PERIPHERAL VASCULAR DISEASE Dr .Ghazi F.Haji Senior lecturer of Cardiology Al-Kindy College of Medicine/Baghdad university 18/04/2018

Acute arterial occlusion ”Objectives” Definition Aetiology Presentations Investigations Management Acute arterial occlusion 18/04/2018 I

Peripheral vascular disease of the lower extremities Definition “Decreased patency” of the arterial supply to the lower extremities leading to Chronic ischemic: (Claudication ,critical limb) Atherosclerotic, Vasculitis,Burger's Disease (ThromboangiitisObliterans),Extrinsic compression (neoplasm) Acute Ischemic : Embolic, Thrombotic” 18/04/2018

Risk Factors Hypertension Cigarette smokers Diabetics Hyperlipidaemia Increased age History of other atherosclerotic disease (coronary artery disease or carotid stenosis) 18/04/2018 I

Pathophysiology “Narrowing of the arterial lumen leads to” Decreased blood flow resulting in. Decreased O2 supply leading to Anaerobic metabolism Increased Lactic Acid leading to: Pain at rest Poor wound healing Painful ulceration 18/04/2018

Chronic Ischaemia Intermittent Claudication Muscle pain which appears during exercise when there is an inadequate arterial flow critical limb -Rest Pain Cold Peripheries Arterial Ulcers Wet/dry gangrene 18/04/2018

Clinical Presentation Cramping/burning muscular pain Localized to a muscle group (calf) Reproducible Relieved with rest Distribution of pain may suggest anatomic location of disease 18/04/2018

Lower Limb Assessment Features of Chronic Ischemic changes “Hair loss, shiny appearance & Trophic changes Pulses: diminished or absent Bruits:” Presence of Gangrene Ulcers Pallor on elevation and rubor on dependency (Buerger's sign) Muscle-wasting Skin and nails: dry, thin and brittle Temperature: Often cool Oedema: un usual 18/04/2018

Intermittent Claudication Differential Diagnosis Spinal Stenosis 18/04/2018

Pain caused by critical Limb Ischemia Rest Pain worse at night May be present throughout the day and night Continuous, aching & severe Located in toes and forefoot. (Patient hangs the leg over the side of the bed) 18/04/2018

INVESTIGATION OF PVD Assess risk factors: Fasting lipids & glucose, HbA1c Non-Invasive Doppler Ankle/Brachial Index Invasive CT Angiogaphy/ MRI Angiography 18/04/2018

18/04/2018

Chronic Ischaemia Conservative Management STOP SMOKING! Increasing exercise tolerance Pharmacotherapy's: Aspirin 75 mg daily or clopidogrel 75 mg daily Statins. The peripheral vasodilator(Pentoxyphylline) , cilostazol, has been shown to improve walking distance ACE I {esp. in Diabetics }&control of DM Avoidance of minor trauma esp. in those with neuropathy 18/04/2018

Surgical Management Endovascular options: to increase inflow if suitable for femoral angioplasty or stenting Surgical bypass of diseased segment using vein or prosthetic graft If un-reconstructable: Try Prostacyclin infusion (Iloprost) Last option is amputation 18/04/2018

Treatment of critical ischemia “Ischemic rest pain/ulcer/gangrene” Angioplasty vs. Surgery 18/04/2018

Femoral Angiography 18/04/2018

Acute Limb Ischaemia Embolus Thrombus Trauma 18/04/2018

Source of Emboli Heart - 90% - Arrhythmias, Valvular heart disease - Prosthetic heart valves, Mural thrombus post MI, Ventricular aneurysm Great Vessels (9%) Atherosclerotic aorta Other (1%) --Paradoxical Thrombus--- Thrombus on a pre-existing atherosclerotic lesion l 18/04/2018

Clinical Features Pain Pallor Parasthesia. Paralysis Pulselessness Perishing Cold Treatment------ Urgent Treatment Heparin Investigations Intervention ? Thrombolytic 18/04/2018

Clinical features Embolism Thrombosis in situ Severity Complete (no collaterals) Incomplete (collaterals) Onset Seconds or minutes Hours or days Limb Leg 3:1 arm Leg 10:1 arm Embolic source Present (usually AF) Absent Bruits Absent Present Diagnosis Clinical Angiography Treatment Embolectomy, warfarin -Medical, bypass, thrombolysis 18/04/2018

Upper limb diseases 1-Arm claudication 2-Atheroembolism (blue finger syndrome). 3-Subclavian steal. When the arm is used, blood is 'stolen' from the brain via the vertebral artery. This leads to vertebro-basilar ischaemia, which is characterised by dizziness, cortical blindness and/or collapse. 18/04/2018

Raynaud's phenomenon and Raynaud's disease Cold (and emotional) stimuli may trigger vasospasm, leading to the characteristic sequence of digital pallor due to vasospasm, cyanosis due to deoxygenated blood, and rubor due to reactive hyperaemia. 18/04/2018

Primary Raynaud's phenomenon (or disease): This affects 5-10% . Young age women aged 15-30 years may be familial Not progress to ulceration or infarction NO significant pain NO underlying cause . No investigation is necessary. The patient should be reassured and advised to avoid exposure to cold. Long-acting nifedipine may be helpful 18/04/2018 I

