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

2. Acute arterial occlusion
”Objectives”
Definition
Aetiology
Presentations
Investigations
Management
Acute arterial occlusion
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3. 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”
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4. Risk Factors Hypertension Cigarette smokers Diabetics Hyperlipidaemia
Increased age
History of other atherosclerotic disease
(coronary artery disease or carotid stenosis)
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5. 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
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6. 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
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7. 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
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8. 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
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9. Intermittent Claudication Differential Diagnosis
Spinal Stenosis
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10. 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)
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11. INVESTIGATION OF PVD Assess risk factors:
Fasting lipids & glucose, HbA1c
Non-Invasive
Doppler Ankle/Brachial Index
Invasive
CT Angiogaphy/ MRI
Angiography
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13. 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
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14. 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
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15. Treatment of critical ischemia “Ischemic rest pain/ulcer/gangrene”
Angioplasty vs. Surgery
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16. Femoral Angiography
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17. Acute Limb Ischaemia
Embolus
Thrombus
Trauma
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18. 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
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19. Clinical Features Pain Pallor Parasthesia. Paralysis Pulselessness
Perishing Cold
Treatment Urgent Treatment
Heparin
Investigations
Intervention
? Thrombolytic
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20. 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
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21. 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.
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22. 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.
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23. Primary Raynaud's phenomenon (or disease): This affects 5-10% .
Young age women aged 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
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24. 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
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25. 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)
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26. 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
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27. 18/04/2018
Dr Habib Tareif, FRCSI

28. 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).
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29. 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
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30. 18/04/2018
Dr Habib Tareif, FRCSI

31. 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,.
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32. 18/04/2018
Dr Habib Tareif, FRCSI

33. 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 y (Occur in younger in marfan sydrome,pregnancy ,truma )
Men are twice as frequently affected as women.
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34. 18/04/2018
Dr Habib Tareif, FRCSI

35. 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.
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36. 18/04/2018
Dr Habib Tareif, FRCSI

37. 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)
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38. 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.
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39. 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.
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40. 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.
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41. Thank you
Any Questions???