Download to read offline
![[QC-ed] AMSA_AMBOSS Lecutre - PAD.pptx](https://cdn.slidesharecdn.com/ss_thumbnails/qc-edamsaambosslecutre-pad-230324194416-cd414909-thumbnail.jpg?width=640&height=640&fit=bounds)
Peripheral arterial diseases diagnosis and treatment
- 1. Peripheral arterial disases Bydr yarjhan
- 2. definition • It generallyrefers to obstruction of arteries supplying the upper and lower extremities that when severe results in ischemia and potential tissue loss.
- 3. • Chronic lowerlimb ischemia • Acute lower limb ischemia • Upper limb ischemia
- 4. • It canpresent as • Acute limb ischemia • Chronic limb ischemia • Acute on chronic limb ischemia(sudden worsening of symptoms who had long history of claudication suggesting thrombosis of crtically stenosed vessel)
- 5. Chronic limb ischemia •Symptoms lasting for more than 2 weeks • Causes • Atherosclerosis • Emboli (fat embolism ,air embolism,mycotic embolization) • Burger disease • Vasculitis • Fibromuscular dysplasia • Raynauds disease • Trauma
- 6. Risk factor • Modifiable •Diabetes • Hypertension • Smoking • Hyperlipedemia • Non modifiable • Old age • Male • Family history
- 7. Stages of limbischemia • Asymptomatic • Intermittent claudication ( crampy pain in muscle brought by exercise or walking and relieved by rest) • Ischemic rest pain (pain occurs at rest more at night ,patient hangs his legs down bed or chair to get relieved ) • Critical limb ischemia (persistant ischemic rest pain which requires analgesia greater than 2 weeks plus associatd with ulceration or gangrene )
- 8. Classification of chroniclimb ischemia • Fontaine classification • Rutherford classification • TASC classification
- 9. Fontaine classification stage interpretation Stage1 asymptomatic Stage 2 Intermittent claudication Stage 3 Rest pain Stage 4 ulceration
- 10. Rutherford classification Grade categoryClinical 0 0 asymptomatic 1 1 Mild claudication 1 2 Moderate claudication 1 3 Severe claudication 2 4 Rest pain 3 5 Minor tissue loss 3 6 Major tissue loss
- 11. Level of arterialobstruction • Aortoiliac occlusive disease(also known as inflow level) • Femoropopliteal level • Infrapopliteal level (also known as outflow level)
- 12. 1-Aortoiliac occlusive disease •Atherolsclerosis causing chronic ischemia of distal aorta and iliac vessel • Can be diffuse or isolated
- 13. Clinical features • Triadof thigh claudication plus buttock claudication with absent femoral pulses • Leriche syndrome (thigh plus buttock claudication plus impotence or erectile dysfunction ) • Ischemic rest pain occurs when disease progressed futher • Signs on examination • Absent femoral pulses • Pelvic bruit
- 14. Classification of aortoliacocclusive disease • Based on atherosclerotic disease pattern • TASC classification ( transatlantic intersociety consenus )( most coomonly used also give us treatment plan )
- 15. type Type 1Type 2 Type 3 Distal aorta and common iliac vessel Diffuse occlusive diseas above inguinal ligament Diffuse occlusive disease involving both above and below inguinal ligament incidence 10 per 25 per 65 per
- 16.
- 20. Investigations • General • Allbaseline (cbc rft lft bsr serum electrolyte ecg echocardiogram chest xray) • Thigh brachial pressure index (less than 0.8 ) • Radiological ( non invasive) • Doppler and duplex scan (for diagnosis ,shows monophasic waveform plus peak systolic velocity geater than 2.5 ) • Ct angiogram (diagnosis ,level of obstruction,to know about collateral ,type of obstruction) • Mr angiogram
- 21. • Invasive test •Angiography (can be diagnostic and therapeutic ) • Digital subtraction angiography (better view eliminate other structures only vascular system identified,smaller details can be identified ) • Additional tests for cause • hbaic, lipid profile,uric acid echocardiography,carotid doppler
- 22. Management • 1-control ofrisk factor • 2-medical treatment • 3-surgical intervention
- 23. Medical treatment • Antiplatelet( aspirin , clopidogrel) • Lipid lowering drugs(statin) • Vasodilator ( ticlopidine,cilostazole eg pletaal ) • B complex • Painkiller
- 24. Surgical interventions • 1-openbypass procedure • 2-open endartectecomy ( rarely done now a days) • 3-endovascular treatment • NOTE • Tasc a and b endovascular treatment preferred • Tasc c and d open technique is prefered
- 25. Indication of surgicaloption • Failure of medical therapy • Patient who are symptomatic • Patient with more distal lesion are unlikely to benefit from medical therapy
- 26. 1-Bypass procedure • 1-aortobifemoralbypass(most commonly performed ,symptomatic improvement more than 80 per) • 2-axillobifemoal bypass(limb saving procedure , can be done in local in emergency setting) • 3-ileofemoral bypass(for unilateral disease) • 4-obturator bypass(sepsis ,neoplasm ,malignancy)(anastomosis between external iliac or common iliac to superficial femoral artery)
- 27. Choice of materialfor graft • Synthetic ( dacron ,PTFE) • Natural (internal mammary ,long saphenous vein reversed or in situ,umblical vein graft) • Note saphenous vein graft is best for infrapopliteal bypass procedure .
