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Peripheral Vascular Disease

Masrul Syafri
Dept Cardiology and Vascular Medicine

Perhipheral vascular disease is


considered to
be any abnormality of the arteries
and veins
outside of the skull and the heart.

Worldwide Causes of
Death

PAD
Characterized by arterial stenosis and
occlusions in the peripheral arterial bed

Can be symptomatic or asymptomatic

Under diagnosed and under treated


disease

Patient and physician awareness is low

Ranges in severity from intermittent


claudication to Acute limb ischemia

Patients have a decreased quality of


life due to a reduction in walking
distance and speed leading to
immobility

Most cases of PAD are asymptomatic

Prevalence

27 million people in Europe and


North America have PAD (16%
of the population 55 yrs or
older)
10.5

million are symptomatic


16.5 million are asymptomatic

Prevalence

Severity of symptoms has been found to


correlate with survival

San Diego Artery study

Survival rates decreased with increasing severity

Another study showed that patients with


symptoms had a 22% survival rate over a
15 yr period compared to a 78% survival
rate of pts w/o symptoms

Belch et al, Arch Intern Med; April 2003; 884-892

Components

Problems with veins

Varicose veins

Blood clots and sequelae

Arteries blocked by atherosclerosis

Carotid, Legs. Kidneys, GI tract

Arterial Aneurysms

Aorta and branches

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

Why it is important to
recognize patients with
PAD?

PAD is a marker of
systemic
atherosclerosis
Patients with
either symptomatic
or asymptomatic
PAD generally have
widespread
arterial disease

Why it is important to
recognize patients with
PAD?
Coexisting vascular Disease:
CAD-- 35 % to 92%
CVD-- 25 % to 50%

Why it is important to
recognize patients with
PAD?

Cause of death:
CAD 40%-60%
CVD 10%-20%
Non-cardiovascular causes--Only
20% to 30 %
Patients with PAD have a 6 fold
increased risk of cardiovascular
disease mortality compared to
patients without PAD

Predictors of Mortality in
PAD

297 patients

213 had intermittent claudication


84 had CLI defined by gangrene, ulcerations or
persistent rest pain > 2 weeks
All subjects had ABI < 0.9

Results

Patients with CLI had a 1 yr death rate of 22%


3 yr survival was 52% compared to 86% in pts with
intermittent claudication
Data suggests that pts with advance PAD have
widespread arteriosclerotic disease
CLI was a stronger predictor of death than a low ABI

Pasaqualini et al, Amer Jour of Cardio 2001;Vol 88:1057-60

Risk Factors for Atherosclerosis


Hyperhomocystein
emia
Diabetes

Hypertension

Smoking

Obesity
Genetics

Dyslipidemia

Age

Atheroscleroris

Atherosclerotic Disease and Complications


(coronary, cerebrovascular, peripheral arterial events

What is Peripheral
Arterial Disease?
PAD=POAD=PVD
Arteriosclerotic occlusive disease of aortoiliac
and/or femoropopliteal arterial system
ALI : Acute Limb Ischaemic
CLI : Critical Limb Ischaemic
CI : Claudication Intermittent

Cardiac Risk

Pts with PVD have a 60% risk of


CAD

Up to 30 % of pts have correctable 3


vessel disease with reduced LVEF

Patients with an ABI < 0.9 are twice


as likely to have CAD

Clinical Presentation

Can vary from severe disabling discomfort at rest


to a bothersome pain of seemingly little
consequence

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

Claudication

Calf

Thigh

Usually occlusion of the common femoral artery

Foot

Cramping in upper 2/3 usually due to SFA stenosis

Occlusive disease of the tibial and peroneal vessels

Buttock and Hip

Aortoiliac occlusive disease (Lariches syndrome)

Diagnostic tests

Ankle-brachial index

Measures the resting and post exercise systolic BP in


both the ankle and arms
Normal > 1.0

Below 0.9 has a 95 % sensitivity for detecting


angiogram positive PVD

0.4 to 0.9 suggests arterial obstruction

Highly predictive of morbidity and mortality of CV events


linked to PAD

Below 0.4 represents advanced ischemia

Diagnostic Tests

Segemental limb pressures

> 20 mmHg reduction significant

Duplex U/S

MRA

Conventional angiography

Angiography

Indicated for:

Defining vessel anatomy

Evaluating therapy

Documenting disease

What are the risk factors


for PAD?
Non-Modifiable Risk Factors:
Male gender
Advanced age
Family history
Modifiable Risk Factors:
Major
Minor
Smoking
Homocystenemia
Hypertension
Obesity
Diabetes
Hypercoaguable state
Hyperlipidemia
Physical inactivity

PRIMARY SITES
OF INVOLVEMENT
Femoral & Popliteal
arteries: 80-90%
Tibial & Peroneal
arteries: 40-50%
Aorta & Iliac arteries:
30%

Harrisons
Principles of Int
Med

Pathogenesis

Pathogenesis

How do patients with PAD


present?
Symptomatic
Intermittent
claudication
Critical Limb Ischemia
Pain at rest
Tissue loss
Gangrene

Asymptomatic

How do patients with PAD


present?

