Peripheral vascular disease

peripheral arterial disease Peripheral vascular disease (PVD), commonly referred to as peripheral arterial disease (PAD) is a condition in which the blood vessels in the lower extremities are narrowed, restricting blood flow. Peripheral vascular disease is primarily caused by atherosclerosis, the buildup of plaque in blood vessels.

Individuals with diabetes, high blood pressure ,high cholesterol, or advanced age, or those who smoke or are inactive, are at risk for developing peripheral vascular disease. PVD also includes a subset of diseases classified as micro vascular diseases resulting from episodal narrowing of the arteries (Raynaud's phenomenon).  

Peripheral arterial disease Epidemiology The prevalence of PAD in the general population is 12–14%, affecting up to 20% of those over 70.  70%–80% of affected individuals are asymptomatic Peripheral vascular disease affects 1 in 3 diabetics over the age of 50. In the USA peripheral arterial disease affects 12–20 percent of Americans age 65 and older. Approximately 10 million Americans have PAD.

cause of PAD The primary cause of peripheral vascular disease is atherosclerosis. Atherosclerosis is the buildup of plaque (consisting mostly of fat and cholesterol) in blood vessels.

The risk factors OF PAD  A number of factors increase the risk of developing peripheral vascular disease. Risk factors for peripheral vascular disease include: Over the age of 50 Smokers Diabetics Overweight Sedentary people People who have hypertension or high cholesterol Family history of heart or vascular disease

30% Buttock & Hip Claudication ±Impotence – Leriche’s Syndrome Thigh Claudication 60% Upper 2/3 Calf Claudication Lower 1/3 Calf Claudication Buttock and hip — aortoiliac disease Thigh — aortoiliac or common femoral artery Upper two-thirds of the calf — superficial femoral artery Lower one-third of the calf — popliteal artery Foot claudication — tibial or peroneal artery Foot Claudication

Pathophysiology The major cause of occlusive PAD is arteriosclerosis, defined as the development of atherosclerotic plaques in the peripheral vasculature. These plaques develop as a result of endothelial activation associated with conditions such as dyslipidemia, diabetes mellitus, hypertension, and tobacco use

CONT Plaques result in the proliferation of vascular smooth muscle, with subsequent damage to the vascular structure. The damaged endothelium of the vasculature has impaired vasodilator capabilities because secretion of nitric oxide,, is decreased and secretion of vasoconstrictive substances, such as endothelin, are increased

Symptom intermittent claudication.is the medical term for pain, numbness, achiness, burning, heaviness or cramping in the lower limbs that occurs during activities such as walking or climbing stairs . This symptom usually decreases after the activity is stopped

Pictures: ULCER associated with claudication + signs of ischaemia occur on dorsum of foot + anterior skin ↓ pulses, cold to touch, hairless skin Painful, punched out edge

CON 0ther symptoms of PAD are : Burning or tingling sensation (paresthesia) Cold feet or legs Decreased or absent pulse in the lower limbs Pale or bluish skin Poor hair growth on the legs Sores or wounds on the lower limbs that heal slowly, poorly, or not at all.

Diagnosis ankle brachial pressure index (ABPI/ABI). When the blood pressure readings in the ankles is lower than that in the arms, blockages in the arteries which provide blood from the heart to the ankle are suspected. An ABI ratio less than 0.9 is consistent with PVD;

con Duplex Ultrasonography and Doppler Color-Flow Imaging Magnetic Resonance Imaging and Angiography

Treatment The specific treatment goal are Reduce pain Reduce the progression of underlying disease and decreasing the risk of any cardiovascular event