- 28. Endovascular treatment • Ballonicdilation • Stent placement
- 29. 2-infrainguinal(femoropopliteal occlusive disease plusinfrapopliteal occlusive disease) • Symptoms lasting from more than 2 weeks • Risk factors and causes are same as of aorto-iliac occlusive disease
- 30. Symptoms • Asymptomatic • Intermittentclaudication of thigh, leg and foot • Discoloration of leg and foot • Ulceration
- 32. Management • Control ofrisk factors • Medical treatment • Surgical intervention • Endovascular Procedure • Bypass procedure • Endartectomy (limited role not performed now days)
- 33. Endovascular Procedure • Indications: •Short segment occlusion • Non-calcified • Tasc classification type a and b • Below popliteal results are not good (Vessel diameter is low) • Types: • Percuataneous Transluminal balloon angioplasty • Subintimal angioplasty • Stenting • Stent graft • Mechanical atherectomy • Laser atherectomy
- 34. Bypass Procedure • Indications: •Multifocal long segment • Below the popliteal level
- 35. • Options: • ForSFA Occlusion • femoropopliteal bypass is performed (Using PTFE or Saphenous vein) (Anastomosis between common femoral and popliteal artery) • For Popliteal or tibial vessel then options are • femoral to posterior tibial bypass (Between common femoral artery and posterior tibial artery) • Femoroperoneal bypass • Common femoral to anterior tibial bypass • SFA anastomosis to dorsalis pedis artery
- 36. Complications of Bypass •Graft stenosis • Limb swelling (Due to damage to lymphatic vessels) • Wound infection
- 37. Acute limb ischemia •Sudden occlusion to blood flow within 14 days of onst of symptom .
- 38. Causes • Embolism • Thrombosis •Traumatic Ischemia • Intra-arterial drug injection • Aortic dissection • Extensive Ilio-femoral DVT (Phlegmasia Cerula Dolens)
- 39. Clinical Features (6P’s) •Pain • Pulseless • Pallor • Poikilothermia • Paresthesia • Paralysis
- 40. Classification • According toviability • Rutherford Classification
- 41. Viability Classification Feature ViableThreatened Irreversible Clinical description Not immediately threatened Salvagable if treated Major tissue loss, amputation is necessary Capillary return Intact Intact but slow Absent Muscle weakness None Mild Paralysis Sensory Loss None Mild Profound anesthesia Doppler Finding Audible Inaudible Inaudible
- 42. Rutherford Classification • Grade1: Viable (No sensory or motor loss and on Doppler arterial and venous, both signals normal) • Grade 2a: Marginally threatened (Minimal sensory with no motor loss on Doppler arterial signal inaudible, venous audible) • Grade 2 b: Immediately threatened (sensory loss, mild motor loss, on Doppler, arterial inaudible, venous can be audible) • Grade 3: (Irreversible)(Sensory loss, motor loss, on Doppler, arterial and venous both inaudible)
- 43. Investigations • General Investigations: •All baselines • Serum LDH, Lactate, ABGs and CPK Levels • Imaging • Non invasive • Doppler and Duplex (Diagnosis, localizes and identifies cause) • CT angiogram and MR Angiogram (Not done in acute setting, helps in diagnosis, calcifications can be seen)
- 44. • Invasive: • Angiography •Digital Subtraction angiography (Newer technique, helps in diagnosis plus intervention at same time, best when previously open surgery is done) • To Know the cause: • Echo • Abdominal angiogram (If we are suspecting aneurysm) • Lipid profile • Carotid Doppler
- 45. Management • Avoidance ofrisk factors • Medical • Surgical intervention (According to the source) • Embolectomy • thrombolytic therapy • revascularization procedure
- 46. Avoidance of riskfactors • Stop smoking • Control diabetes, hypertension • Statins for dyslipidemia
- 47. Medical • Place thepatient in reverse trendelenberg position • Analgesic/painkiller • IV fluids for dehydration • Oxygen inhalation • Anticoagulants (Heparin or warfarin, inj Clexane)
- 48. Embolectomy • Through FogartyCatheter • As long as the limb is viable (Grade 1 or Grade 2a) • After embolectomy, fasciotomy must be done • For lower limb, femoral artery and transpopliteal embolectomy can be done
