1. Peripheral Arterial Disease Mohammed Al-Omran, MD, MSc, FRCSC Assistant Professor & Consultant Vascular Surgery King Saud University

2. What is Peripheral Arterial Disease? PAD=POAD=PVD PAD=POAD=PVD Arteriosclerotic occlusive disease of aortoiliac and/or femoropopliteal arterial system Arteriosclerotic occlusive disease of aortoiliac and/or femoropopliteal arterial system

3. What are the risk factors for PAD? Non-Modifiable Risk Factors: Male gender Male gender Advanced age Advanced age Family history Family history Modifiable Risk Factors: Major Major Smoking Smoking Hypertension Hypertension Diabetes Diabetes Hyperlipidemia Hyperlipidemia Minor Homocystenemia Homocystenemia Obesity Obesity Hypercoaguable state Hypercoaguable state Physical inactivity Physical inactivity

4. Pathogenesis

5. Pathogenesis

6. How do patients with PAD present? Asymptomatic Symptomatic Intermittent claudicationIntermittent claudication Critical Limb IschemiaCritical Limb Ischemia Pain at rest Pain at rest Tissue loss Tissue loss Gangrene Gangrene

7. How do patients with PAD present?

8. How do we diagnose PAD? Symptomatic Asymptomatic ABI measurement ABI measurement Non-invasive tests (arterial duplex, Non-invasive tests (arterial duplex, CTA, MRA) CTA, MRA) Invasive test (Conventional angiogram) Invasive test (Conventional angiogram) ABI measurement ABI measurement History Physical Examination

9. How do we diagnose PAD? Symptomatic 10% Asymptomatic 90%

10. Ankle Brachial Index ABI= Ankle SBP(PT or DP)/ Highest Arm SBP

11. Ankle Brachial Index ABI value Indicates <0.9Abnormal 0.8- 0.9 Mild PAD 0.5- 0.8 Moderate PAD <0.5 Severe PAD <0.25 Very Severe PAD The ABI has limited use in evaluating calcified vessels that are not compressible as in Diabetics

12. Investigations

13. Investigations

14. Why it is important to recognize patients with PAD? PAD is a marker of systemic atherosclerosis PAD is a marker of systemic atherosclerosis Patients with either symptomatic or asymptomatic PAD generally have widespread arterial disease Patients with either symptomatic or asymptomatic PAD generally have widespread arterial disease

15. Why it is important to recognize patients with PAD? Coexisting vascular Disease: Coexisting vascular Disease: CAD-- 35 % to 92% CAD-- 35 % to 92% CVD-- 25 % to 50% CVD-- 25 % to 50%

16. Why it is important to recognize patients with PAD? Cause of death: Cause of death: CAD– 40%-60% CAD– 40%-60% CVD– 10%-20% CVD– 10%-20% Non-cardiovascular causes--Only 20% to 30 % Non-cardiovascular causes--Only 20% to 30 % Patients with PAD have a 6 fold increased risk of cardiovascular disease mortality compared to patients without PAD Patients with PAD have a 6 fold increased risk of cardiovascular disease mortality compared to patients without PAD

17. Natural History Weitz JI et al, Circulation 1996; 94: 3026-49.

18. Natural History Annual risk : - Mortality 6.8% - MI 2.0% - Intervention 1.0% - Amputation 0.4% Ouriel K, Lancet 2001; 358: 1257-64.

19. Worldwide Causes of Death

20. Goals of treating patients with PAD Relief symptoms Relief symptoms Improve quality of life Improve quality of life Limb salvage Limb salvage Prolong survival Prolong survival

21. Risk Factors Modification Improve Lower Limb Circulation Strategies in treating patients with PAD

22. Risk Factors Modification Diet and weight controlDiet and weight control ExerciseExercise Hypertension controlHypertension control Diabetes controlDiabetes control Lipid controlLipid control Smoking Cessation Smoking Cessation Strategies in treating patients with PAD

23. Improve Lower Limb Circulation Conservative (Exercise Program)Conservative (Exercise Program) Intervention ( Revascularization)Intervention ( Revascularization) - Angioplasty +/- Stenting - Angioplasty +/- Stenting - Surgical Bypass - Surgical Bypass Strategies in treating patients with PAD

24. Percutanous Transluminal Angioplpasty PTA

25. Surgical Bypass

26. Acute Limb Ischemia

27. What is an Acute Limb Ischemia? Sudden decrease or worsening in the limb perfusion causing a potential threat to the limb viability resulting from a sudden obstruction of the arterial system Sudden decrease or worsening in the limb perfusion causing a potential threat to the limb viability resulting from a sudden obstruction of the arterial system

28. What are the causes of acute arterial occlusion ? Embolus Embolus Thrombosis Thrombosis Others Others Trauma Trauma Iatrogenic Iatrogenic Arterial dissection Arterial dissection

29. What is the possible source for an embolus? Spontaneous (80%) Cardiac source arrhythmias, MI, prosthetic valve, endocarditis Non- Cardiac source Proximal AS plaque, Proximal Aneurysm, Paradoxical emboli Iatrogenic (20%) Angiographic manipulation Surgical manipulation

30. What are the common sites for embolus lodgment in the arterial tree?

31. How do patients with acute limb ischemia present? Sudden onset of diffuse and poorly localized leg pain Sudden onset of diffuse and poorly localized leg pain 6 Ps 6 Ps Paresthesias Paresthesias Pain Pain Poikilothermia (coolness) Poikilothermia (coolness) Pallor Pallor Pulselessness Pulselessness Paralysis Paralysis

32. Investigations Acute Limb Ischemia is a Acute Limb Ischemia is a CLINICAL DIAGNOSIS CLINICAL DIAGNOSIS If time allows, especially if atherosclerotic thrombosis is suggested, preoperative angiography is often wise If time allows, especially if atherosclerotic thrombosis is suggested, preoperative angiography is often wise

33. Goal of treating patients with Acute Limb Ischemia Rapid restoration of adequate arterial perfusion without the development of morbid local or systemic complications Rapid restoration of adequate arterial perfusion without the development of morbid local or systemic complications

34. Treatment EMEGENCY (Golden time is 6 hours) EMEGENCY (Golden time is 6 hours) ABC ABC IV Heparin (anticoagulation) IV Heparin (anticoagulation) Rapid surgical thromboembolectomy Rapid surgical thromboembolectomy +/ - surgical bypass +/ - surgical bypass +/- thrombolytic therapy +/- thrombolytic therapy +/- primary amputation +/- primary amputation

35. Surgical Thrmboemblectomy Procedure

36. Thrombolysis

37. What do we worry about after revascularization? Reperfusion Injury Reperfusion Injury Local Local Compartment Syndrome Compartment Syndrome Systemic Systemic Hyperkalemia Hyperkalemia Acidosis Acidosis Myoglobulinuria Myoglobulinuria

38. Compartment Syndrome

39. Thank You Mohammed Al-Omran, MD, MSc, FRCSC Assistant Professor & Consultant Vascular Surgery King Saud University