Treatment: 1. RISK FACTOR MODIFICATION: Smoking Cessation Rigorous BSL control BP reduction Lipid Lowering Therapy 2. EXERCISE: Claudication exercise rehabilitation program 45-60mins 3x weekly for 12 weeks 6 months later +6.5mins walking HBA1C as close to 6.0 as possible (Selective B-1 blockade ok Anti-hypertensive medications may worsen the PAD symptoms by reducing blood flow and supply of oxygen to the limbs, and may have long-term effects on disease progression). controversial due to the presumed peripheral haemodynamic consequences of beta blockers, leading to worsening symptoms of intermittent claudication. There is currently no evidence that beta blockers adversely affect walking distance in people with intermittent claudication. However, due to the lack of large published trials beta blockers should be used with caution if clinically indicated. Aim LDL 2.6mmol/L with PAD Aim LDL <1.8mmol/L with ATH in other vessels Improved endothelial dysfunction via increases in nitric oxide synthase and prostacyclin [40]. (See "Endothelial dysfunction".)Reduced local inflammation that is induced by muscle ischemia by decreasing free radicals [41].Increased exercise pain tolerance [38].Induction of vascular angiogenesis [42].Improved muscle metabolism by favorable effects on muscle carnitine metabolism and other pathways [43].Reductions in blood viscosity and red cell aggregation BEWARE HF with cilostazol (inhibits platelet aggregation and acts as an arterial vasodilator) Two compared ACE inhibitors against placebo. In the HOPE study there was a significant reduction in the number of cardiovascular events in 168 patients receiving ramipril (OR 0.72, 95% confidence interval 0.58 to 0.91). In the second trial using perindopril in a small numbers of patients, there was a marginal increase in claudication distance but no change in ankle brachial pressure index (ABPI) and a reduction in maximum walking distance.The third trial in patients undergoing angioplasty suggested that the calcium antagonist verapamil reduced restenosis, although this was not reflected in the maintenance of a high ABPI. Another small study demonstrated no significant difference in arterial intima-media thickness with men receiving the thiazide diuretic hydrochlorathiazide compared to those receiving the alpha-adrenoreceptor blocker doxazosin. 3. MEDICAL MANAGEMENT: Antiplatelet therapy e.g. Aspirin/Clopidogrel Phosphodiesterase Inhibitor e.g. Cilostazol Foot Care

NONPHARMACOLOGIC THERAPY In most cases, lifestyle modifications can be the most effective treatment for peripheral arterial disease. This include: Eating a diet low in saturated fat Exercise Smoking Cessation

PHARMACOLOGIC THERAPY Diabetes control Treatment of Hypertension cholesterol-lowering drugs  Antiplatelet Therapies like Aspirin ,Ticlopidine ,Clopidogrel Drug to reduce pain like Cilostazol, Pentoxifylline

con ciIostazol is a mediation that can help increase physical activity (enabling one to walk a greater distance without the pain of claudication).  Cilostazol is recommended for some patients with claudication when lifestyle modifications and exercise are ineffective This drug possesses antiplatelet and vasodilator effects mediated by the inhibition of phosphodiesterase type 3.

Pentoxifylline a methylxanthine derivative The exact mechanism of action is unclear; however, it appears to decrease blood viscosity by decreasing fibrinogen, improving the deformability of both red and white blood cells, and eliciting antiplatelet effects Pentoxifylline improved walking distance, but its benefits are weaker than those of Cilostazol

Vasodilators Numerous vasodilators (i.e., prostaglandin- E1, prostacyclin, papaverine have been used to treat IC. None, however has convincingly or consistently improved exercise performance

Other therapy Ginkgo biloba is aherbal therapies reported to increase in pain-free walking It has been proposed that ginkgo's therapeutic value is related to its antiplatelet properties Vitamin E

Procedures used to treat PAD If blood flow is completely or almost completely blocked, the following procedure may be used Angioplasty Bypass grafting, in which the blocked blood vessel is bypassed with a blood vessel harvested from another part of your body or with manufactured tubing. 

