1. Peripheral Artery Occlusive Disease
Dr.mehdi hadadzadeh
Cardiovascular surgeon

2. Peripheral Artery Occlusive Disease

3. Prevalence Approximately 1 million Americans become symptomatic Q year
Approximately 5% of men and 2.5% of women complain of intermittent claudication by history
If asymptomatic disease is included (as determined by ABI) 13% of women and 16% of men have peripheral vascular disease
Of these only 1% have critical limb ischemia

4. Risk Factors Age Male gender (over age 70 risk equalizes)
DM (tend to have more distal and diffuse disease; 7 fold increase risk of amputation)
Tobacco (risk even stronger than for CAD; with smokers experiencing IC up to 10 yrs earlier)
HTN
Hyperlipidemia

5. Prognosis Over 5-10 yrs 70% of pt’s have no change or improve
20-30% worsen
10% require intervention
1% require amputation
In patients with IC the majority of morbidity and mortality comes from increased risk of CAD/CVD

6. Associated Risks (CAD/CVD)
Estimated that of those with lower extremity arterial disease at least 10% also have CVD and 28% have CAD
Of patient with LE arterial disease 75% will die of a coronary or cerebrovascular event

7. History Quality (aching, numbness, weakness, fatigue)
Location (calf, buttock, or thigh)
Severity of pain and functional limitations
Typically induced by walking and relieved by rest
True claudication typically resolves in <10 minutes after stopping activity
Nocturnal pain and pain at rest are indications of more severe disease
Risk Factors
History alone tends to underestimate PAD; nocturnal pain usually resolves by putting legs in dependent position

8. Physical Exam Condition of skin and appendages Pulses Check for bruits
Pallor during leg elevation
Time for color return after leg restored to dependent position
ABI

9. Symptoms
Intermittent claudication
Rest pain
Erectile dysfunction
Sensorimotor impairment
Tissue loss
Signs
Muscular atrophy
Decrease hair growth
Thick toenails
Tissue necrosis ulcers infection
Absent pulses
Bruits

10. Clinical Presentations of PAD
~15%
Classic (typical) claudication
50%
Asymptomatic
~33%
Atypical leg pain (functionally limited)
1%–2%
Critical limb ischemia

13. Unilateral claudication of thigh, calf
Aortoilliac
Claudication of both buttoks, thighs and calves, femoral and disal pulses absent,bruits, impotence
Illiac
Unilateral claudication of thigh, calf
Unilateral absence of femoral and distal pulses
femoropopliteal
Unilateral claudication in calf , femoral pulse palpable with absent unilateral distal pulses
Distal obstruction
Femoral & popliteal pulses palpable, ankle pulses absent, cluadication in calf & foot

14. Ankle Brachial Index (ABI)
ABI <0.9 is 99% sensitive and 99% specific for angiographically diagnosed PAD
Supine position
Check systolic BP in upper extremities (using Doppler) – use highest value
Systolic BP in lower extremities – use highest value
Divide ankle SBP by brachial SBP
May be falsely elevated in calcified vessels (DM)
Systolic Hypertension in the Elderly Program (SHEP trial) found that an ABI <0.9 predicted all-cause mortality RR 3.8
Several other studies with same conclusions prompted recommendations to use ABI as integral part of screening of patients over 55 for CAD/CVD

15. ABI Normal = >0.90 0.70 – 0.89 = mild disease
0.50 – 0.69 = moderate disease
<0.50 = severe disease (rest pain/tissue loss)
If strongly suspect IC but WNL, can repeat following exercise (leg pressures only)

16. Other Noninvasive Testing
Segmental Pressure Measurements
Pulse Volume Recordings
Duplex Scanning
MRA

17. Segmental Pressure Measurements
Measures SBP at multiple levels (upper and lower thigh, upper calf, ankle)
Pressure reductions between levels help to localize occlusion
Normally pressures increase as move further down the leg (>20mmHg gradient abnl)
Limited with calcified artery walls (ie: diabetics)

18. Pulse Volume Recordings
Pneumatic cuffs placed similarly to SPM with pulse volume recorders
Calibrated air plethysmographic wave form recording system
Instead of SBP, measure volume of blood entering the arterial segment during systole
Generates a waveform which normally has rapid systolic peak and dicrotic notch
Not limited by calcifications of vessel walls

19. PVR

20. SPM and PVR
Useful in measuring general local and severity of obstruction
Allow for objective monitoring of patient’s change over time through serial exams
Do not precisely localize disease or distinguish occlusion from severe stenosis

