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Peripheral Artery Occlusive Disease

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Presentation on theme: "Peripheral Artery Occlusive Disease"— Presentation transcript:

1 Peripheral Artery Occlusive Disease
Dr.mehdi hadadzadeh Cardiovascular surgeon

2 Peripheral Artery Occlusive Disease

3 Prevalence Approximately 1 million Americans become symptomatic Q year
Approximately 5% of men and 2.5% of women complain of intermittent claudication by history If asymptomatic disease is included (as determined by ABI) 13% of women and 16% of men have peripheral vascular disease Of these only 1% have critical limb ischemia

4 Risk Factors Age Male gender (over age 70 risk equalizes)
DM (tend to have more distal and diffuse disease; 7 fold increase risk of amputation) Tobacco (risk even stronger than for CAD; with smokers experiencing IC up to 10 yrs earlier) HTN Hyperlipidemia

5 Prognosis Over 5-10 yrs 70% of pt’s have no change or improve
20-30% worsen 10% require intervention 1% require amputation In patients with IC the majority of morbidity and mortality comes from increased risk of CAD/CVD

6 Associated Risks (CAD/CVD)
Estimated that of those with lower extremity arterial disease at least 10% also have CVD and 28% have CAD Of patient with LE arterial disease 75% will die of a coronary or cerebrovascular event

7 History Quality (aching, numbness, weakness, fatigue)
Location (calf, buttock, or thigh) Severity of pain and functional limitations Typically induced by walking and relieved by rest True claudication typically resolves in <10 minutes after stopping activity Nocturnal pain and pain at rest are indications of more severe disease Risk Factors History alone tends to underestimate PAD; nocturnal pain usually resolves by putting legs in dependent position

8 Physical Exam Condition of skin and appendages Pulses Check for bruits
Pallor during leg elevation Time for color return after leg restored to dependent position ABI

9 Symptoms Intermittent claudication Rest pain Erectile dysfunction Sensorimotor impairment Tissue loss Signs Muscular atrophy Decrease hair growth Thick toenails Tissue necrosis ulcers infection Absent pulses Bruits

10 Clinical Presentations of PAD
~15% Classic (typical) claudication 50% Asymptomatic ~33% Atypical leg pain (functionally limited) 1%–2% Critical limb ischemia



13 Unilateral claudication of thigh, calf
Aortoilliac Claudication of both buttoks, thighs and calves, femoral and disal pulses absent,bruits, impotence Illiac Unilateral claudication of thigh, calf Unilateral absence of femoral and distal pulses femoropopliteal Unilateral claudication in calf , femoral pulse palpable with absent unilateral distal pulses Distal obstruction Femoral & popliteal pulses palpable, ankle pulses absent, cluadication in calf & foot

14 Ankle Brachial Index (ABI)
ABI <0.9 is 99% sensitive and 99% specific for angiographically diagnosed PAD Supine position Check systolic BP in upper extremities (using Doppler) – use highest value Systolic BP in lower extremities – use highest value Divide ankle SBP by brachial SBP May be falsely elevated in calcified vessels (DM) Systolic Hypertension in the Elderly Program (SHEP trial) found that an ABI <0.9 predicted all-cause mortality RR 3.8 Several other studies with same conclusions prompted recommendations to use ABI as integral part of screening of patients over 55 for CAD/CVD

15 ABI Normal = >0.90 0.70 – 0.89 = mild disease
0.50 – 0.69 = moderate disease <0.50 = severe disease (rest pain/tissue loss) If strongly suspect IC but WNL, can repeat following exercise (leg pressures only)

16 Other Noninvasive Testing
Segmental Pressure Measurements Pulse Volume Recordings Duplex Scanning MRA

17 Segmental Pressure Measurements
Measures SBP at multiple levels (upper and lower thigh, upper calf, ankle) Pressure reductions between levels help to localize occlusion Normally pressures increase as move further down the leg (>20mmHg gradient abnl) Limited with calcified artery walls (ie: diabetics)

18 Pulse Volume Recordings
Pneumatic cuffs placed similarly to SPM with pulse volume recorders Calibrated air plethysmographic wave form recording system Instead of SBP, measure volume of blood entering the arterial segment during systole Generates a waveform which normally has rapid systolic peak and dicrotic notch Not limited by calcifications of vessel walls

19 PVR

20 SPM and PVR Useful in measuring general local and severity of obstruction Allow for objective monitoring of patient’s change over time through serial exams Do not precisely localize disease or distinguish occlusion from severe stenosis

