, prevention aspects are covered. Spinal anatomy and Biomechanics are covered. Epidemiology and role of various types of spine surgery, microdiscectomy, endoscopic spine surgery are also described.
PROCTOLOGY AND USE OF LASER SURGERY.
CLINICAL EXAMINATION
RELEVANCE OF PR AND PROCTOSCOPY
HAEMORRHOIDS
FISTULA ANO
PILONIDAL SINUS
FISSURE
ROLE OF LASER SURGERY
PER RECTAL EXAMINATION
PROCTOSCOPY
to down load this presentation from this link
https://mohmmed-ink.blogspot.com/2020/11/deep-vein-thrombosis-dvt.html
deep vein thrombosis, diagnosis and managment.
It is estimated that 20% of American women and 7% of American men suffer from venous disease. Venous disease results in symptoms such as aching, fatigue, swelling, and pain in the legs which can interfere with daily living.Cosmetic issues may affect quality of life.
At least 20% of patients with venous disease will develop leg ulcers. This presentation outlines the normal anatomy and physiology of venous drainage of the extremities as well as the common venous disorders such as varicose veins and deep vein thrombosis.
Deep Vein Thrombosis is an important and frequently missed out diagnosis that can often lead to sudden death in post operative patients. Did this powerpoint for an O&G seminar. Mainly focusses on DVT in OBG and its management and prevention. Kindly leave a comment and let me know what you think.
Lymphoscintigraphy As an Imaging Modality in Lymphatic SystemApollo Hospitals
Lymphedema is a chronic debilitating disease that results from chronic lymphatic insufficiency. Lymphoscintigraphy forms an authentic yet simple diagnostic and screening procedure in patients with preclinical and clinical lymphedema of different etiologies. Our study population consisted of 540 patients with diagnosed lymphedema of different etiologies and grading. Here we highlight our experience of lymphoscintigraphy in different clinical situations and staging of lymphedema. Lymphoscintigraphy is a simple, noninvasive procedure, which documents clinical diagnosis and guides the management of Lymphedema
PHYSIOTHERAPY IN COMMON VASCULAR CONDITIONS.pptxKunjalPardeshi1
Vascular disease includes any condition that affects your circulatory system, or system of blood vessels. This ranges from diseases of your arteries, veins and lymph vessels to blood disorders that affect circulation.
Blood vessels are elastic-like tubes that carry blood to every part of your body. Blood vessels include:
Arteries that carry blood away from your heart.
Veins that return blood back to your heart.
Capillaries, your tiniest blood vessels, which link your small veins and arteries, deliver oxygen and nutrients to your tissues and take away their waste.
Peripheral vascular disease is the disease that involves narrowing of blood vessels including artery , vein and lymphatic vessels. Here introduction, definition and Types of peripheral vascular
disease are well classified in flowchart. Types of arterial , venous and lymphatic disease described . All the diseases are explained with their definition, risk factors, causes, sign and symptoms,diagnostic evaluation,medical management, surgical management with diagramatic presentation, nursing management is explained. Youtube link of procedures is also available in ppt. Nursing diagnosis of PVD is included .
Nursing Care of Clients with Peripheral Vascular Disorders Part 2 of 3 Carmela Domocmat
Nursing Care of Clients with Peripheral Vascular Disorders Part 2 of 3: Arterial disorders such as Arterial occlusive disease, Arterial embolism, Arterial thrombosis, Thromboangiitis obliterans (Buerger’s disease), Aortitis, Aortoiliac disease, Aneurysms, Raynaud’s disease, and Thoracic outlet syndrome
A complete overview of the most common cardiac and vascular conditions affecting Americans today. While designed for nurses and nursing students, the pharmacology and pathophysiology included is a useful refresher for paramedics and other healthcare.
Made by Ranjith R Thampi. A surgery powerpoint I made during internship for Management of Varicose Veins. Tried to cover as much as possible on the topic. Kindly comment before you download. Thanks!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
1. Lower Limb Peripheral Vascular Disease
Lower limb peripheral vascular disease includes
arterial,venous, and lymphatic disorders.