Secondary Raynaud's phenomenon (or syndrome) Occur in older people Association with connective tissue disease (most commonly systemic sclerosis or the CREST syndrome, ), vibration-induced injury (from the use of power tools) and thoracic outlet obstruction (e.g. cervical rib). Progress to fingertip ulceration, and necrosis . Significant pain Need investigation Need treatment :avoid exposure to cold The fingers must be protected from trauma, Antibiotics requires to treatment infection Sympathectomy . Prostacyclin infusions 18/04/2018

Burger's Disease (Thromboangiitis Obliterans) Clinical Features Males <45 years Upper and lower limb involvement Heavy smokers It is most common in those from the Mediterranean and North Africa. It characteristically affects distal arteries, giving rise to claudication in the feet or rest pain in the fingers or toes Disease also affects the veins, giving rise to superficial thrombophlebitis Diagnosis: Angiogram Major limb amputation is the most frequent outcome if patients continue to smoke(Choice cigarette or your limb) 18/04/2018

Diseases of the aorta Aneurysm, dissection Aneurysm: This is an abnormal dilatation of the aortic lumen; a true aneurysm involves all the layers of the wall, whereas a false aneurysm does not 18/04/2018

18/04/2018 Dr Habib Tareif, FRCSI

Aetiology Atherosclerosis -Families and genetic factors Hypertension -Infection -syphilis (saccular aneurysms) . aortitis include Takayasu's disease , Reiter's syndrome giant cell arteritis and ankylosing spondylitis Marfan's syndrome (autosomal dominant trait and is caused by mutations in the fibrillin gene on chromosome 15. Affected systems include the skeleton (arachnodactyly, joint hypermobility, scoliosis, chest deformity and high arched palate), the eyes (dislocation of the lens) and the cardiovascular system (aortic disease and mitral regurgitation). 18/04/2018

Types of aneurysm, investigation & treatment Types : abdominal(mass) ,thoracic(high pressure +aortic regurgitation) Investigations:. Chest X-ray, ultrasound , echocardiography, MRI or CT Treatment with β-blockers reduces the rate of aortic dilatation and the risk of rupture. Elective replacement of the ascending aorta 18/04/2018

18/04/2018 Dr Habib Tareif, FRCSI

Abdominal aortic aneurysms (AAAs) AAAs are present in 5% of men aged over 60 years and 80% are confined to the infrarenal segment. Men are affected three times more commonly than women. The usual age at presentation is 65-75y . Ultrasound is the best way of establishing the diagnosis and of following up CT provides more accurate information about the size and extent of the aneurysm,. 18/04/2018

18/04/2018 Dr Habib Tareif, FRCSI

Aortic dissection A tear of the aortic wall(intima) allows arterial blood to enter the media, which is then split into two layers, creating a 'false lumen' alongside the existing or 'true lumen'. The aortic valve may be damaged and the branches of the aorta may be compromised. Disease of the aorta and hypertension are the most important aetiological factors.. It may also rupture into the left pleural space or pericardium with fatal consequences.. The peak incidence is in 60-70 y (Occur in younger in marfan sydrome,pregnancy ,truma ) Men are twice as frequently affected as women. 18/04/2018

18/04/2018 Dr Habib Tareif, FRCSI

Types Aortic dissection is classified anatomically and for management purposes into type A and type B ( regarding debakey and stanford classification) Type A dissections account for two-thirds of cases and frequently also extend into the descending aorta. 18/04/2018

18/04/2018 Dr Habib Tareif, FRCSI

Factors that may predispose to aortic dissection Hypertension (80% of cases) Aortic atherosclerosis Aortic coarctation Collagen disorders (e.g. Marfan's syndrome, Ehlers-Danlos syndrome) Fibromuscular dysplasia Previous aortic surgery (e.g. CABG, aortic valve replacement) Pregnancy (usually third trimester) Trauma Iatrogenic (e.g. cardiac catheterisation, intra-aortic balloon pumping) 18/04/2018

Clinical features Involvement of the ascending aorta typically gives rise to anterior chest pain, and involvement of the descending aorta give rise to intrascapular pain. The pain is typically described as 'tearing' and very abrupt in onset; collapse is common.. There may be asymmetry of the brachial, carotid or femoral pulses and signs of aortic regurgitation. Occlusion of aortic branches may cause MI (coronary), stroke (carotid) paraplegia (spinal), mesenteric infarction with an acute abdomen (coeliac and superior mesenteric), renal failure (renal) and acute limb (usually leg) ischaemia. 18/04/2018

Investigations The chest X-ray (wide medistinum ,left-sided pleural effusion ) The ECG -left ventricular hypertrophy in patients with hypertension, or rarely changes of acute MI (usually inferior). Doppler echocardiography ( aortic regurgitation, a dilated aortic root and, occasionally, the flap of the dissection). Transoesophageal echocardiography CT and MRI angiography are both highly specific and sensitive. 18/04/2018

Management The early mortality of acute dissection is approximately 1-5% per hour so treatment is urgently required. Initial management comprises pain control and antihypertensive treatment(labetelol alfa and beta ,sodium nitruoprusside ,nicardipin ,ACEI.) Endoluminal repair or implanting a stent graft placed from the femoral artery Type A dissections require emergency surgery to replace the ascending aorta. Type B aneurysms are treated medically unless there is actual or impending external rupture, or vital organ (gut, kidneys) or limb ischaemia, as the morbidity and mortality associated with surgery is very high. 18/04/2018

Thank you Any Questions???