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1. Management of Peripheral
vascular diseases/Thrombosis
Sunil Kumar Daha

2. Peripheral vascular diseases
Arterial
(i) Chronic lower limb arterial disease
- Intermittent claudication
- Critical limb ischemia
- Thromboangitis obliterans
( Buerger’s disease)
(ii) Chronic upper limb arterial disease
- Arm claudication (rare)
- Atheroembolism
- Subclavian steal
(iii) Raynaud’s phenomenon/disease
(iv) Acute limb ischemia
(v) Aortic Aneurysms
Venous
(i) Vericose veins
(ii) Thrombophlebitis
(iii) Deep Vein Thrombosis (DVT)

3. Arterial Peripheral vascular
diseases

4. Best Medical Therapy (BMT) for Peripheral
Arterial Disease
• Smoking cessation
• Regular exercise (30 mins of walking, three times per
week)
• Antiplatelet agents (aspirin 75 mg or clopidogrel 75
mg daily)
• Reduction of cholesterol (diet and statin therapy)
• Diagnosis and treatment of diabetes mellitus
• Diagnosis and treatment of frequently associated
conditions (e.g. hypertension, anaemia, heart
failure)

5. Chronic lower limb arterial disease
Clinical features
• Pulse: diminished or absent
• Bruits: denote turbulent flow but bear no relationship to the severity of
underlying disease
• Reduced skin temperature
• Pallor on elevation and rubor on dependency (Buerger’s sign)
• Superficial veins that fill sluggishly and empty (gutter) upon minimal
elevation
• Muscle wasting
• Skin and nails: dry, thin and brittle
• Loss of hair

6. Intermittent claudication
• It is an ischemic pain affecting the muscles of leg upon walking.
• Pain most commonly felt in calf muscle because superficial femoral
artery is mostly affected.
• Pain in thigh or buttock if iliac arteries are involved.
• Pain comes on after a reasonably constant claudication distant
• Pain subsides on stopping walking
• ABPI (Ankle and brachial pressure index) 0.5-0.9

7. Critical limb ischemia
• Rest (night) pain
• Require opiate analgesia and/or
• Tissue loss (ulceration or gangrene)
• present for more than 2 weeks
• In the presence of an ankle BP of less than 5o mm Hg
• ABPI usually below 0.5
• Rest pain only, with ankle BP more than 50 mmHg, is known as
subcritical limb ischemia (SLI).
• Pain relieved by hanging limb out of bed.

8. Chronic Lower Limb Arterial Disease
1. Non-pharmacological:
BMT
2. Pharmacological:
• Cilostazol: 100 mg BD
 MOA: Inhibit phosphodiesterase III  Inceases cAMP
Vasodilatation
• Naftidrofuryl: 100-200mg TDS
 MOA: Inhibit vascular and platelet 5-HT2 receptor 
decreases lactic acidosis

9. 3. Surgical:
• Angioplasty
- Percutaneous Transluminal Angioplasty (first option)
• Arterial Stenting
- For recurrent iliac diseases
• Bypass Surgery
• Amputation
- If the vascular damage is unreconstructable

10. Thromboangitis obliterans (Buerger’s
Disease)
• Results in severe vascular insufficiency and gangrene of the extremities
• Characterised by focal acute and chronic inflammation of medium-sized
and small arteries especially the tibial and radial arteries.
• Associated with thrombosis
• Almost exclusively in heavy tobacco smokers
• Usually develops in male before 35 of age (in youngs).
• Wrist and ankle pulses are absent but brachial and popliteal pulses are
present
• Disease also affects the veins giving rise to superficial thrombophlebitis.

11. • Patient must stop smoking  remits itself
• Sympathectomy and prostaglandin infusion
• Limb amputation if the patient continue smoking
Thromboangitis obliterans (Buerger’s
Disease)
Takayasu’s disease(pulseless disease)
• Corticosteroids
• Surgical bypass to improve perfusion

12. Raynaud’s phenomenon/disease
• Results from exaggerated vasoconstriction of arteries and arterioles in
the extremities
• particularly in fingers and toes
• But also sometimes in nose, earlobes and lips
• Induces paroxysmal pallor or cyanosis
• Involved digit characteristically show red-white-blue pattern of color
changes from most proximal to most distal
• Reflecting proximal vasodilation, central vasoconstriction and more
distal cyanosis respectively.
• Can be primary or secondary

13. Primary Raynaud’s phenomenon:
• Avoid exposure to cold
• Long acting nifedipine 10 mg twice daily
Secondary Raynaud’s phenomenon:
• Fingers must be protected from cold
• Antibiotics in case of infection
• Prostacyclin infusion
• sympathectomy
Raynaud’s phenomenon/disease

14. Acute limb ischemia
• Frequently caused by acute thrombotic occlusion of pre-existing
stenotic arterial segment, thromboembolism or trauma that may be
iatrogenic.
Signs and symptoms (5P’s):
Pain
Pallor
Paraesthesia
Paralysis
Pulselessness

15. • 3000-5000 U intravenous bolus of low molecular weight heparin
provided that patient has no contraindications (e.g. acute aortic
dissection or trauma) and target aPTT  2-3 seconds.
• Antiplatelet agents
• High dose statins
• Intravenous fluids to avoid dehydration
• Correction of anaemia
• Oxygen saturation
Management

16. Aneurysmal Diseases
Abdominal Aortic Aneurysms (AAA)
• Medical Therapy
 Control HTN
 Stop Smoking
 Have lipid-lowering medications
 Regular ultrasound surveillance
• Surgical Therapy
 Open Surgical Repair
 Endovascular Aneurysm Repair (EVAR)
 Laparoscopic Surgical Repair
 Regular ultrasound surveillance
Indications of Surgery
• ≥5.5 cm diameter
• expanding >1 cm/year
• symptomatic

17. Thoracic Aortic Aneurysms (TAA):
• If the aneurysm is > 6 cm then operative repair or stenting.
• EVAR for isolated descending thoracic aneurysms
Cardiovascular syphilis
• Penicillin
• Aneurysms and valvular diseases are treated by usual methods

18. Venous Peripheral vascular
diseases

19. Vericose veins
1. Conservative measures
• Compression (e.g., bandages, support stockings, intermittent pneumatic compression devices)
• Elevation of the affected leg
• Lifestyle modifications
• Weight loss
2. Endovenous or interventional therapy
• Endovenous obliteration
• External laser therapy
• Sclerotherapy (injecting substance that collapse the veins permanently)
3. Surgery:
• Ligation
• Phlebectomy
• Stripping

20. Thrombophlebitis
• Low molecular weight heparin with NSAID or alone for 45 days

21. Deep vein thrombosis
• Bed rest until anticoagulation and then later mobilized, with an elastic stocking
giving graduated pressure over the leg.
• Low-molecular-weight heparins (LMWH)
• Warfarin is started immediately and the heparin stopped when the INR is in the
target range.
• Thrombolytic therapy is occasionally used for patients with a large iliofemoral
thrombosis.

22. References:
• Kumar and Clark’s Clinical Medicine, 8th edition(Page 784)
• Davidson’s Principles and practice of Medicine, 22nd edition(Page
600)

23. Thank You