21. Pre-intervention Planning
Ultrasound—duplex scanning (also used for follow up of patency post-intervention)
MRA (non-invasive, no ionizing radiation, contrast dye; but more artifact)
Angiogram (gold standard; dx and rx in one procedure):invasive
Approximately 82% sensitive and 92-96% specific for detection of significant disease when compared to arteriogram
Lesions can be localized which is helpful in planning treatment
Generally used only for intervention planning or following up patency post angioplasty or bypass

24. Therapeutic Approaches:
Medical
surgical

25. Medical Treatments
Risk factor reduction
Exercise
Medications

26. How to exercise for maximal benefit?
Greatest improvement in pain distances occurred with:
1. Exercise to near maximal pain
2. At least 3 times per week
3. Duration of at least 6 months
4. Walking as exercise mode

27. Medications Vasodilators (not effective) Antiplatelet Agents
Pentoxifylline (Trental)
Cilostazol (Pletal)

28. Antiplatelet Agents
Strong evidence that aspirin is benefitial both in reducing progression of arterial occlusive disease and in reducing vascular death (MI, stroke)

29. Pentoxifylline (Trental) 400mg TID
An agent which is thought to improve erythrocyte deformability, reduce blood viscosity and decrease platelet reactivty
Effectiveness considered unknown
AHA recommends use only in cases where exercise therapy has failed or patients are unable to exercise

30. When to refer to vascular specialist?
Most patients can be managed with risk factor modification, exercise and pharmacotherapy
Arteriography is not necessary for diagnostic evaluation of patients with PAD and is indicated only when condition requires revascularization
Therefore, referral is indicated for:
Lifestyle limiting claudication refractory to exercise and pharmacotherapy
Evidence of critical limb ischemia (rest pain or tissue loss)

31. Percutaneous Translumenal Angioplasty
High initial success rates of 90%
Long-term success rates vary from 51-70%
Best for stenosis (rather than occlusion), short segment disease, larger vessels (ie: iliac), no DM, normal renal function

32. Bypass Surgery
Generally accepted as most effective treatment for those with debilitating PAD
In some contexts surgery appears superior (infrainguinal lesions 5 yr patency 38% for PTA and 80% with surgery)

34. Causes
Embolism, thrombosis & vascular injury are the causes of acute lower limb ischemia.
Emboli:
The Sources of arterial emboli are :
●Cardiac (90%)
Arrhythmia (atrial fibrillation)
Valvular heart diseaes. ( MS)
Prosthetic heart valves.
Hx of myocardial infarction.
Atrial myxoma.
●Arterial source (9%)
Atherosclerotic aorta
Aneurysm
●Other (1%)
Hx of medication (oral contraceptives)

35. Emboli usually impact at branching points in arterial tree, particularly at the bifurcation of the aorta, the common femoral bifurcation & popliteal trifurcation.
Sites of occlusion embloi to the lower limb:
Femoral artery %
Aorta & iliac artery 26%
popliteal artery %
tibial artery %

36. Thrombosis:
Thrombosis usually occur on a pre-existing atherosclerotic lesion.
Occasionally thrombosis occur on relatively normal artery
In patients with hypercoagulabale states ex:
Pt with malignancy, polycythemia
or pt taking high doses of oestrogen.
Trauma
It is important to determine a history of
arterial trauma, arterial catheterization,
intra-arterial drug induced injection, limb fractures.

37. The 6 P’s : Clinical Features ■ Pain. ■ Pallor. ■ Pulselessness.
■Perishing cold.
■ Paraesthesia.
■ Paralysis.

38. Clinical differentiation between thrombosis & embolism
No obvious cardiac source.
history of cluadication.
abnormal pulses in contralateral limb.
Angiogram: diffuse atherosclerotic
Well developed collateral
Embolism:
obvious cardiac source
No hx of cluadication
Normal pulses in contralateral limb
Angiogram: minimal atherosclerotic
Few collateral

39. TX:Immediately
Anticoagulant with heparin to prevent propagation of thrombus & distal thrombosis & this achieved by giving a bolus of units of heparin intravenously & an infusion of about 1000 units of heparin per hour

40. Example of acute arterial embolus
“Saddle” Embolus of right iliac artery

41. Man Embolectomy : agement
This operation usually performed under local anaesthesia.
A groin incision is made & the common femoral artery is opened. often the clot is found in the artery a Fogarty balloon catheter is passed in turn into the proximal & distal arteries the balloon is inflated & the catheter withdrawn removing the clot.
Fogarty balloon catheter

42. Management Thrombolytic therapy:
Percutaneous intra-arterial thrombolytic therapy.
Takes approximately hours to dissolve the clot.
Agents used: streptokinase, urokinase & tissue plasminogen activator.
Mechanism:
The convert plasminogen to plasmin which the active lytic agent.