Peripheral Artery Disease “Hardening of arteries” - atherosclerosis Caused by plaque accumulation on arterial walls – thrombus formation - stenosis

Peripheral Artery Disease Occludes blood flow in peripheral arteries – arms and legs

Peripheral Artery Disease ETIOLOGY : Risk factors - Smoking - Diabetes Mellitus - Dyslipidemia - Hypertension

Peripheral Artery Disease Increased Risk: 50 years old Male African American Obese Personal history of vascular disease, MI, or stroke

Chronic lower limb arterial disease PAD affects the leg eight times more often than the arm. Lower limb ischaemia presents as two distinct clinical entities: intermittent claudication (IC) and critical limb ischaemia (CLI). The presence and severity of ischaemia can be determined by clinical examination and measurement of the ankle-brachial pressure index (ABPI), which is the ratio between the (highest systolic) ankle and brachial blood pressures. In health the ABPI is > 1.0, in IC typically 0.5–0.9 and in CLI usually < 0.5.

Intermittent claudication (IC) Ischaemic pain affecting the muscles of the leg upon walking. The pain is usually felt in the calf because the disease most commonly affects the superficial femoral artery. However, the pain may be felt in the thigh or buttock if the iliac arteries are involved. Typically, the pain comes on after a reasonably constant ‘claudication distance’, and rapidly subsides on stopping walking.

Clinical features of chronic lower limb ischaemia Pulses: diminished or absent Bruits: denote turbulent flow Reduced skin temperature Pallor on elevation and rubor on dependency (Buerger’s sign) Superficial veins that fill sluggishly and empty (‘gutter’) upon minimal elevation • Muscle-wasting Skin and nails: dry, thin and brittle Loss of hair

Critical limb ischaemia (CLI) Rest (night) pain, requiring opiate analgesia, and/or tissue loss (ulceration or gangrene), present for more than 2 weeks, in the presence of an ankle BP of < 50mmHg at high risk of losing their limb, and sometimes their life, in a matter of weeks or months without surgical bypass or endovascular revascularisation by angioplasty or stenting.

Peripheral Artery Disease Tissue Necrosis a.k.a. Gangrene

Buerger’s disease (thromboangiitis obliterans) Inflammatory obliterative arterial disease usually presents in young (20–30 years) male 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. Wrist and ankle pulses are absent but brachial and popliteal are present.. It often remits if the patient stops smoking; sympathectomy and prostaglandin infusions may be helpful. Major limb amputation is the most frequent outcome if patients continue to smoke.

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. Primary Raynaud’s phenomenon (or disease) This affects 5–10% of young women aged 15–30 years in temperate climates and may be familial. It does not progress to ulceration or infarction, and significant pain is unusual. The underlying cause is unclear. The patient should be reassured and advised to avoid exposure to cold. Long-acting nifedipine may be helpful.

Secondary Raynaud’s phenomenon (or syndrome) This tends to occur in older people in association with connective tissue disease (most commonly systemic sclerosis ,vibration induced injury and thoracic outlet obstruction (e.g. cervical rib). Unlike primary disease, it is often associated with fixed obstruction of the digital arteries, fingertip ulceration, and necrosis and pain. The fingers must be protected from cold and trauma,. Sympathectomy helps for a year or two. Prostacyclin infusions are sometimes helpful.

Acute limb ischaemia This is most frequently caused by acute thrombotic occlusion of a pre-existing stenotic arterial segment, thromboembolism, and trauma which may be iatrogenic. All patients with suspected acutely ischaemic limbs must be discussed immediately with a vascular surgeon; a few hours can make the difference between death/ amputation and complete recovery of limb function.

Symptoms/signs Pain Pallor Pulselessness Perishing cold Unreliable, as the ischaemic limb takes on the ambient temperature Paraesthesia Paralysis Important features of impending irreversible ischaem

Investigations Duplex ultrasonography, MRI or CT with intravenous injection of contrast agents. Intra-arterial digital subtraction angiography is usually reserved for those undergoing endovascular revascularisation.

Diabetic vascular disease ‘diabetic foot Approximately 5–10% of patients with PAD have diabetes Arterial calcification Resistant to angioplasty Immunocompromise Multisystem arterial disease Coronary and cerebral arterial disease increase the risk of intervention Distal disease Diabetic vascular disease has a predilection for the calf vessels. Sensory neuropathy Even severe ischaemia and/or tissue loss may be completely painless. often present late with extensive destruction of the foot an deformity (Charcot joints) . Motor neuropathy Weakness of the long and short flexors and extensors leads to abnormal foot architecture, abnormal pressure loads, callus formation and ulceration. Autonomic neuropathy This leads to a dry foot deficient in sweat that normally lubricates the skin and contains antibacterial substances. Scaling and fissuring create a portal of entry for bacteria.

Peripheral Artery Disease Treatment: Smoking cessation Drugs antiplatlets,cilostazol,Statins Regular exercise Angioplasty/PTCA Bypass grafting Sympathectomy Digit/Limb Amputation