Types Of Peripheral Vascular Disease
Arterial
- Atherosclerotic peripheral arterial
disease
Thromboangiitis obliterans, also called
Buerger’s disease
- Vasospastic disease (Raynaud’s
phenomenon, livedo reticularis,
acrocyanosis)
Venous
- Chronic venous insufficiency
- Superficial thrombophlebitis
Venous thromboembolism, includes
deep venous thrombosis and pulmonary
embolism
Lymphatic
- Primary lymphedema
- Secondary lymphedema
Arterial Disease of the Lower
Limb
Anatomy (Lower Limb)
Abdominal Aorta> 2 common Iliac Arteries
th
(Level of 4 lumbar vertebra) > Internal and
external Iliac Arteries
External Iliac artery (pass under inguinal
ligament) > common femoral artery (thigh)
>superficial and deep femoral arteries
Superficial artery > popliteal artery (level of
knee) > anterior and posterior tibial artery
(divides below the knee)
Anterior tibial artery > dorsalis pedis artery
1
ARTERIAL DISEASES
Atherosclerotic Peripheral Arterial
Disease (PAD)
Epidemiology and Risk Factors
- Cause partial or incomplete obstruction
of the arteries of the legs
- Major cause of morbidity and mortality
worldwide
- Commonly seen because of other
vascular d/o like stroke
- Common in America
- Men=Female
- Blacks (common)
- Smoker (higher risk)
- Diabetes (major risk factor)
Lower Limb Peripheral Vascular Diseases| Mica Pusing
2. (paleness of the skin), paresthesia,
paralysis
present for less than 2 weeks
requires emergent vascular surgery>
must be done to prevent irreversible
tissue loss
- embolectomy, thrombolysis,
st
amputation(30% in the 1 month of
presentation)
Critical Limb Ischemia
- ischemia> more than 2 weeks
- causes rest pain, ischemic ulcer and
gangrene
- begins once toe pressure falls to less
that 30 to 50 mm Hg
- rest pain : toe pressure falls 30mmHg
- higher pressure is needed to heal
wound than needed to maintain intact
skin
- 40mmHg: asymptomatic, intact skin,
develop nonhealing ischemic ulcer after
minor trauma
Evaluation
-
Clinical Presentation
-
asymptomatic, intermittent claudication
(IC), critical limb ischemia (CLI), and
acute limb ischemia, with the most
common being asymptomatic
Clinical Presentation of PAD
-Asymptomatic (most common)
-Intermittent claudication: Reproducible paon
in the lower limb with exertion that resolves
quickly with rest
-Acute limb ischemia: a sudden decrease in
limb perfusion that threatens loss of the limb
-Critical limb ischemia: chronic ischemia that
causes either rest pain or wounds.
Asymptomatic
- complete occlusion was found in 1/3 of
pt.
- lack of symptoms is due to low physical
ax
- functional impairment is present
- functional decline is related to anklebrachial index (ABI)
Intermittent Claudation(IC)
- leg pain with exertion that is relieves
with rest
- claudation produces ischemia in the
affected muscle > pain
- pain can be felt in : buttock, hip, thigh,
calf, or foot
- limits the pt. ability to walk
- decreased walking speed and distance
- decreased leg function
Acute Limb Ischemia
- can be caused by embolism, thrombosis
or dissection
- limb threatening medical emergency
- pt. present with pain,
poikilothermia(disruption of normal
hypothalamic thermoregulatory
function), pulselessness, pallor
2
-
functional history should be taken to include
mobility, activities of daily living, and
independent activities of daily living.
- The presence of risk factors for PAD must
be noted
- physical examination: lower limb pulses
(evaluated) including the dorsalis pedis,
posterior tibial, popliteal, and femoral.
- legs and feet: changesof skin temperature,
color, and evidence of poor vascular flow.
- Dreased blood flow> atrophy thin shinny
skin, decreased hair growth, nails are
thickand brittle; foot >red or purple; pallor
when elevated
Vascular Testing for Peripheral Arterial
Disease
Ankle–Brachial Index.
- compares the brachial systolic pressure with
the ankle systolic pressure
- 95% sensitive in detecting PAD
- Obtained in pt. 70, patients aged 50 to 69
who have cardiovascular risk factors
Toe Pressures
- obtained by placing asmall cuff on the first
or second toe.
- For pt, with elevated ABI
- .7 : abnormal
Segmental Limb Systolic Pressure Measurement
- taken in the thigh, calf, and ankle
- Occlusive disease is noted by a significant
decrease in systolic pressure
Lower Limb Peripheral Vascular Diseases| Mica Pusing
3. Segmental Plethysmography (Pulse Volume
Recordings)
- recordings are obtained at the thigh, calf,
and ankle.
Occlusive lesions are detected by a change
in waveform from one level to the next.
