Peripheral Arterial Disease Dr. Rehab F.M.Gwada

Objectives of the Lecture The student at the end of this lecture will be able To define Peripheral Arterial Disease(PAD)& associated risk factors. To describe its causes &pathogenesis. To explain the clinical pictures associated with PAD to diagnose PAD& outline appropriate treatment goals? To describe the strategies of Treatment in patient with PAD ?

Content of Lecture What is Peripheral Arterial Disease? What are the risk factors for PAD? Peripheral Vascular Disease Causes& Pathogenesis Symptoms of PAD How do we diagnose PAD? Goals of treating patients with PAD the strategies of Treatment in patients with PAD

Arteries Large elastic arteries have walls consisting of: Tunica Media Tunica Intima Consist of endothelium, subendothelium& elastic tissue Function: to prevent intravascular clotting Tunica Media Consist of: smooth muscle &elastic fiber Function: to propel the blood Tunica Adventitia Consist of connective tissue and small blood vessels Function: to prevent undue expansion of artery

Peripheral Vascular Disease Peripheral Vascular Disease (PVD) refers to diseases of blood vessels outside the heart and brain. It's often a narrowing of vessels that carry blood to the legs, arms, stomach or kidneys. There are two types of these circulation disorders Functional peripheral vascular diseases don't have an organic cause. They don't involve defects in blood vessels' structure. They're usually short-term effects related to "spasm" that may come and go. Raynaud's disease is an example. It can be triggered by cold temperatures, emotional stress, working with vibrating machinery or smoking. Organic peripheral vascular diseases are caused by structural changes in the blood vessels, such as inflammation and tissue damage. Peripheral artery disease is an example. It's caused by fatty buildups in arteries that block normal blood flow. Peripheral Vascular Disease PVD definition is from the American Heart Association

What is Peripheral Arterial Disease? Peripheral arterial disease (PAD), commonly referred to as peripheral artery occlusive disease (PAOD), refers to the obstruction of large arteries not within the heart vasculature, or brain. PVD can result from atherosclerosis, inflammatory processes leading to stenosis, an embolism, or thrombus formation. It causes either acute or chronic ischemia (lack of blood supply). Often PAD is a term used to refer to atherosclerotic blockages found in the lower extremity.

Signs &Symptoms About 20% of patients with mild PAD may be asymptomatic; other symptoms include: Claudication - pain, weakness, numbness, or cramping in muscles due to decreased blood flow. Claudication walking induced pain in one or both legs [primarily affecting calves] does not go away with continued walking , relieved by rest Present in 15-40% of PAD Associated with diminished ability to perform ADL

Signs &Symptoms Noticeable change in color (blueness or paleness). Paleness of the leg or foot when elevated Blue/red discoloration of the foot when hanging down Absence of pulses in the foot. coolness. Diminished hair and nail growth on affected limb and digits. Sores, wounds, or ulcers that heal slowly or not at all. gangrene of the digits.

How do patients with PAD present?

What are the risk factors for PAD? Non-Modifiable Risk Factors: Male gender Advanced age Family history Modifiable Risk Factors: Major Smoking Hypertension Diabetes Hyperlipidemia Minor Homocystenemia Obesity Hypercoaguable state Physical inactivity Homocysteine: An amino acid that is produced by the human body, usually as a byproduct of consuming meat. Homocysteine is normally converted into other amino acids. An abnormal accumulation of homocysteine, which can be measured in the blood, can be a marker for the development of heart disease. Elevated levels of homocysteine in the blood appear to increase the risk of heart attack, stroke, peripheral vascular disease, and venous thrombo'embolism (blood clots in the veins). Homocysteine is believed to damage blood vessels in several ways. It injures the cells that line arteries and stimulates the growth of smooth muscle cells. Homocysteine can also disrupt normal blood clotting mechanisms. Elevated levels of homocysteine also appear to increase the risk of Alzheimer's disease. The ways to lower homocysteine are to eat less meat and take supplements of the B vitamins folic acid (folate), B6, and B12 that are needed by the enzymes that process homocysteine.

Peripheral Vascular Disease Causes atherosclerosis. Blood block: can block a blood vessel (thrombus/emboli). Diabetes: Over the long term can damage blood vessels Inflammation of the arteries: This condition is called arteritis and can cause narrowing or weakening of the arteries.

