Chronic peripheral vascular disease (Ischaemia( Assistant prof. Dr.Abdulameer M. Hussein

Objective To understand the chronic peripheral arterial disease, definition ,causes, clinical features and management.

Chronic peripheral vasculardisease (Ischaemia) Peripheral vascular disease (PVD), also known as peripheral arterial disease (PAD) or peripheral artery occlusive disease (PAOD), which can result from Atherosclerosis. inflammatory processes leading to stenosis Diabetes Mellitus. Burger’s disease SLE, Rheumatoid arthritis Arteriopathy ( pulseless disease = Takayasu’s disease )

PATHOGENESIS “atherosclerosis is a chronic inflammatory response of the arterial wall initiated by injury to the endothelium”

Atherosclerosis is a slow, complex disease in which fatty substances, cholesterol, cellular waste products, calcium, and other substances build up – called plaque - in the inner lining of an artery. Arteriosclerotic vascular disease is a condition where the arteries become narrowed and hardened due to an excessive build up of plaque around the artery wall. The disease disrupts the flow of blood around the body, posing serious cardiovascular complications

Risk Factors For Atherosclerosis Major Risk factor Minor Risk factors A) constitutional Age Sex Genetic Familial B) Acquired Hyperlipidemia Hypertension Cigarette smoking Diabetes mellitus Environmental influence Obesity Hormone estrogen def Physical inactivity Stress Infection(C. pneumonia CMV) Homocystin urea Alcohol

Complications of atherosclerosis 1- Narrowing of vascular lumen … chronic ischemia. 2- Superimposed thrombosis … acute ischemia. 3- Ulceration with liberation of fatty core … acute ischemia, fat emboli, DIC. 4- Pressure atrophy of the media with fibrosis….weakening of the wall …. Aneurysmal dilatation. 5- Dystrophic calcification.

Major manifestations of atherothrombosis include Cerebrovascular disease Coronary artery disease Renal artery stenosis Visceral arterial disease Peripheral arterial disease Intermittent claudication Critical limb ischemia Major Manifestations of Atherothrombosis Vascular disease leading to atherothrombosis, is the result of a generalized process that affects multiple vascular beds, including the cerebral, coronary, and peripheral arteries. Coexistence of vascular disease in multiple beds increases the risk for developing ischemic events such as MI and stroke.1 Atherothrombosis in cerebral arteries may precipitate a transient ischemic attack (TIA) or an ischemic stroke. A TIA, by definition, lasts for fewer than 24 hours, but the majority resolve within 1 hour. A TIA may be a warning of an impending stroke, with the risk for a stroke being 8-12% during the first week following a TIA and 11-15% at one month. 2 Atherothrombosis in coronary arteries produces a spectrum of ischemic coronary syndromes that include stable angina, unstable angina, non–ST-segment elevation myocardial infarction (NSTEMI; also known as non–Q-wave MI), and ST-segment elevation (STEMI; also known as Q-wave MI). Cardiovascular disease is the single largest cause of death in the United States and Europe.3 Atherothrombosis in peripheral vessels, known as peripheral arterial disease (PAD), can produce a variety of symptoms ranging from intermittent claudication to pain at rest.4 Patients with the most serious PAD have critical limb ischemia that produces pain at rest and threatens the viability of the limb by increasing the risk for gangrene and necrosis. 4 PAD is a strong marker for cardiovascular disease. Over a 10-year period, PAD increases risk for death due to cardiovascular disease approximately 6-fold.5 Note: Clopidogrel is not indicated for all the conditions listed on this slide. References: Aronow WS, Ahn C. Prevalence of coexistence of coronary artery disease, peripheral arterial disease, and atherothrombotic brain infarction in men and women 62 years of age. Am J Cardiol 1994; 74: 64-65. Coull AJ, Lovett JK, Rothwell PM . Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. BMJ 2004; 328 (7435): 32. American Heart Association. 2002 Heart and Stroke Statistical Update. Weitz JI, Byrne J, Clagett GP et al. Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: a critical review. Circulation 1996; 94: 3026-3049. Criqui MH, Langer RD, Fronek A et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med 1992; 326: 381-386.

Prevalence and Incidence The prevalence of peripheral vascular disease in people aged over 55 years is 10 – 25% and increases with age. 70 – 80% of affected individuals are asymptomatic. Only a minority requires revascularization or amputation.

Clinical Presentation Patients have a decreased quality of life due to a reduction in walking distance and speed leading to immobility Ranges in severity from intermittent claudication to limb ischemia Can present with buttock, thigh, calf or foot claudication singly or in combination Diminished pulses with occasional bruits over stenotic lesions Poor wound healing, unilateral cool extremity, shiny skin, hair loss, and nail changes

Only 1 in 10 patients with PAD has classical symptoms of intermittent claudication 1 in 5 people over 65 has PAD† Only 1 in 10 of thèse patients has classical symptômes of intermittent claudication (IC) Only 1 in 10 patients with PAD has classical symptoms of intermittent claudication The GetABI study shows the prevalence of PAD in a typical unselected sample of patients in a primary care setting is substantial. On average, about every fifth unselected patient (age-adjusted prevalence 19.8%) in primary care has an ABI < 0.9, indicating generalised atherothrombosis. Sensitivity of diagnosis – proportion of PAD patients in whom PAD is detected correctly by means of the WHO Intermittent Claudication (IC) questionnaire – was 11.1% when using the ABI as a yardstick against which the questionnaire was completed. Reference: Diehm C et al. High prevalence of PAD and co-morbidity in 6880 primary care patients: cross sectional study. Atherosclerosis 2004; 172; 95-105. † ABI<0.9

Claudication literally 'limping' (Latin), is a medical term usually referring to impairment in walking, or pain, discomfort or tiredness in the legs that occurs during walking and is relieved by rest.