Doppler Velocity Waveform Analysis
- performed to localize the lesion
Transcutaneous Partial Pressure of Oxygen
- test to predict wound healing
- usedto select amputation level
- TcPo2 less than 30 mm Hg : poor wound
healing
- TcPo2 above 40mm Hg : adequate skin
perfusion for healing
Angiography
- gold standard imaging test for PAD
- used to visualize the arterial anatomy and
the extent of PAD before revascularization
procedures.
Magnetic Resonance Angiography
- safer
- sensitivity and specificity are greater than
90% for evaluating PAD
Multidetector Computed Tomography Angiography.
- Faster and safer as compared to MRA
Management
Patients with PAD are more likely to have coronary
artery disease and cerebral artery disease than
patients without PAD.
goals of tx:
- reduce ischemic symptoms,
- increase walking ability
improve function, prevent and heal wounds
- prevent limb loss
- reduce morbidity and mortality
management
- education
- risk factor modification
- pharmacotherapy,
- exercise
- vascular interventions
Risk Factor Modification
Includes:
smoking cessation,
- - weight reduction
control of hyperlipidemia, hypertension,
and diabetes
smoking cessation:
3
-
can reduce their risk of amputation and
cardiovascular events even if it does not
improve claudication symptoms
Pain Management
- diabetic neuropathy: impair sensation
enough that the pt cannot feel ischemic pain
- ischemic pain relieved by reperfusion
- opiates for pain control
- pt that develop rest pain at night when they
lie down and find that keeping the foot in a
dependent position provides relief
Wounds
- ischemic wounds are best treated with
reperfusion of the limb
- tissue might not have sufficient blood supply
to repair itself after the trauma of
debridement.
- Dry gangrene can be allowed to
autoamputate as long as there is no evidence
of infection and there is adequate perfusion
to support healing of the underlying tissue
- Dependent rubor : fade with elevation and is
not associated with induration or increased
warmth.
erythema of cellulitis is often associated
with induration, increased warmth, swelling,
and does not fully resolve with elevation of
the limb.
Exercise
- improve walking time and walking distance
in PAD patients
Foot Protection
- Footwear should have enough length,
breadth, and depth to prevent pressure on
any bony prominences, deformities, or
calluses
Surgical Intervention
- Open surgical bypass is used in more diffuse
lesions.
- surgical interventions include limb salvage
and amputation
Arteriosclerosis Obliterans
-
-
disease commonly present because of
symptoms of intermittent claudication
or critical leg ischemia
intermittent claudication: active
Pts describe claudication as numbness,
weakness, giving way, aching, cramping,
or pain
Lower Limb Peripheral Vascular Diseases| Mica Pusing
4. -
-
inactive: rest pain, ulceration,
dependent rubor, or gangrene may be
the presenting findings
symptoms occur distal to the level of
stenosis
-
Angioplasty
- indicated for focal stenosis or short
Tx
Risk factor modification
major risk factors for peripheral arterial
occlusive disease:
- age
- diabetes mellitus
current smoking status(2x risk)
alterations in lipid metabolism
Hypertension
elevated plasma homocysteine levels
- elevated fibrinogen levels
Antiplatelet Therapy
-
decrease the rate of atherosclerotic
disease progression, decrease the
incidence of thrombotic events in the
limbs, and decrease the rate of adverse
coronary and cerebral vascular ischemic
events
Rehabilitation
General Self-Care Measures
- instructed to monitor their extremities
carefully for redness or skin breakdown
- Extremes of temperature should be
avoided
- Wash feet with mild soap and warm
water
- Rubbing when drying the foot is
avoided since it can injure the skin
- Skin bet toes should be dried to avoid
maceration
- Prevent the cracking of skin
- Proper foot wear
- Decrease activity
Exercise
- Elicit maximum walking time
- Should receive structured claudication ex
rehab program for at least 3 sessions weekly
over a period of 12 weeks
4
instruct to walk until claudication
occurs, rest until it subsides, and
continue repeating the cycle for 1 hour
each day.
