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 Pain takes a central position in a varied group of disorders, due to insufficient blood supply to the extremities.  It results in ischemia of the peripheral.

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Presentation on theme: " Pain takes a central position in a varied group of disorders, due to insufficient blood supply to the extremities.  It results in ischemia of the peripheral."— Presentation transcript:

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2  Pain takes a central position in a varied group of disorders, due to insufficient blood supply to the extremities.  It results in ischemia of the peripheral tissues,which causes pain and often functional limitation in the patient.  Pain is a signal indicating a serious problem.  Two important groups of disorders can be distinguished: critical vascular disease and the Raynaud’s phenomenon.  Raynaud’s phenomenon can be subdivided into a primary and a secondary type

3  Critical ischemic vascular disease is most common in patients over 55 years old as a result of arterial vascular disease. The annual incidence is 0.25 to 0.45 patients per 1,000 population. The disease initially presents as vague pain in the extremities, but ends in necrosis and amputation of the extremity in the course of 5 years.

4  Raynaud’s phenomenon occurs frequently in our society with an incidence of 3% to 21%.  Primary form:( Raynaud’s disease), No underlying cause cause  Secondary form( Raynaud’s syndrome) Has an underlying cause,usually associated with systemic underlying cause,usually associated with systemic pathology,in particular rheumatic pathology. pathology,in particular rheumatic pathology.

5  The main pathophysiology : impaired perfusion of the peripheral parts of the extremities.  Initially, it manifests itself as white discoloration of the fingers or toes & later as blue discoloration leading to ulcers.  In 90% of the cases with these diseases,Raynaud’s phenomenon is the first symptom.

6  classified under secondary Raynaud’s.  The age at onset : under 45 years.  An immune-mediated arteritis  The pathology is not fully known,but smoking or smoke cessation can seriously affect the symptomatology.

7 The incidence:  In the U.S & Eroup : %  In some Asian countries : 60%  It may be related to smoking & the type of tobacco used.

8  Critical ischemic disease : Arteriosclerosis due to HTN or diabetes.  Primary Raynaud’s is idiopathic & will be diagnosed as such if underlying systemic pathology has been excluded. underlying systemic pathology has been excluded.  Secondary Raynaud’s Try to establish a diagnosis as soon as possible in order to Try to establish a diagnosis as soon as possible in order to influence the evolution of the disease. influence the evolution of the disease.

9  Sclerotic disease: larg impact on the functioning of vital organs such as the lungs,liver,or kidneys.  Buerger’s disease & paraneoplastic phenomenons  It can be an adverse effect of chemotherapy (cisplatinum,bleomysine,and vincristine).

10 Table 2. Differences between Primary and Secondary Raynaud’s Phenomenon Primary Secondary Incidence 3% to 5% 0.2% In combination with other diseases No Yes Associated with antibodies No Often Dilated capillaries in nail bed No Often Familial predisposition Yes Yes Connective tissue disorders in family Yes Yes Medicinal treatment necessary Rarely Often Complications No, rarely Yes Improves after some time Yes, often Sometimes From Pope JE9 Reprinted by permission of the publishe

11  The exact mechanism remains as yet largely unclear.  The physiological vasoconstriction on noradrenaline is enhanced by cold & that there is an increased sensitivity to α 2-agonists& serotonin.  The vasoconstrictive endothelin-1 would also be involved & the CGRP & Cyclooxygenase supposedly play a (modulating) role.

12  Secondary form: connective tissue, collagen or a rheumatic disease, often with autoimmune features(scleroderma,sjogren’s disease,RA,SLE, polymyositis)  Peripheral vascular disease(Buerger’ disease)  In rare cases: in combination with a malignancy or chemotherapy(cisplatinum,bleomycine,and vincristine).

13  Classic neuroanatomic research by Pick6 demonstrated that sympathetic and sensory fibers enter the arterial (and venous)adventitia to form an intrinsic neural network ("adventitial plexus"), mostly composed of sensory afferents. From this plexus bundles of nonmyelinated fibers (mostly sympathetic) approach the media ("border plexus"), and extensions of this network ramify within the media ("muscular plexus").

14  Neuropathic pain also appears to be transmitted by sensory afferents but, unlike nociceptive pain, it has autonomic (sympathetic nerve) components as well. This results in the wellestablished (although poorly understood) role of sympathetic modulation for neuropathic pain by pharmacologic or anesthetic blockade or by sympathectomy.

15 History:  pain in the extremities  Critical ischemic disease: nonspecific pain in the extremities while walking that disappears at rest. The first symp:intermittent claudication The first symp:intermittent claudication Eventually,slow-healing ulcers will develop. Eventually,slow-healing ulcers will develop.  Older population  Raynaud’s Ph: pain in the distal parts of extremities with white discoloration,at a later stage, darkens & ulcers may eventually develop.