Claudication Foot Calf Thigh Buttock and Hip Occlusive disease of the tibial and peroneal vessels Calf Cramping in upper 2/3 usually due to SFA stenosis Thigh Usually occlusion of the common femoral artery Buttock and Hip Aortoiliac occlusive disease (Lariche’s syndrome)

I: mild pain on walking ("claudication) Classification I: mild pain on walking ("claudication) II: severe pain on walking relatively shorter distances (intermittent claudication) III: rest pain . IV: tissue loss (gangrene).

Natural History of PAD Associated with significant mortality because of association with coronary and cerebrovascular events including death, MI, and stroke 6x more likely to die within 10 yrs than patients without PAD 5 yr mortality rate in pts with claudication is about 30% Continued use of smoking results in a two fold risk of mortality

Evaluation Inspection -hair -capillary refill -cyanosis/rubor -edema -nails -foot architecture/callouses -cellulitis -ulcers -gangrene

Palpation Sitting Supine

Findings Suggestive of PVD Decreased Pulses -Femoral -Popliteal -Dorsalis Pedis -Posterior Tibial Muscle atrophy/hair loss/nail changes Dependent Rubor Ulcers/Gangrene

Evidence of poor wound healing in the area where the blood flow is restricted Decreased blood pressure in an affected limb Whooshing sounds (bruits) over the arteries, heard with a stethoscope Signs of a pulsating bulge (aneurysm) in the abdomen or behind the knee

Diagnosis Ankle brachial pressure index (ABPI/ABI) which is a measure of the fall in blood pressure in the arteries supplying the legs. A reduced ABPI (less than 0.9) is consistent with PVD. Values of ABPI below 0.8 indicate moderate disease and below 0.5 severe disease. Doppler ultrasound Angiography Computerized tomography (CT) scanners provide direct imaging of the arterial system as an alternative to angiography.

TREATMENT Dependent on the severity of the disease, the following steps can be taken

Conservative measures Anti-platelet agents Diabetic control Smoking cessation Anti-hypertensives Statin therapy Weight reduction Exercise rehabilitation Revascularization/PTCA/stenting

Intervention therapy Indications for intervention (PTA) Persistent limiting claudication that prevents patient from performing daily activities Rest pain Tissue loss Patients who are poor surgical candidates Long term success of PTA depends on site and length of the lesion Limited to focal, short segment occlusions No significant difference in outcome between PTA or surgery

Angioplasty (PTA or percutaneous transluminal angioplasty) can be done on solitary lesions in large arteries, such as the femoral artery. Plaque excision, in which the plaque is scraped off of the inside of the vessel wall.

Surgical therapy Lesions might be better treated surgically if: Long segments Multi focal stenosis Eccentric, calcified lesions

We may do Bypass grafting. Sympathectomy . Amputation

It is called Thrombo angitis oblitrans because BURGER’S DISEASE It is called Thrombo angitis oblitrans because histologically was characterized by thrombosis in both arteries and veins, and were associated with marked inflammatory response which may lead to complete obstruction it affect medium and small vessel , usually femoral and brachial arteries are not involved.

Clinical features It begins in young adult life between 20 -35 years Associated with smoking especially early smoking Exacerbation with smoking Remission with stop smoking Cold sensitivity Intermittent claudication Rest pain Pale & cold Numbness and Paraesthesia Diminish pulses May be gangrene

Thromboangitis Obliterans

TREATMENT Conservative treatment Surgical treatment Sympathectomy Amputation when gangrene develop

Is a disease characterized by episodic attacks of RAYNAUD’S DISEASE Is a disease characterized by episodic attacks of vasospasm causing closure of the small sized arteries and arteriole of the distal part of the extremity in response to cold exposure or emotional stimuli, it usually affect upper limb arteries

The condition is attributed to abnormal sensitivity in the Pathology The condition is attributed to abnormal sensitivity in the direct response of the artery to cold. When cooled these vessels go into spasm and as a result the part become pale, then the decrease in the blood flow lead to accumulation of metabolite in the capillaries so the capillaries dilated and become filled with deoxygenated blood so the part become swollen and dusky.

As the attack passes off the arteries relax, oxygenated blood returns into the capillaries so hands become red with burning pain. Later oblitrative changes occur leading to ischemic changes of the tips of the fingers

Raynauds’ Disease

Clinical Features Burning pain in the fingers. Color changes ( pallor, cyanosis and redness). Normal peripheral pulses. Later ulceration and gangrenous changes.

TREATMENT Avoid the causative factors Operative treatment – Dorsal sympathectomy

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