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Presentation on theme: "PERIPHERAL VASCULAR DISEASE Presented by Jill Kerkman."— Presentation transcript:


2 Pathophysiology nForm of atherosclerosis nProgressive disease  May occur suddenly if an embolism occurs or when a blood clot rapidly develops in a blood vessel restricted by an atherosclerotic plaque, and the blood flow is quickly cut off.

3 nPVD is a generic term that encompasses vascular insufficiencies such as arteriosclerosis, arterial stenosis, Raynaud’s phenomenon. nPeripheral arteriosclerosis is common in the elderly and is often associated with hypertension and hyperlipidemia.  PVD is frequently observed in patients with CAD, diabetes, and a long-term history of smoking.

4 Two types of PVD nFunctional  Doesn’t have an organic cause.  Doesn’t involve defects in blood vessels’ structure, usually short-term effects and come and go.  Ex: Raynaud’s disease. nOrganic  Caused by structural changes in the blood vessels, such as inflammation.  Ex: Peripheral artery disease, caused by fatty buildups in arteries.

5 How Common is PVD? nAffects about 1 in 20 people over the age of 50, or 8 million people in the US. nPVD is only diagnosed in 50% of the population. nSymptomatic PVD carries at least a 30% risk of death within 5 years and almost 50% within 10 years, primarily due to MI (60%) or stroke (12%).

6 Symptoms of PVD nLeg or hip pain during walking (intermittent claudication). nThe pain stops when you rest. nNumbness, tingling or weakness in the legs. nBurning or aching pain in feet or toes when resting. nSore on leg or foot that won’t heal. nCold legs or feet. nColor change in skin of legs or feet. nLoss of hair on legs.

7 The 5 P’s nPeripheral signs of PVD are the classic 5 P’s  Pulselessness  Paralysis  Paraesthesia  Pain  Pallor

8 nParalysis and paraesthesia suggest limb- threatening ischemia and mandate prompt evaluation and consultation. nAdvanced PVD may manifest as mottling in a “fishnet pattern”, pulselessness, numbness, or cyanosis. Paralysis may follow, and the extremity may become cold; gangrene eventaully may be seen. Poorly healing injuries or ulcers in the extremities help provide evidence of preexisting PVD.

9 Who is at risk for PVD? nOver the age of 50 nSmokers nDiabetics nOverweight (especially with syndrome X or hyperinsulinism) nMale sex nSedentary people nPeople who have hypertension or high cholesterol nFamily history of heart or vascular disease

10 Pain Scale nA subjective grading scale for PVD pain is as follows:  Grade 1: Definite discomfort or pain, but only of initial or modest levels (established, but minimal).  Grade 2: Moderate discomfort or pain from which the patient’s attention can be diverted, for example by conversation.  Grade 3: Intense pain (short of Grade 4) from which the patient’s attention cannot be diverted.  Grade 4: Excruciating and unbearable pain.

11 How is PVD Diagnosed? nAnkle-Brachial Index Test (ABI)  The blood pressure in your arms and ankles is checked using a regular blood pressure cuff and a special ultrasound stethoscope called a Doppler.  The pressure in your ankle is compared to the pressure in your arm to determine how well your blood is flowing.  The index is determined by dividing ankle systolic BP by arm systolic BP.

12 ABI nMeasurements are usually taken at rest and after standardized treadmill exercise (i.e.. For 5 min. at 2mph, 12%). nA normal resting ABI is 1 or 1.1. nAn index of 0.9 or less indicates the presence of obstructive disease. n0.5 or less suggests multiple-level arterial disease. nAn ABI of less than 0.26 indicates severe, limb- threatening arterial compromise.

13 Duplex Ultrasonography and Doppler Color-Flow Imaging nTechnical advances in ultrasonography have allowed reproducible measurements of blood vessels and blood flow as well as standardization of criteria for assessment of PVD. nDoppler color-flow imaging are useful in localizing diseased segments, and spectral imaging can assess lesion severity.

14 Magnetic Resonance Imaging and Angiography nUseful in evaluating arterial dissection and characterizing vessel-wall morphology (including hematoma or thrombus). nComputed Tomography (CT) Angiography

15 Treatment for PVD nSevere lower extremity PVD is treated initially with cardiovascular disease risk factor modification:  Exercise training  Medication  Diet  Stop Smoking  Interventional Radiology  Surgery  Gene-Based Therapy

16 Exercise nResearch has shown that regular exercise is the most consistently effective treatment for PVD. nPatients who have taken part in a regular exercise program for at least 3 months have seen substantial increases in the distances they are able to walk without experiencing painful symptoms.

17 Exercise Prescription nTraining Intensity  Initial Set by result of peak treadmill. Starting exercise work load brings on claudication pain.  Subsequent Speed or grade increased if patient walks > 10 minutes. Grade increased first if speed > 2 mph. Speed increased first if < 2 mph.

18 Exercise Prescription nDuration  Initial 35 minutes (intermittent walking)  Subsequent Add 5 minutes every session until 50 minutes (intermittent walking) is possible

19 Exercise Prescription nFrequency  3-5 times per week. nSpecificity of Activity  Treadmill walking is the recommended exercise.