How do we diagnose
PAD?

Symptomatic

History
Physical Examination
ABI measurement
Non-invasive tests (arterial
duplex,
CTA, MRA)
Invasive test (Conventional
Asymptomatic
angiogram)
ABI
measurement

How do we diagnose
PAD?
Symptomatic
10%

Asymptomatic
90%

Ankle Brachial Index

ABI= Ankle SBP(PT or DP)/ Highest Arm SBP

Ankle Brachial Index


ABI value

Indicates

<0.9
0.8- 0.9
0.5- 0.8
<0.5
<0.25

Abnormal
Mild PAD
Moderate PAD
Severe PAD
Very Severe PAD

The ABI has limited use in evaluating calcified vessels that are not
compressible as in Diabetics

Investigations

Investigations

Natural History

Annual risk :
- Mortality 6.8%
- MI 2.0%
- Intervention

1.0%

- Amputation

0.4%

Ouriel K, Lancet 2001; 358: 1257-64.

Goals of treating patients


with PAD
Relief symptoms
Improve quality of life
Limb salvage
Prolong survival

Strategies in treating
patients with PAD
Risk Factors
Modification

Improve Lower Limb Circulation

Strategies in treating
patients with PAD
Risk Factors Modification

Diet and weight control


Exercise
Hypertension control
Diabetes control
Lipid control
Smoking Cessation

Strategies in treating
patients with PAD
Improve Lower Limb Circulation
Conservative (Exercise Program)
Intervention ( Revascularization)
- Angioplasty +/- Stenting
- Surgical Bypass

Percutanous Transluminal
Angioplpasty
PTA

Surgical Bypass

Acute Limb
Ischemia

What is an Acute Limb


Ischemia?

Sudden decrease or worsening in


the limb perfusion causing a
potential threat to the limb viability
resulting from a sudden obstruction
of the arterial system

What are the causes of acute


arterial occlusion ?

Embolus
Thrombosis
Others
Trauma
Iatrogenic
Arterial dissection

What is the possible source for


an embolus?
Spontaneous (80%)
Cardiac source
arrhythmias, MI, prosthetic valve, endocarditis

Non-Cardiac source
Proximal AS plaque, Proximal Aneurysm,
Paradoxical emboli

Iatrogenic (20%)
Angiographic manipulation
Surgical manipulation

What are the common sites for


embolus lodgment in the arterial
tree?

How do patients with acute


limb ischemia present?

Sudden onset of diffuse and poorly


localized leg pain
6 Ps
Paresthesias
Pain
Poikilothermia (coolness)
Pallor
Pulselessness
Paralysis

Investigations

Acute Limb Ischemia is a


CLINICAL DIAGNOSIS
If time allows, especially if
atherosclerotic thrombosis is
suggested, preoperative
angiography is often wise

Goal of treating patients


with Acute Limb Ischemia

Rapid restoration of adequate


arterial perfusion without the
development of morbid local
or systemic complications

Treatment

EMEGENCY (Golden time is 6 hours)


ABC
IV Heparin (anticoagulation)
Rapid surgical
thromboembolectomy
+/ - surgical bypass
+/- thrombolytic therapy
+/- primary amputation

Surgical Thrmboemblectomy
Procedure

Thrombolysis

What do we worry about


after revascularization?
Reperfusion

Injury

Local
Compartment Syndrome
Systemic
Hyperkalemia
Acidosis
Myoglobulinuria

Claudication
intermittent

Claudication

Patients suffer from peripheral


atherosclerosis
Symptomatic deficiency in blood
supply to exercising muscle which is
relieved by rest
Largely a disorder of the elderly
Only 1-2% of those ages 37-69
Clinical history extremely important

HOW DOES AN INTERMITTENT


CLAUDICATION PATIENT
PRESENT CLINICALLY?

