Peripheral Arterial Disease (PAD) is the progressive obstruction of arteries below the aortic bifurcation due to atherosclerosis. It has a prevalence of 5-20% in those over 50 years old. Symptoms range from intermittent claudication to critical limb ischemia with rest pain and tissue loss. Late presentation is common due to asymptomatic or atypical symptoms. Diabetes significantly increases the risk and severity of PAD. Treatment involves risk factor modification, endovascular or surgical revascularization, wound care, and in severe cases amputation. Regular screening and multidisciplinary care can help prevent amputation in those with PAD and foot ulcers.

1. Peripheral Arterial Disease
Check the Pedal Pulse
Alaa Wafa . MD
Associate Professor of Internal Medicine
PGDIP DM Cardiff University UK
Diabetes & Endocrine Unit.
Mansoura University
2014

2. Amputation every 30 Seconds
Every 30 Sec. there is an Amputation
somewhere in the World
The global burden of diabetic foot disease. Lancet. Vol 366 November 12, 2005

3. Reasons for Late Presentation

4. Peripheral Arterial Disease
Progressive Atherosclerotic Partial
or Complete Obstruction
of one or more Arteries below the
Aortic Bifurcation
Academic
Definition
Robert S. et al.: Peripheral Arterial Disease Textbook. McGraw-Hill, USA. 2009.
PAD = PVD = PAOD = LEAD
ABI<0.9isHemodynamicDefinitionofPAD

5. Academic Definition of PAD.
Progressive Atherosclerotic Partial or Complete obstruction
of one or more Arteries below the Aortic Bifurcation

6. Prevalence of PAD by
Age Group
Eur J Vasc Endovasc Surg 2007; 33: S7
National Heart, Lung & Blood Institute, USA.
5% from adults > 50 years
20% from adults > 65 years

7. PAD Signs & Symptoms
Signs Symptoms

8. Intermittent Claudication
• Muscle discomfort may vary from patient to
other, resulting in different terms
• Pain
• Cramps
• Tightness
• Heaviness
• Burning
• Weakness
• Fatigue
• Collaterals acts as Stabilizing Factor
Robert S. et al.: Peripheral Arterial Disease Textbook. McGraw-Hill, USA. 2009.

9. Limitations of Symptomatic Diagnosis
Only 1 in 10 of these patients
has classical symptoms of
intermittent claudication (IC)
Diabetic Neuropathy
Sedentary Life

10. Stage Clinical Presentation
Stage I Asymptomatic
Stage II IIa: Mild Claudication
IIb: Severe Claudication
Stage III Rest Pain
Stage IV Tissue Loss (Ulceration and/or
Gangrene)
Fountain Classification of PAD
Stage III & IV: Critical Limb Ischemia

11. Fate of the Leg
Disabling Claudication or Pain at RestStabilized by
Collaterals
Norgen L. et al.: Intersociety Consensus for PAD (TASC II). Eur J Vasc Endovasc Surg Vol 33, Supplement 1, 2007.
5 Years
Deterioration

12. Fate of the Leg
Critical Limb
Ischemia
Norgen L. et al.: Intersociety Consensus for PAD (TASC II). Eur J Vasc Endovasc Surg Vol 33, Supplement 1, 2007.
Amputation
30%
Mortality
25%

13. Risk Factors for Peripheral Arterial Disease

14. Factors Magnifying Critical
Limb Ischemia incidence
Norgen L. et al.: Intersociety Consensus for PAD (TASC II). Eur J Vasc Endovasc Surg Vol 33, Supplement 1, 2007.

15. Diabetes
• Diabetes increases the risk of PAD by
4 Folds as well as Progression to CLI
• In diabetic Patients, every 1% increase
in A1C is accompanied by 26% increase in PAD
• Insulin Resistance is a Major Risk Factor for PAD
• Combined Early Large Vessels involvement with
Neuropathy leads to 10 times need for Major
Amputation (Aggressive Deterioration)

16. Diabetes
• More Severe & Longstanding Diabetes
is associated with more incidence of PAD
• Major Contributor are Advanced Glycated
End Products (AGEs)
– Combined excess Glucose with Collagen Fibers
– AGEs encourage Plaque Formation, Atherosclerosis &
increased trapping of LDL

18. Diabetic Vascular Complications
 All patients with diabetes are at risk of developing several chronic
complications, categorized as microvascular and macrovascular1,2
Diabetic
Retinopathy
Microvascular Complications Macrovascular Complications
Diabetic
Nephropathy
Diabetic
Neuropathy
Stroke
Peripheral
Vascular Disease
Heart
Disease
1. Fowler. Clinical Diabetes 2008;26(2):77-82.
2. http://www.who.int/diabetesactiononline/diabetes/basics/en/index3.html
DPNP

19. Diabetic Peripheral Neuropathic Pain:
A Frequent and Debilitating Complication
 10%-20% of patients with diabetic peripheral neuropathy
develop pain1
 This pain broadly interferes with daily functioning and quality
of life1-4
• General activity
• Walking
• Energy level
• Social activities
• Ability to sleep
• Change in mood, feelings of depression and anxiety
• Overall enjoyment of life
1. Argoff et al. Mayo Clin Proc 2006;81(4 Suppl):S3-11.
2. Boulton. Clin Diabetes 2005;23:9-15.
DPNP 3. Galer et al. Diabetes Res Clin Pract 2000;47(2):123-8.
4. Gore et al. J Pain Symptom Manage 2005;30(4):374-85.