21 Pre-intervention Planning
Ultrasound—duplex scanning (also used for follow up of patency post-intervention) MRA (non-invasive, no ionizing radiation, contrast dye; but more artifact) Angiogram (gold standard; dx and rx in one procedure):invasive Approximately 82% sensitive and 92-96% specific for detection of significant disease when compared to arteriogram Lesions can be localized which is helpful in planning treatment Generally used only for intervention planning or following up patency post angioplasty or bypass



24 Therapeutic Approaches:
Medical surgical

25 Medical Treatments Risk factor reduction Exercise Medications

26 How to exercise for maximal benefit?
Greatest improvement in pain distances occurred with: 1. Exercise to near maximal pain 2. At least 3 times per week 3. Duration of at least 6 months 4. Walking as exercise mode

27 Medications Vasodilators (not effective) Antiplatelet Agents
Pentoxifylline (Trental) Cilostazol (Pletal)

28 Antiplatelet Agents Strong evidence that aspirin is benefitial both in reducing progression of arterial occlusive disease and in reducing vascular death (MI, stroke)

29 Pentoxifylline (Trental) 400mg TID
An agent which is thought to improve erythrocyte deformability, reduce blood viscosity and decrease platelet reactivty Effectiveness considered unknown AHA recommends use only in cases where exercise therapy has failed or patients are unable to exercise

30 When to refer to vascular specialist?
Most patients can be managed with risk factor modification, exercise and pharmacotherapy Arteriography is not necessary for diagnostic evaluation of patients with PAD and is indicated only when condition requires revascularization Therefore, referral is indicated for: Lifestyle limiting claudication refractory to exercise and pharmacotherapy Evidence of critical limb ischemia (rest pain or tissue loss)

31 Percutaneous Translumenal Angioplasty
High initial success rates of 90% Long-term success rates vary from 51-70% Best for stenosis (rather than occlusion), short segment disease, larger vessels (ie: iliac), no DM, normal renal function

32 Bypass Surgery Generally accepted as most effective treatment for those with debilitating PAD In some contexts surgery appears superior (infrainguinal lesions 5 yr patency 38% for PTA and 80% with surgery)


34 Causes Embolism, thrombosis & vascular injury are the causes of acute lower limb ischemia. Emboli: The Sources of arterial emboli are : ●Cardiac (90%) Arrhythmia (atrial fibrillation) Valvular heart diseaes. ( MS) Prosthetic heart valves. Hx of myocardial infarction. Atrial myxoma. ●Arterial source (9%) Atherosclerotic aorta Aneurysm ●Other (1%) Hx of medication (oral contraceptives)

35 Emboli usually impact at branching points in arterial tree, particularly at the bifurcation of the aorta, the common femoral bifurcation & popliteal trifurcation. Sites of occlusion embloi to the lower limb: Femoral artery % Aorta & iliac artery 26% popliteal artery % tibial artery %

36 Thrombosis: Thrombosis usually occur on a pre-existing atherosclerotic lesion. Occasionally thrombosis occur on relatively normal artery In patients with hypercoagulabale states ex: Pt with malignancy, polycythemia or pt taking high doses of oestrogen. Trauma It is important to determine a history of arterial trauma, arterial catheterization, intra-arterial drug induced injection, limb fractures.

37 The 6 P’s : Clinical Features ■ Pain. ■ Pallor. ■ Pulselessness.
■Perishing cold. ■ Paraesthesia. ■ Paralysis.

38 Clinical differentiation between thrombosis & embolism
No obvious cardiac source. history of cluadication. abnormal pulses in contralateral limb. Angiogram: diffuse atherosclerotic Well developed collateral Embolism: obvious cardiac source No hx of cluadication Normal pulses in contralateral limb Angiogram: minimal atherosclerotic Few collateral

39 TX:Immediately Anticoagulant with heparin to prevent propagation of thrombus & distal thrombosis & this achieved by giving a bolus of units of heparin intravenously & an infusion of about 1000 units of heparin per hour

40 Example of acute arterial embolus
“Saddle” Embolus of right iliac artery

41 Man Embolectomy : agement
This operation usually performed under local anaesthesia. A groin incision is made & the common femoral artery is opened. often the clot is found in the artery a Fogarty balloon catheter is passed in turn into the proximal & distal arteries the balloon is inflated & the catheter withdrawn removing the clot. Fogarty balloon catheter

42 Management Thrombolytic therapy:
Percutaneous intra-arterial thrombolytic therapy. Takes approximately hours to dissolve the clot. Agents used: streptokinase, urokinase & tissue plasminogen activator. Mechanism: The convert plasminogen to plasmin which the active lytic agent.


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