Leg pain caused and reproduced by a certain


degree of exertion
Relieved by rest
Not affected by body position
Atherosclerotic lesions usually found in arterial
segment one level above affected muscle group
Calf claudication more commonly due to
disease in femoral arteries and less commonly
due to disease in popliteal or proximal tibial or
peroneal arteries; Hip/Thigh/Buttock
claudication due to aortoiliac disease
Am J Cardiol 2001; 87 (suppl):
3D-13D

DIFFERENTIAL DIAGNOSIS
CALF
Venous occlusion
Tight bursting pain /
dull ache that worsens
on standing and
resolves with leg
elevation
Positional pain relief
Chronic compartment
syndrome
Tight bursting pain
Positional pain relief
Nerve root compression
Positional pain relief
Bakers cyst
Positional pain relief

HIP/THIGH/BUTTOCK
Arthritis
Persistent pain, brought
on by variable amounts
of exercise
Associated symptoms in
other joints
Spinal cord compression
History of back pain
Symptoms while
standing
Positional pain relief
FOOT
Arthritis
Buerger disease
(thromboangitis obliterans)

Am J Cardiol 2001; 87
(suppl): 3D-13D

DIAGNOSIS

History taking
Careful examination of leg
Pulse evaluation
Ankle-brachial index (ABI):
SBP in ankle (dorsalis pedis and posterior
tibial arteries)
___________________________________
SBP in upper arm (brachial artery)

Am J Cardiol 2001; 87 (suppl): 3D13D


NEJM 2001; 344: 1608-1621

Ankle-Brachial Index
Values and Clinical
Classification
Clinical PresentationAnkle-Brachial Index
Normal

> 0.90

Claudication

0.50-0.90

Rest pain

0.21-0.49

Tissue loss

< 0.20

Values >1.25 falsely elevated; commonly


seen in diabetics
Am J Cardiol 2001; 87
(suppl): 3D-13D

The history and physical examination


(pulse evaluation and careful
examination of the leg) are usually
sufficient to establish the diagnosis

WHY IS IT NECESSARY TO
TREAT INTERMITTENT
CLAUDICATION ?

Symptoms worsen in 25% of patients


Approximately 5% will require
amputation within 5 years
Around 5-10% have critical limb
ischemia; risk of limb loss
Increased risk of mortality, primarily
for cardiovascular causes

Am J Cardiol 2001; 87 (suppl): 3D-13D

IMPACT ON QUALITY OF LIFE

Functional status severely impaired


Gradual process of decline if symptoms are ignored
Symptoms considered a normal part of aging
process
Leveraged disability
Detrimental to quality of life; affects both leisure
and work activities

Peak exercise performance is about 50% that of agematched controls, equivalent to moderate to severe
heart failure patients
Am J Cardiol 2001; 87 (suppl): 14D-18D
Am J Med 2002; 112: 49-57

GOALS OF TREATMENT

To relieve exertional symptoms


and improve walking capacity
To improve quality of life
To reduce total mortality as well
as cardiac and cerebrovascular
morbidity and mortality
NEJM 2001; 344: 1608-21

MANAGEMENT

Risk factor modification


Exercise therapy
Antiplatelet therapy
Medical therapy targeted at
symptoms
Revascularisation procedures

Natural History of PAD in US


Population
Population Aged >55y
Asymptomatic
ABI <0.9
10%
PAD
outcomes

Intermittent
claudication
5%

Critical leg ischemia


1%
Cardiovascular
morbidity/mortality

(5-year outcomes)

Stable
Worsening Leg bypass Major
claudicationclaudication surgery amputation
73%
7%
4%
16%

Nonfatal eventsMortality
(MI/stroke)
30%
20%

Adapted from Weitz JI. Circulation 1996;94:3026-49.

Intervention for Tissue Loss/


Rest Pain, Severe Claudication
Medications
Risk factor assessment & reduction
Exercise program
PTA/Stents
Operation

MODIFICATION OF RISK
FACTORS

Smoking cessation
Diabetes control (FBG 80-120 mg/dl, PPG <
180 mg/dl, HbA1c < 7%)
Dyslipidemia management (LDL < 100
mg/dl, TG < 150 mg/dl): Statins (RR 38%;
4S)
Hypertension control (BP < 130/85 mmHg)
Ramipril [RR 28%; HOPE (n=4051)]

Am J Cardiol 2001; 87 (suppl): 3D


NEJM 2001; 344: 1608-21
Am J Med 2002; 112: 49-57

EXERCISE PROGRAM

Improves walking ability


Requires motivation and personalised
supervision
Benefits lost if not maintained on
regular basis
Overall effectiveness limited

NEJM 2001; 344: 1608-21

Compartment Syndrome

Thank You
.

Pathogenesis