16 Physical Examination  Discoloration : white and then dark blue  No arterial pulsation in the affected area  The extremity will feel colder & may show skin lesions that heal very poorly

17  Tendency to necrosis  Tendency to necrosis in distal peripheral parts Weight loss  Weight loss  Malignancy  Blood pressure  Focus on disorders of the connective tissues  The hands & feet should be inspected (wounds, ulcers)  Presence of dilated capillaries in the nail bed is also important

18 Additional Tests Additional Tests  Sedimentation  Antibodies  Renal function Critical ischemic vascular disease: Critical ischemic vascular disease:  Imaging of the coronary arteries,provide information about the prognosis &surgical intervention

19  In Buerger’s & Raynaud’s imaging is less relevant,clinical& laboratory examination will provide sufficient information to make the diagnosis.  Once the diagnosis established,the evolution can be followed by means of capillaroscopy,which determines both the number of capillaries & the rate of RBC circulation.  Determination of the transcutaneous oxygen saturation

20 Differential Diagnosis  Secondary Raynaud’s : concomitant disorders  Primary form: acrocyanosis & primary livedoreticularis(red-blue discolored skin in a reticular pattern)

21 Classification of Perfusion Disorders in Peripheral Arterial Vascular Disease according to Fontaine Classification of Perfusion Disorders in Peripheral Arterial Vascular Disease according to Fontaine  Stage I No symptoms ( sufficient peripheral circulation )  Stage II Pain upon exertion, intermittent claudication  II a ability to walk > 100 m  II b ability to walk < 100 m  Stage III Pain at rest in the extremity concerned and in the supine position due to a poor muscle perfusion. The pain often temporarily decreases if the leg is dependent  Stage IV Trophic disorders such as necrosis/gangrene

22 Conservative management for ischemic vascular disease  Patients with vascular disease initially receive conservative & pharmacological therapy, if the symptoms persist, it may be decided to perform vascular surgery.

23 Interventional management for ischemic vascular disease Interventional management for ischemic vascular disease  Aim : Pain reduction& cure of the ulcers in order to prevent amputation. 1.sympathectomy 2.spinal cord stimulation

24 Sympathectomy Sympathectomy :  Vasodilatatory effect on the collateral circulation resulting from a reduced sympathetic tone  Improved oxygenation of the tissues leads to less tissue damage  Decreased pain  Increased healing of the ulcers

25  Although the effect of sympathectomy in critical ischemic vascular disease is not consistent,several studies have shown a trend toward better pain reduction and ulcer healing,which justifies its consideration.

26  A Cochrane Review of 2005 concluded that SCS in critical ischemic vascular disease: 1.leads to fewer amputations 2. provides better pain relief 3.restores more patients to Fontaine stage II

27 Table 4. Summary of the Evidence for Interventional Management for Ischemic Vascular Disease Technique Evaluation Sympathectomy 2B± Spinal cord stimulation 2B±

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29  It should be noted that SCS also is associated with complications including implantation problems,as well as additional intervention due to lead migration & infection.  SCS is more expensive than conservative therapy.  SCS may reduce amputation rate & pain in selected patients with CIVS that is refractory to conservative & minimally invasive pain treatment.

30  The treatment of the primary form is usually conservative & not pharmacological.  In case of primary,it is generally sufficient to inform the patient well & advise them to avoid provoking factors by : › wearing warm clothes › stopping smoking › taking sufficient exercise › avoiding vasoconstrictive medication

31 if pharmacological treatment is required,the vasodilators : › nifedipine (CCB) › prazosin ( α 1-blocker)  but their effects have been disappointing.  The main problems with these drugs are the adverse effects & the loss of efficacy long-term.  The treatment of secondary form is initially aimed at the underlying disease.

32  Sympathectomy is not often performed  It can be considered in patients with dystrophic changes leading to ulceration.  In a retrospective study, Matsumoto et el. Found an initially favorable result in 92.9% after endoscopic thoracic sympathectomy(ETS); however,recurrent symptoms were subsequently noted in 82.1%.  But these patients did not exhibit ulcerations during the study period.

33  Sympathectomy is not often performed  It can be considered in patients with dystrophic changes leading to ulceration.  In a retrospective study, Matsumoto et el. Found an initially favorable result in 92.9% after endoscopic thoracic sympathectomy(ETS); however,recurrent symptoms were subsequently noted in 82.1%.  But these patients did not exhibit ulcerations during the study period.

34 Other Treatments Botulinum Toxin A Injection  A study by Van Beek et al. describes 11 patients with rest pain & finger ulcers who received perivascular injections with botulinum toxin A.  There was an immediate favorable effect on the pain in 100% of the patients.  In 9 patients(82%),the ulcers healed spontaneously & this effect was still present in these patients after follow-up of as long as 30 months.

35 Recommendations for Raynaud’s Phenomenon  Sympathectomy can be considered in the treatment of Raynaud’s phenomenon,but only after multidisciplinary evaluation of the patient & in close consultation with the patient ‘s rheumatologist,vascular surgeon or internist.

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37 THE END


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