-
-
segmental occlusions in which the
adjacent vessels are relatively free of
disease
localized stenosis of the common iliac
artery (less than 5 cm in length) is the
most favorable situation for angioplasty
decrease effectiveness in distal vessel
surgical revascularization
-
-
considered in patients with rest pain,
impending tissue loss, or significant
limitation of lifestyle
Pedal bypass grafting for critical limb
ischemia is a durable procedure with
acceptable graft patency and a very
good limb salvage rate
Intermittent Pneumatic Compression
- Skin blood flow, as reflected by TcPO
- External compression briefly raises
tissue pressure, emptying the
underlying veins and transiently
reducing venous pressure without
occluding arterial blood flow
Epidural Spinal Cord Stimulation (SCS)
- may decrease ischemic limb pain and
enhance perfusion
- result from vasodilation, possibly
through an effect on resting
sympathetic tone
Acute Arterial Occlusion
-
-
-
three causes:
o thrombosis
o aortic dissection
o emboli
thrombosis
o insitu occurs at the site of the
vascular abnormality,
Dissection
o Aotic dissection associated to
hypertention arthrosclerosis,
Lower Limb Peripheral Vascular Diseases| Mica Pusing
5. connective tissue disorders,
trauma
-
Emboli
o Large enough to occlude large
arteries typically cardiac source
o Arterial embolus unusual cause
paradoxic embolus(DVT>pass
foramen ovale)
o Multiple ad recurrent
Other Arterial Diseases
UPPER EXTREMITY ISCHEMIA
- Coldness and color changes: presenting
sx
Thromboangiitis Obliterans
(Buerger’s Disease)
-
nonatherosclerotic PAD affecting young
male smokers
- inflammatory disease that affects smalland
medium-sized arteries of the upper and
lower distal extremities
- considered to be a form of vasculitis
- M>F
- Higher risk for smokers
- high risk for amputation as compared to
PAD
Clinical Presentation, Evaluation, and
Diagnosis of Thromboangiitis Obliterans
- legs are more involved than the arms,
however, three or four limbs involved when
assessed with angiography
- Allen test to assess for asymptomatic
involvement of the upper extremities; (+)
indicates small artery disease in the upper
limbs but is not specific to TAO
Management of Thromboangiitis Obliterans
- Smoking cessation is key to disease
management
Vasospastic Disease (Raynaud’s
Phenomenon, Livedo
Reticularis,Acrocyanosis)
Raynaud’s Phenomenon
-
pain, and numbness in the fingers and
sometimes the toes
- triggered by cold temperatures, emotional
stress, vibration, or anything that activates the sympathetic nervous system
- Secondary Raynaud’s phenomenon is
associated with other disorders, such as
connective tissue diseases such as
scleroderma and lupus
- Patients should be instructed to keep the
whole body warm, avoid sudden decreases
in temperature, stop smoking, avoid
caffeine, avoid sympathomimetic drugs, and
reduce stress
Livedo Reticularis
-
seen on the arms and legs and occasionally
the trunk
- common in young women
- trigeer: cold
Acrocyanosis
-
causes the hands and feet to be bluish and
cold but is not painful
common in young women
aggravated by cold exposure
episodic
Venous Disorders of the Lower
Limb
Peripheral venous disorders include the following
conditions:
1. Chronic venous insufficiency (CVI) and venous
leg ulcers
2. Superficial thrombophlebitis
3. Deep venous thrombosis (DVT)
4. VTE, which is a collective term for DVT with
pulmonary embolism (PE)
Chronic Venous Insufficiency
Epidemiology of Chronic Venous Insufficiency
-
2x common in women but severity is higher
in men
-
Predisposing factor:
o
o
o
more common in young women and those
with a family history of the disorder
affect both hand and feet but affect hand
more often
occurs when the normal vascular response
becomes exaggerated causes color changes,
o
o
Pathogenesis
5
Lower Limb Peripheral Vascular Diseases| Mica Pusing
prolonged standing,
obesity,
positive family history,
multiparity,
advanced age,
historyof leg injury, surgery, heart
failure, paralysis, and DVT
6. o
-
-
-
persistent ambulatory venous hypertension
in the superficial and deep venous systems
in the lower limbs
Normal functioning of the venous blood
flow system depends on competent valves,
calf muscle pump mechanism, and normal
venous anatomy
Incompetence in any valves disrupts the
unidirectional flow of blood from the
superficial to the deep systems and toward
the heart, resulting in ambulatory venous
hypertension
Clinical Features
-
-
-
-
Initial complaints can be purely cosmetic
Chief clinical manifestation: dilated leg
veins, edema, leg pain, skin pigmentation,
subcutaneous fibrosis, dermatitis, and
ulceration
Patients can describe heaviness and aching
in the legs with prolonged standing. The
pain is usually localized to the calf or along
the varicose veins and is relieved by walking
or lying down with the leg elevated.
