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Peipheral arterial dse
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.
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Peipheral arterial dse
- 1. Peripheral Arterial Disease Checkthe Pedal Pulse Alaa Wafa . MD Associate Professor of Internal Medicine PGDIP DM Cardiff University UK Diabetes & Endocrine Unit. Mansoura University 2014
- 2. Amputation every 30Seconds 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 LatePresentation
- 4. Peripheral Arterial Disease ProgressiveAtherosclerotic 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 ofPAD. Progressive Atherosclerotic Partial or Complete obstruction of one or more Arteries below the Aortic Bifurcation
- 6. Prevalence of PADby 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 • Musclediscomfort 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 SymptomaticDiagnosis Only 1 in 10 of these patients has classical symptoms of intermittent claudication (IC) Diabetic Neuropathy Sedentary Life
- 10. Stage Clinical Presentation StageI 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 theLeg 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 theLeg 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 forPeripheral Arterial Disease
- 14. Factors Magnifying Critical LimbIschemia incidence Norgen L. et al.: Intersociety Consensus for PAD (TASC II). Eur J Vasc Endovasc Surg Vol 33, Supplement 1, 2007.
- 15. Diabetes • Diabetes increasesthe 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 NeuropathicPain: 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: ClinicalPresentation 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
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- 23. 1. HISTORY HISTORY Duration of diabetes Qualityof 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 Assessmentof 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 ofvibratory 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 FOOTULCER Texas Classification Wagner Classification
- 28. 3. INVESTIGATIONS CompleteBlood Count Pulse-Volume Recording Doppler Ultrasound Ankle-Brachial Index Plain Radiography CT and MRI Bone scan Angiography
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- 38. Role of Serotoninin 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 Modesof Action 5-HT2 ↑ Platelets aggregation ↑ Vasoconstriction ↑ RBCs Rigidity
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- 41. Global Guideline forthe Management of PAD (TASC II). Inter-Society Consensus for the Management of Peripheral Arterial Disease
- 42. Pharmacotherapy A. Drugs withevidence 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
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