Peripheral Vascular Disease Causes Infection: The inflammation and scarring caused by infection can block, narrow, or weaken blood vessels. Structural defects can cause narrowing. Most of these cases are acquired at birth, and the cause remains unknown. Injury Blood vessels can be injured in an accident

How do we diagnose PAD? History & symptomes Physical Examination Capillary filling time:(2-3sec in worm day to 5sec in cold one) Test for rubor Non-invasive tests ABI(Ankle Brachial Index) measurement Segmental Pressures Exercise Test Doppler & duplex ultrasound, MR angiography. Invasive test (Contrast arteriography)

Test for rubor Changes in skin color that occur with elevation and dependency for the limb are evaluated. The legs are elevated & supported for 45 degree for one minute above the level of the heart while the patient is lying supine. severe , wide Pallor of the skin will occur in the feet if arterial circulation is poor (within 25 sec. indicate severe ischema) . The time necessary for blanching to develop is noted. The legs are then placed in a dependent position, and the color of the feet is noted.

Test for rubor Normally in dependency, a pinkish flush appears in the feet after several seconds(10sec). Abnormally , in severe ischemia , the delay is 40 sec or more. In occlusive arterial disease, a bright reddening or rubor of the distal legs and feet occurs. The rubor may take as long as 25 to 40  seconds to appear. Dependent rubor. Note the reddish appearance of the left leg and foot on dependency compared to the normal color of the patient’s right foot and leg

Ankle Brachial Index ABI= Ankle SBP/ Arm SBP

the severity of the PAD Ankle Brachial Index ABI value Indicates <0.9 Abnormal 0.8- 0.9 Mild PAD 0.5- 0.8 Moderate PAD <0.5 Severe PAD <0.25 Very Severe PAD

PAD Diagnostic Test: Segmental Pressures arteries of your leg. Similar to the ABI plus 2 or 3 additional blood pressure cuffs. These additional cuffs are placed just below the knee and one large cuff or two narrow cuffs are placed above the knee and at the upper thigh. These cuffs are then inflated above your normal systolic blood pressure, and then slowly deflated. Using the Doppler instrument, a significant drop in pressure between two adjacent cuffs indicates a narrowing of the artery or blockage along the arteries in this portion of your leg. This allows the physician to identify more precisely the location of such blockages in the arteries of your leg .

Goals of treating patients with PAD Relief symptoms Limb salvage Improve quality of life Prolong survival

Strategies of Treatment for patients with PAD Risk Factors Modification Improve Lower Limb Circulation

Treatment of patients with PAD Risk Factors Modification Smoking Cessation Hypertension control Diabetes control Regular exercise Diet and weight control Lipid control

Treatment of patients with PAD Improve Lower Limb Circulation Conservative (Exercise Program): -Graded ambulation or bicycling program - Burger-Allen Exercise Antiplatelet( reduce risks of MI , ischemic stroke and death from vascular causes). Intervention ( Revascularization) - Angioplasty +/- Stenting - Plaque excision - Surgical Bypass - Rarely, sympathectomy is used. - amputation is often a last resort to stop infected ( In gangrene).

Angioplasty

Graded ambulation or bicycling program The patient should be encouraged to walk or bicycling far as possible, without causing intermittent claudicationas carried out 3 to 5 days per week mild warm-up activities before initiating ex. include stretching calf ms , isometric pumping ex. For ankle & toes

Graded ambulation or bicycling program Precautions: avoid exercising outside during very cold weather wear shoes that fit properly and will not cause skin irritations, blisters, or sores Patient with a history of cardiac disorders , must be monitored closely

Graded ambulation or bicycling program Contraindications: : leg pain increased over time Patient with resting pain ulcerations of the feet and wound or fungal infections

Burger-Allen Exercise Procedure: A three-stage exercise procedure is carried out 3times /day. First position(stage) Patient lies supine with legs elevated and supported at a 45 to 60 degree angle. Maintained position for 1 to 3 minutes, or until blanching of the extremity occurs actively dorsiflex and planterflex the feet

Burger-Allen Exercis

Burger-Allen Exercise Second position(stage) sits up and dangles his feet over the edge of the bed.. actively dorsiflexes and planterflexes his ankles for 3 minutes or until rubor in the feet develops.

Burger-Allen Exercise Third position(stage) supine with his feet and legs covered with a blanket for warmth and rests for 5 minutes. The entire three-stage procedure is repeated 3 to 6 times during each treatment session.

Burger-Allen Exercise Termination: Exercises and elevation of the limbs are discontinued if pain or cramping of the calf muscles occurs. Contraindications: -Recent acute thrombosis or embolus. -Increased swelling in the lower extremities

Prognosis Individuals with PAD have an elevated risk for cardiovascular events and the majority will eventually die of a cardiac ( 40%-60%) or cerebrovascular(10%-20%) etiology prognosis is correlated with the severity of the PAD as measured by the Ankle brachial index (ABI). In patients with intermittent claudication, the risk of death from coronary events is three to four times higher than matched controls without claudication. Severity of PAD is closely associated with risk of MI , ischemic stroke , and death from vascular cause .

Discuss the Strategies of Treatment for patients with PAD? Question Discuss the Strategies of Treatment for patients with PAD? Thank you