deep venous system obstruction can
experience venous claudication, a mild
aching sensation at rest that becomes an
intense cramping-type sensation in the calf
with ambulation
cutaneous manifestation:
o brownish pigmentation
(perimalleolar area)
o reddish purple hue (from venous
engorgement and obstruction)
Diagnostic Evaluation
-
Duplex ultrasound scanning has become the
test of choice for evaluation (allows
identification of any underlying
unrecognized acute or subacute DVT, as
well as the site and type of pathology
causing the CVI
Management
-
-
-
limb elevation is used for edema control,
patients should be instructed to elevate the
limb above heart level.
Periodic elevation of the leg 20 cm above
heart level during the day has been shown to
relieve edema by effectively lowering the
hydrostatic pressure to nearly zero
Compression stockings
6
reduce superficial venous volume
and venous hypertension, assist calf
muscle pump, and help prevent
transcapillary leakage of fluid into
the interstitial tissue
- Contraindications for compression therapy
include arterial insufficiency with ABI of
less than 0.6, ankle pressure less than 60 mm
Hg, active skin disease, or allergy to any of
the stocking components
- Physiologically, intravenous pressure in the
leg vein reflects the weight of the blood
column between the site of measurement
and the right atrium
- In the supine position: leg vein pressure: bet.
10-20 mmHg > total occlude at pressure of
:20-25mmHg
- Thromboembolic stockings exert a pressure
between 14 and 20 mm Hg.
- During standing, intravenous pressure in the
lower leg veins: around 60 mm Hg,
depending on the height of the individual.
- An external pressure of 35 to 40 mm Hg has
been shown to narrow the veins in the
standing position, and 60 mm Hg will totally
occlude the veins in the standing position.
- For mild disease and those with underlying
arterial disease, compression stockings with
20 to 30 mm
Venous Ulceration
-
disabling complication of CVI
most often large, irregular in shape, and
have a flat wound edge with a shallow moist
ruddy or beefy granulation base
- risk is highest when the ambulatory venous
pressure is 80mm Hg or greater
- Compression therapy is the mainstay of
treatment and is aimed at lessening the
impact of the underlying venous
insufficiency
Superficial Thrombophlebitis
-
-
treated with elevation, superficial heat, and ambulation with 30 to 40 mm Hg
compression stockings.
Nonsteroidal anti-inflammatory drugs are
useful in reducing pain and limiting local
inflammation
Venous Thromboembolism
Epidemiology
-
primarily a disease of old age
incidence increases with age
Lower Limb Peripheral Vascular Diseases| Mica Pusing
7. -
Male to female ratio = 1.2:1
Higher in women in childbearing yrs
Higher incidence in African American and
whites
-
-
Pathogenesis
-
Primary or idiopathic DVT occurs in the
absence of recognized thrombotic risk
factors
- secondary DVT occurs in the presence of
known risk factors
- Virchow’s Triad
o venous stasis
o vessel wall injury
o variation in coagulability of the
blood (important contributor in
pathogenesis of DVT)
- Thrombi usually begin to form at low flow
sites (deep veins of the calf, soleus sinuses,
behind the cusps of venous valves, and at
the entrance of tributary veins)
Risk factos associated with virchows triad
stasis
Hypercoagulable
Endothelial
state
injury
Age(>60)
Estrogenic
PostOp state
medication
Immobility Pregnancy
Cenous acess
Paralysis
Cancer
Trauma, burns
HR/
Family HX
Spinal cord
Myocardial
injury
infarction
Anesthesia Sepsis
Sepsis
in past
surgery
Obesity
Inherited
vasculitis
hypercoagulable state
Long
Factor v leiden
Prior DVT
distance
mutation
travel
-
-
Surgery of hip and knee, venous
catheterization, and burns can cause vessel
wall damage that initiates thrombus
formation
Venous thrombi consist of deposit of fibrin,
red cells, platelets and leukocytes
Most clinically significant PE originates
from DVT of the proximal lower limb
(popliteal, femoral, or iliac veins)
Clinical Features of Venous
Thromboembolism
7
-
-
Classic signs of edema, erythema, warmth,
tenderness, and positive Homan’s sign are
nonspecific and might not be always present
Patients can present with unilateral edema
and tenderness confined to the calf muscle
or along the distribution of the deep veins of
medial thigh without any other signs.