- 49. Thrombus • Thrombolytic therapyor Revascularization procedure • Can be given systemically or percutaneous catheter directed thrombolysis • Indications: Class I and Class IIa, viable tissue, thrombus after angioplasty, native vessel occlusion
- 50. Contraindications of thrombolysis •Absolute: • CVA within 2 months • Active bleeding within 10 days • Intracranial trauma within 3 months • Intracranial surgery within last 3 months • Malignancy (Intracranial) • Metastasis
- 51. • Relative: • CPRwithin last 10 days • Major non-vascular surgery or trauma within last 10 days • Uncontrolled hypertension (>180/110) • Intracranial tumor • Recent eye surgery • Minor Contraindications: • Liver failure • Pregnancy
- 52. Agent for thrombolysis •SK, Urokinase, TPA • Complications after thrombolysis: • Bleeding • Embolisation • Compartment syndrome
- 53. Revascularisation Procedure • Thrombectomy(Open or endovascular approach) • By pass procedure (For acute on chronic limb ischemia)
- 54. Complication of revasculaizationprocedure • Reperfusion injury • Compartment syndrome
- 55. Amputations • If gangrenedevelops, then go for amputation
- 56. Thromoboangitis obliterans(burger disease) •Common in young , middle age, males, smokers • Moe common in lower limbs • Non atherosclerotic inflammatory disorder of mdium sized and distal vessel with cell mediated hypersensitivity to type 1 and 3 collagen. • Segmntal,progressive,occlusive ,inflammatory disease of small and medium sized vessel that presents as Raynaud phenomenon with microabcesses,along with giant cell infiltration with skip lesions.
- 57. Classification • Type 1upper limb, rare • Type 2 involving legs infrapopliteal • Type 3 femoropopliteal • Type 4 aortoiliofemoral • Type 5 generalized
- 58. Clinical features • Intermittentclaudication • Rest pain • Ulceration gangrene • Absent pulses
- 59. Investigation • Doppler andduplex • Usg abdomen(to rule aneurysm) • Angiogram (gold standard)(corkscrew appearance du to dilation of vasa vasorum,inverted tree appearance,vasopasm) • biopsy
- 60. Management • Conservative • Medicalmanagement • Surgical intervention
- 61. Conservative • Stop smoking •Burger position (head end raised foot lowered) • Care of foot(avoid trauma,dryness of foot,wear socks with foot wear)
- 62. Medical manageement • Antiplatlet •Statin • Vasodilator • Painkiller • Genetic therapy(intramsuscular injection of VEGF to promote angiogenesis)
- 63. Surgical intervention • Sympathectomy(injecting xylocaine or phenol in L2,3,4 vertebrae ) • pofundoplasty (to open collaterals and improve perfusion,localized stenosis) • amputation
- 64. Raynaud phenomenon • Episodicattack of small arteries and arterioles of distal extermites in response to cold or emotional stimuli. • Types • 1-Raynaud syndrome (due to underlying collagn disorder like scleroderma and rheumatoid arthritis) • 2-Raynaud disease (idiopathic causes)
- 65. Clinical features • Femalepatient when exposed to cold suffers Raynaud phenomenon (initially pale ,then cyanosis ,then redness of extremites occurs).
- 66. Treatment • Avoid predisposingfactor such as cold • Medical management (pentoxiphyline,aspirin,calcium chnnel blocker,ace inhibitor,nitrates) • Cervical sympathectomy
- 67. Upper limb ischemia •Causes • Atherosclerosis causing chronic limb ischemia • Emboli causing acute limb ischemia • Raynaud disease • Thoracic outlet syndrome • Thromoangitis obliterans • Trauma • Vasculitis • Diseases (scleroderma ,CREST syndrome) • Drugs
- 68. Symptoms • Upper limbclaudiction • Weakness • Ulceration gangrene
- 69. Investigation • General investigation •Cbc lft rft bsr ecg lipid profile • Radiological • Xray neck (to rule out cervical rib) • Doppler and duplex • Ct mr angiogram • Ct scan neck chest
- 70. Management • Medical managementis same • Surgical management
- 71.
- 72. Chronic ischemia • Endovascularapproach • Bypass procedure(aortosubclavian bypass,subclavian axillry bypass)