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

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

3. 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 )

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

5. 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

7. 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

8. 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.

9. 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:
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 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:
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:

10. 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.

11. 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

12. 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;
† ABI<0.9

13. 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.

14. 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)

15. 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).

16. 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

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

18. Palpation
Sitting
Supine

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

20. 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

21. 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.

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

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

24. 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

25. 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.

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

27. We may do
Bypass grafting.
Sympathectomy .
Amputation

28. 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.

29. 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

30. Thromboangitis Obliterans

31. TREATMENT
Conservative treatment
Surgical treatment
Sympathectomy
Amputation when gangrene develop

32. 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

33. 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.

34. 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

35. Raynauds’ Disease

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

37. TREATMENT
Avoid the causative factors
Operative treatment – Dorsal sympathectomy

38. THANK YOU