Vascular Medicine for medical students Zsolt Pécsvárady zspecs@chello.hu Pécs

Basic considerations: ARTERIES: Atherosclerosis is the 1st major cause of the morbidity and mortality in the western societies. ( 50% or more from all diseases ) Must find as early as possible. Atherosclerosis alter the whole vascular system of the body. The symptoms and signs of the disease depend on the localisations of the organs involed ( heart, brain, kidney, GI tract, extremities ), but we have to check the disease in all locations. Because of the symmetry of our body, bilateral simultaneous palpation or auscultation is a great help in the diagnosis. Nearly 80 % of the diagnosis is available from medical history and physical examination.

Medical history: symptoms Not enough blood supply - early stages: during activity ( reversible ) - advance stage: end organ failure ( irreversible )

Periferal arterial disease – PAD – Main symptom is intermittant claudication ( IC ) Latin word claudico = to limp 90 % of patients, IC is due to stenosis or occlusion of the arteries supplying the lower extremities Bruit at the place of stenosis ( between 30-70 % stenosis only )

Rose criteria as tool for intermittent claudication 1 Rose criteria as tool for intermittent claudication 1. Do you get pain in either leg on walking? Yes No   2. Does this pain ever begin when you are standing still or sitting? Yes No 3. In what part of your leg do you feel it? Pain includes calf/calves Pain does not include calf/calves ( If calves not mentioned, ask: Anywhere else?) 4. Do you get it if you walk uphill or hurry? Yes No Never hurries or walks uphill 5. Do you get it if you walk at an ordinary pace on the level? Yes No 6. Does the pain ever disappear while you are walking? Yes No 7. What do you do if you get it when you are walking? Stop or slow down Carry on 8. What happens to it if you stand still? Relieved Not relieved 9. How soon? 10 min. or less More than 10 min.

Sign and symptoms of PAD Exercional leg pain and relief with rest Cool or cold feet to palpation Nocturnal and rest pain relieved with dependency Absent pulses Blanching or pallor on elevation Delay venous filling after elevation Dependent rubor Atrophy of subcutaneous fatty tissue Shiny skin Loss of hair on foot and toes Thickened nails, often with fungal infections Gangrene or nonhealing ulcer

Palpation Auscultation Blood Pressure measurement

Phsysical examination: palpation Pulse: absent = 0 diminished = 1 normal = 2 Congenital absence of pedal pulses: 1000 children (age: 1-10 yr ) without PAD: 12% missing of Art. D.P. 500 youngsters (age: 0-19 yr) without PAD: 8.7% missing Art. D.P. 0.2% misssing Art. T.P. But: Leng & Fowkes, J Clin Epid.1992;45:1101 Ludbrook et al, BMJ, 1962:1:1724

Functional test ( 1 ): Treadmill test to evaluate the claudication distance Standard slope: 12 % Standard speed: 3,2 km/h

Functional test ( 2 ): Ratchow test

Functional tests ( 3 ) : Allen test Pressing radial / ulnar artery and ischemisation

Functional test ( 4 ) : Adson test ( Thoracic Outlet Syndr ) art. radialis art. subclavia

CW Doppler measurement a. D.P.

ABI = Ankle-brachial index BP lower extremities * ABI = -------------------------- BP upper extremities** * The higher between aDP or aTP in one leg ** The higher between the two arms Normal: 0.91–1.30 Mild to moderate: 0.70–0.90 Moderate to severe: 0.40–0.69 Severe: <0.40 Non compressable >1.30

Segmental blood pressure measurement w / CW Doppler a. T.P. a. D.P.

Segmental BP measurement

Bi-directionalis Doppler pulse wave analysis

Periferal arterial disease Ed. Coffmann, Eberhardt Humana Press 2003

ABI and mortality rate independent predictor for CV risk 100 ABI >0.85 80 survival (%) 60 ABI 0.40–0.85 40 ABI <0.40 20 2 4 6 8 10 years McKenna M, et al. Atherosclerosis. 1991;87:119-128.

Duplex ultrasound 2D presentation Doppler measurement Indications – structure of blood vessel wall, IMT, plaque analysis Doppler measurement haemodinamique changes degree of stenosis ( speed of flow) Indications stenosis, occlusion, aneurysma, pseudoaneurysma, AV-fistula, controll after operation or PTA ( percutan transluminal angioplasty )

Intima Media Thickness

Angiography Invasive but gold standard

3D CT, MRI near future

Comparison of non-invazive screening technics in earlyPAD Method Cost Specificity Senzitivity ABI + 95 Carotis IMT 81-100 85-86 EBT +++ 59 89 MRI +++++ 83 100 N.Wong et al 2002 Meta-analysis