A 3-cm or greater difference in calf
circumference 10 cm below the tibial
tuberosity is associated with a high
likelihood of having DVT
Patients with obstructive iliofemoral
thrombosis can present with a markedly
swollen, cyanosed leg or with a white, cold
leg if there is associated arterial spasm
Diagnostic Evaluation of Venous
Thromboembolism
Duplex Ultrasound for Deep Venous Thrombosis
- choice for detection of DVT
Magnetic Resonance Venography
100% sensitivity in diagnosis
- of DVT proximal to the inguinal ligament
- safe to use in pregnant women
- concern: in pt with renal insufficiency
D-Dimer Assay
- Elevated levels of d-dimer occur with acute
thrombosis, but this does not discriminate
between physiologic (e.g., postoperative or
posttrauma) or pathologic (e.g., deep vein)
thrombi
Diagnostic Testing for Pulmonary Embolism
Ventilation Perfusion Scintigraphy
A normal study can effectively rule out
clinically important PE.
Spiral Computed Tomography.
- It is minimally invasive compared with
pulmonary angiography but allows
visualization of pulmonary vessels,
parenchyma, pleura, and mediastinum.
Pulmonary Angiography
- costly, invasive, technically demanding, and
has significant radiation exposure.
Treatment of Acute Venous
Thromboembolism
-
goals of treatment:
o prevent PE
o recurrent VTE,
o postphlebitis syndrome
Lower Limb Peripheral Vascular Diseases| Mica Pusing
8. -
Anticoagulation is the mainstay of
treatment, and the treatment regimen is
similar to that for DVT and PE
Ambulation After DVT
- Adjunctive therapy with graduated belowknee stockings with 30 to 40 mm Hg
pressure at the ankle is indicated after
proximal DVT.
Lymphatic Disease in the Lower
Limbs
-
-
-
-
-
-
-
lymphatic vasculature is divided into
superficial and deep systems located in the
popliteal fossa and the inguinal region
superficial system : from the skin and
subcutaneous tissues
deep system: muscles and joints
lymph has no valve
lymph capillaries flows into the lymph
precollector then collectors
lymph angion
o a segment of a lymph collector
located between two valves
o Contain smooth muscle
o Contract around 10-12 time/min at
rest
Lymphangiomotoricity
o frequency and amplitude of these
contractions
o affected by : internal stretch,
temperature, hormones, external
stretch from manual lymph
drainage or muscle or joint pump
during exercise
Lymphedema
o caused by a defect in the lymphatic
system that leads to protein-rich
interstitial fluid overload.
primary lymphedema
o Hereditary and congenital types
o Less common
o Divided into three major types:
congenital, lymphedema praecox,
lymphedema tarda
Congenital lymphedema
o Onset in the first 1-2 years of life
o Bilateral
o Aplastic lymphatics
o Due to gene defect hat involves
lymphathogenesis
Lymphadema praecox
o Onset between 1-35 y/o
o Hypoplastic lymphatics
o Unilateral
8
-
-
Lymphadema tard
o Onset is after age of 35
o Week lymphatics unable to
compensate when stresses with
overload injury
Secondary lympedema
o Most common type
o Usually caused by canser
o Unilateral pain swelling
o Precaution
Meticulous skin care
Meticulous nail care
Avoid anything that cause
swelling (needle sticks,
blood pressure cuff, tight
clothing, leaving the leg in
dependent position for
long period)
o Clinical presentation
Pitting edema but
becomes nonpitting(tissue
become fibrotic)
Pt. complains limb feels
heavy and stiff
o Complication
Cellulitis
Lymphangitis
Lymphangiosarcoma
o Treatment goals
Improve function of limb
Prevent complication
Improve quality of life
o The treatment phase involves
sessions 5 days/wk and includes
manual lymph drainage (MLD),
exercise, skin and nail care, and
compression. MLD consists of light
strokes to help stimulate lymph
production and transport
o The bandages should not be
removed and should be worn until
the next treatment session. Exercise
is performed twice a day for 15
minutes while wearing
compression bandages
o Once the patient has reached
maximum limb reduction, therapy
moves from the initial treatment
phase to the maintenance phase
o The maintenance phase is a lifelong
process of preventing
reaccumulation of lymphedema and
protecting the skin
Reference
Lower Limb Peripheral Vascular Diseases| Mica Pusing
9. Physical medicine and rehabilitation 4th edition by
Braddom
9
Lower Limb Peripheral Vascular Diseases| Mica Pusing