Raynaud's phenomenon RN is a vasospastic disorder causing discoloration of the fingers, toes, and occasionally other areas. This condition . Named after French physician Maurice Raynaud (1814–1881), the phenomenon is the result of vasospasms that decrease blood supply to the respective regions. Stress and cold are classic triggers of it. Although blood vessels naturally become narrower under these circumstances,

Type of RN There are two types: Primary Raynaud's (Raynaud's Disease)—This is the most common form. Primary Raynaud's occurs by itself, in the absence of other medical conditions. Secondary Raynaud's (Raynaud'ssyndrom)— This is the more severe form. People with secondary Raynaud's also have some other underlying medical condition that is thought to also cause Raynaud's

. Some common conditions associated with Raynaud's include: Rheumatoid arthritis Carpal tunnel syndrome HTN and DM

Pathophysiology . Cold-induced vasospastic attacks in patients with primary Raynaud's phenomenon involve a heightened vasoconstriction of these digital arteries that is mediated by α2-adrenergic receptor. The cause of this exaggerated response to cold stimuli is unknown

causes The causes of primary and secondary RP are unknown. Both abnormal nerve control of the blood-vessel diameter and nerve sensitivity to cold exposure have been suspected as being contributing factor

Symptoms Symptoms of RP depend on the severity, frequency, and duration of the blood vessel spasm In a typical RP attack, The digits initially turn white, indicating ischemia; then blue, signaling deoxygenating; and finally, digits appear red when reperfusion  Symptoms of RP resolve as the provoking factor (cold or stress) is removed.

con Patients with severe secondary RP can sometimes experience a serious decrease in blood flow that does not resolve even after the provoking factor or cold is removed. . Serious deeper tissue injury can occur that can lead to finger loss in some

Diagnosis . Primary Raynaud's disease is diagnosed only when secondary causes have been excluded. Common criteria for the diagnosis of primary Raynaud's phenomenon are Vasospastic attacks caused by cold or emotional stress Symmetric attacks involving both hands No evidence of digital ulcerations, pitting, or gangrene No suggestion of a secondary cause A normal sedimentation rate

Treatment No pharmacologic Management Treatment options are dependent on the type of Raynaud's present. Most patients with both primary and secondary Raynaud's phenomenon will respond to conservative management

con Environmental triggers should be avoided, e.g. cold, vibration, etc. Avoid Emotional stress. Extremities should be kept warm Avoid Smoking. Consumption of caffeine another vasoconstrictors must be prevented.

pharmacologic therapy Drugs can be used to treat primary and secondary Raynaud's phenomenon if it interferes with the patient's ability to work or perform daily activities or if digital lesions develop. Drug therapy should always be used in addition to no pharmacologic measures.

Calcium Channel Blockers Nifedipine, a potent peripheral vasodilating calcium channel blocker, has become the drug of choice in patients with Raynaud's disease not controlled by conservative measures. In primary Raynaud's ten or more episodes per week are common. Nifedipine therapy results in an approximate 50% decrease in the number of attacks, in addition to a decrease in severity by one-third.

cont Patients who do not benefit from nifedipine will not benefit by switching to anothe vasoselective calcium channel blockers (CCBs), but Patients who cannot tolerate the side effects of nifedipine (e.g., ankle edema) might benefit by switching to another CCB

Other drug therapy The α1-adrenergic antagonists Prazosin, 1 mg three tim can be used oral phosphodiesterase inhibitors, such as sildenafiland vardenafil, which also promote vasodilation The ACE inhibitors act as vasodilators and have been investigated in several small studies. Flouxitine a selective serotonin reuptake inhibitor, and other antidepressant medications may reduce the frequency and severity of episodes if caused mainly by psychological stress

Fluoxetine a selective serotonin reuptake inhibitor, and other antidepressant medications may reduce the frequency and severity of episodes if caused mainly by psychological stress nitroglycerin (NTG) ointment to the hands The extract of the Ginkgo biloba leaves may reduce frequency of attacks. Arginine, which increase nitric oxide acts as a vasodilator

Surgical Intervention In severe cases, a sympathectomy  procedure can be performed. Here, the nerves that signal the blood vessels of the fingertips to constrict are surgically cut