20. Diabetic Neuropathy: Clinical Presentation
Large-fiber
Neuropathy
Small-fiber
Neuropathy
Proximal Motor
Neuropathy
Acute
Mononeuropathies Pressure Palsies
Sensory loss: 0+++
(touch, vibration)
Pain: ++++
Tendon reflex:
N
Motor deficit: 0+++
Sensory loss: 0+
(thermal, allodynia)
Pain: ++++
Tendon reflex: N
Motor deficit: 0
Sensory loss: 0+
Pain: ++++
Tendon reflex:
Proximal motor deficit:
++++
Sensory loss: 0+
Pain: ++++
Tendon reflex: N
Motor deficit:
++++
Sensory loss in nerve
distribution: ++++
Pain: +++
Tendon reflex: N
Motor deficit: ++++
III VI
Truncal
Ulnar
Lateral
popliteal
Median
Reprinted from: Vinik et al. Diabetologia 2000;43(8):957-73.DPNP

21. DIABETIC FOOT

23. 1. HISTORY
HISTORY
Duration of
diabetes
Quality of
glycemic
control
Complications
and
comorbidities
Patient foot specific
medical history
Initial
wounding
event
History of
recurrent
wounds
Previous
wound
healing
Prior
diagnostic
testing
Prior treatment
and response
Social
history

24. 2. EXAMINATION
Assessment
of PAD
Assessment of
Neuropathy
Foot and
Ulcer
examination
Infection
Evaluation

25. FOOT &ULCER EXAMINATION
• Evaluate etiology:neuropathic,ischemic,neuro-ischemic
• Evaluation of perfusion
• Ischemic skin changes
• Dermatological changes-callus, muscle wasting
• Ulcer characteristics-location,site,shape,size
• Wound edges,wound bed,wound base,paeriwound skin
• and exudates
• Presence of necrosis and wound associated pain
• Biomechanical status-forefoot deformities,weakness,gait
abnormalities
• Complications-cellulitis,gangrene,osteomyelitis
• Charcot deformity
INFECTION EVALUATION
• Red,hot,tender
• Swelling
• Exudates
• Delayed healing
• Friable and discolored granulation tissue
• Foul odor
• Wound breakdown
• Increased ESR & CRP

26.  Signs-
loss of vibratory and position sense
loss of deep tendon reflexes
trophic ulceration
foot drop
muscle atrophy
excessive callus formation
 Semmes-Weinstein filament
 Biothesiometer
 Pulsation of dorsalis pedis artery and
posterior tibial artery
 Bruit at iliac or femoral arteries
 Skin atrophy
 Loss of pedal hair growth
 Toe cyanosis
 Ulceration or ischemic necrosis
 Pallor and rubor after 1-2 minutes of
elevation above heart level
 History of claudication
ASSESSMENT OF
NEUROPATHY
ASSESSMENT OF PERIPHERAL
ARTERIAL DISEASE

27. CLASSIFICATION OF
DIABETIC FOOT ULCER
 Texas Classification
 Wagner Classification

28. 3. INVESTIGATIONS
 Complete Blood Count
 Pulse-Volume Recording
 Doppler Ultrasound
 Ankle-Brachial Index
 Plain Radiography
 CT and MRI
 Bone scan
 Angiography

31. PREVENTION
PREVENTION
Patient
Education
Foot
examination
Optimizing
glycemic
control
Smoking
cessation
Custom
Footwear
and
Orthotics
Debridement
of calluses
Multidisciplinary
team
Prophylactic
foot surgery
Revascularization

32. CUSTOM FOOTWEAR

33. TREATMENT

34. Vascular
perfusion
Debridement
Infection
Control
Off-
loading
Wound
coverage
Treatment of
Charcot foot
Hyperbaric
Oxygen
Treatment
Dietary
Changes
Activity
restriction
Amputation

35. Recent
Management
options for PAD

36. Cilostazol

37. Naftidrofuryl

38. Role of Serotonin in PAD
Serotonin
5-HT2
5 Hydroxytryptamine-2
100% stored in Platelets
•Promotes Platelets Aggregation
•Thrombus Formation
•Augments Aggregating Factors
•RBCs Aggregation (Rouleaux)
•Increase Blood Viscosity
•Direct Vasoconstriction
•Collaterals: Serotonin Sensitive
•Serotonin Sensitivity is defined by
Hyper-reactivity to Serotonin
(increased by Age, Hypertension, ischemia
Atherosclerosis Hypercholesterolemia)

39. Naftidrofuryl Multi Modes of Action
5-HT2
↑ Platelets aggregation
↑ Vasoconstriction
↑ RBCs Rigidity

40. Guidelines
Recommendations

41. Global Guideline for the Management of
PAD (TASC II).
Inter-Society Consensus for the Management of
Peripheral Arterial Disease

42. Pharmacotherapy
A. Drugs with evidence of clinical utility in claudication
(Grade A)
Blood
Platelets
RBCsV. Smooth
Muscles
5-HT
Naftidrofuryl is the only
available specific Serotonin
S2 - receptor blocker on
blood platelets and
vascular smooth muscles
Global Guideline for the Management of
PAD (TASC II).
10

43. dralaawafa@hotmail.com