20 Stop Smoking nOn average, smokers are diagnosed with PVD as much as 10 years earlier than non- smokers. nStopping smoking now is the single most important thing you can do to halt the progression of PVD or prevent it in the future.

21 Medications nDrugs that lower cholesterol or control high blood pressure. nDecrease blood viscosity.  Trental, Persantine, or Coumadin nAntiplatlet agents: their primary long-term benefit is reduction in cardiovascular events and mortality.  ASA doses of 75 to 325mg QD have shown protective benefits.  Ticlid and Plavix also have shown promise in disease prevention and in therapy after vascular intervention.

22 Interventional Radiology Treatments nAngioplasty nStents nThrombolytic Therapy nStent-Grafts

23 Gene-Based Therapy nThe field of molecular genetics has provided new understanding of vascular physiology and pathology and has opened exciting frontiers in the treatment of PVD. nDirect gene transfer by intramuscular injection of DNA encoded with vascular growth factors has resulted in growth of new vessels and collateral circulation in chronically occluded lower extremity arterial vessels.

24 Surgical Treatments for PVD nThrombectomy nBypass Grafts


26 Aneurysms nMost common lethal peripheral vascular abnormality.  An artery whose diameter is 1.5 times the normal. nAortic aneurysms are caused by weakening of the artery walls due to atherosclerosis. The weakened walls balloon out, forming an aneurysm. nWhen blood pumps from the heart through the aorta, it places pressure on the aneurysm walls. Over time, the aneurysm can get bigger and bigger, until eventually it may rupture.

27 Aortoiliac Occlusive Disease nTypically involves the distal abdominal aorta as well as the common and external iliac arteries. nAortobifemoral bypass with a prosthetic graft has been the traditional treatment of choice for aortoiliac occlusive disease since the 1960’s. nThe operative morbidity and mortality are in the 2% range, and long-term patency exceeds 90%.

28 Superficial Femoral Occlusive Disease nPresents with symptoms of claudication of the calf and sole of the foot.  Usually improves as collateral circulation develops. nBest treatment initially is antiplatelet therapy in combination with a vigorous exercise program.

29 Tibial Artery Disease nDistal atherosclerotic disease involving the tibioperoneal trunk and the tibial vessels is the most difficult to treat and leads to the greatest morbidity and tissue loss. nABI is typically less than 0.4 before rest pain develops, and any value less than 0.3 almost always results in ischemic tissue loss.

30 Upper Extremity Disease nAtherosclerotic disease involving the arms is almost always limited to the larger proximal vessels and rarely involves the brachial, radial, or ulnar arteries. nAlthough these patients have no symptoms, they can have a large discrepancy in BP between the left and right arms.  Always prudent to measure BP in both arms.

31 Thrombosis nA thrombus, or blood clot, within a blood vessel. nNormally, a blood clot forms to prevent bleeding but a thrombus is an abnormal blood clot in the vessel when it is not even punctured. nThe clotting process may be encouraged by the buildup of fatty acids on the vessel walls. nThrombosis in the vein may cause pain and swelling.

32 Deep Venous Thrombosis nA blood clot in a deep vein. nMay form on the valves within the vein, and may subsequently increase in size to totally occlude the vein. nSometimes parts of the clot may break off and travel in the bloodstream to the lungs and cause serious health problems (pulmonary embolism). nDVT is perhaps the most dangerous problem. nPatients with DVT have a 30 to 40% risk of recurrence later in life.

33 Phlebitis nInflammation of the leg veins. nTwo types:  Inflammation of the veins on the surface of the leg (more common).  Inflammation of the deep veins of the leg. nPhlebitis is caused by an infection or injury. nCan cause a blood clot to form and this clot can then embolize and result in pulmonary embolism. This is the worst thing that can happen if you have phlebitis.

34 Pulmonary Embolism nAn embolus is a clot or any other piece of material that is carried around in the blood. nPulmonary embolism is where the embolus gets stuck in a vessel going to the lungs. nThe only way a clot can go to a vessel in the lungs is if it passes through the heart and is pumped out of the pulmonary artery. nSo, the closer the clot is to the heart, the more likely to get a pulmonary embolism.

35 Varicose Veins nCaused because either the blood flow is too slow making the vein pile up with blood or the valve in the vein is not working well so the blood falls down due to gravity and piles up in the veins of the legs. nSclerotherapy: Irritant chemical is injected into the veins, causing them to scar and seal off. This “detours” the blood to nearby healthier veins. nStripping: Procedure used to remove larger varicose veins. Parts of the vein can be removed or tied off, or the entire vein can be removed.

36 nSurgery continues to play an important role in the management of peripheral vascular disease. nRevascularization procedures provide excellent outcomes for many patients at risk for loss of a limb or seriously impaired quality of life. nAlthough endovascular techniques are now being used for managing many vascular problems, the traditional surgical approaches still offer well-documented benefits.



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