Download What is Peripheral Arterial Disease? Peripheral arterial disease

Peripheral Arterial Disease
Dr. Rehab F.M.Gwada
Objectives of the Lecture
• The student at the end of this lecture will be able
• To define Peripheral Arterial Disease(PAD)&
associated risk factors.
• To describe its causes &pathogenesis.
• To explain the clinical pictures associated with PAD
• to diagnose PAD& outline appropriate treatment
goals?
• To describe the strategies of Treatment in patient
with PAD ?
Content of Lecture
•
•
•
•
•
•
•
What is Peripheral Arterial Disease?
What are the risk factors for PAD?
Peripheral Vascular Disease Causes& Pathogenesis
Symptoms of PAD
How do we diagnose PAD?
Goals of treating patients with PAD
the strategies of Treatment in patients with PAD
Arteries
• Large elastic arteries have walls consisting of:
Tunica Intima
• Consist of
endothelium,
subendothelium
& elastic tissue
• Function: to
prevent
intravascular
clotting
Tunica Media
• Consist
of:
smooth muscle
&elastic fiber
• Function:
to
propel the blood
Tunica
Adventitia
• Consist
of
connective tissue
and small blood
vessels
• Function:
to
prevent
undue
expansion
of
artery
Peripheral Vascular Disease (PVD) refers to diseases of blood vessels outside
the heart and brain. It's often a narrowing of vessels that carry blood to the
legs, arms, stomach or kidneys. There are two types of these circulation
disorders
Functional peripheral vascular diseases don't have an
organic cause. They don't involve defects in blood vessels'
structure. They're usually short-term effects related to
"spasm" that may come and go. Raynaud's disease is an
example. It can be triggered by cold temperatures,
emotional stress, working with vibrating machinery or
smoking.
Peripheral
Vascular
Disease
Organic peripheral vascular diseases are caused
by structural changes in the blood vessels, such
as inflammation and tissue damage. Peripheral
artery disease is an example. It's caused by
fatty buildups in arteries that block normal
blood flow.
PVD definition is from the American Heart Association
What is Peripheral Arterial Disease?
• Peripheral arterial disease (PAD), commonly referred
to as peripheral artery occlusive disease (PAOD), refers
to the obstruction of large arteries not within the heart
vasculature, or brain.
• PVD can result from atherosclerosis, inflammatory
processes leading to stenosis, an embolism, or
thrombus formation. It causes either acute or chronic
ischemia (lack of blood supply).
• Often PAD is a term used to refer to atherosclerotic
blockages found in the lower extremity.
Signs &Symptoms
• About 20% of patients with mild PAD may be
asymptomatic; other symptoms include:
• Claudication - pain, weakness, numbness, or
cramping in muscles due to decreased blood
flow.
Claudication
walking induced pain in one or both legs
[primarily affecting calves] does not go away with
continued walking , relieved by rest
Present in 15-40% of PAD
Associated with diminished ability to perform
ADL
Signs &Symptoms
•
•
•
•
•
•
Noticeable change in color (blueness or paleness).
Paleness of the leg or foot when elevated
Blue/red discoloration of the foot when hanging down
Absence of pulses in the foot.
coolness.
Diminished hair and nail growth on affected limb and
digits.
• Sores, wounds, or ulcers that heal slowly or not at all.
• gangrene of the digits.
How do patients with PAD
present?
What are the risk factors for PAD?
Non-Modifiable Risk Factors:
Male gender
Advanced age
Family history
Modifiable Risk Factors:
Major
Minor
Smoking
Homocystenemia
Hypertension
Obesity
Diabetes
Hypercoaguable state
Hyperlipidemia
Physical inactivity
Peripheral Vascular Disease Causes
• atherosclerosis.
• Blood block: can block a blood vessel (thrombus/emboli).
• Diabetes: Over the long term can damage blood vessels
• Inflammation of the arteries: This condition is called arteritis
and can cause narrowing or weakening of the arteries.
Peripheral Vascular Disease Causes
• Infection: The inflammation and scarring
caused by infection can block, narrow, or
weaken blood vessels.
• Structural
defects
can
cause
narrowing. Most of these cases are
acquired at birth, and the cause remains
unknown.
• Injury Blood vessels can be injured in an
accident
How do we diagnose PAD?
History & symptomes
Physical Examination
Capillary filling time:(2-3sec in worm day to 5sec in cold one)
Test for rubor
Non-invasive tests
ABI(Ankle Brachial Index) measurement
Segmental Pressures
Exercise Test
Doppler & duplex ultrasound,
MR angiography.
Invasive test (Contrast arteriography)
Test for rubor
Changes in skin color that occur with elevation and dependency for the
limb are evaluated.
 The legs are elevated & supported for 45 degree for one minute above
the level of the heart while the patient is lying supine.
 severe , wide Pallor of the skin will occur in the feet if arterial
circulation is poor (within 25 sec. indicate severe ischema) .
 The time necessary for blanching to develop is noted.
The legs are then placed in a dependent position, and the color of the
feet is noted.
Test for rubor
Normally in dependency, a pinkish flush appears in the feet after several
seconds(10sec).
Abnormally , in severe ischemia , the delay is 40 sec or more.
In occlusive arterial disease, a bright reddening or rubor of the distal legs and
feet occurs.
The rubor may take as long as 25 to 40 seconds to appear.
Dependent rubor. Note the reddish appearance of the left leg and foot on dependency
compared to the normal color of the patient’s right foot and leg
Ankle Brachial Index
ABI= Ankle SBP/ Arm SBP
the severity of the PAD
Ankle Brachial Index
ABI value
Indicates
<0.9
0.8- 0.9
0.5- 0.8
<0.5
<0.25
Abnormal
Mild PAD
Moderate PAD
Severe PAD
Very Severe PAD
PAD Diagnostic Test:
Segmental Pressures
• arteries of your leg. Similar to the ABI plus
2 or 3 additional blood pressure cuffs.
These additional cuffs are placed just
below the knee and one large cuff or two
narrow cuffs are placed above the knee
and at the upper thigh. These cuffs are
then inflated above your normal systolic
blood pressure, and then slowly deflated.
• Using the Doppler instrument, a
significant drop in pressure between two
adjacent cuffs indicates a narrowing of
the artery or blockage along the arteries
in this portion of your leg. This allows the
physician to identify more precisely the
location of such blockages in the arteries
of your leg .
Goals of treating patients with PAD
•
•
•
•
Relief symptoms
Limb salvage
Improve quality of life
Prolong survival
Strategies of Treatment for patients
with PAD
Risk Factors Modification
Improve Lower Limb Circulation
Treatment of patients with PAD
Risk Factors Modification
•
•
•
•
•
•
Smoking Cessation
Hypertension control
Diabetes control
Regular exercise
Diet and weight control
Lipid control
Treatment of patients with PAD
Improve Lower Limb Circulation
• Conservative (Exercise Program):
-Graded ambulation or bicycling
program
- Burger-Allen Exercise
• Antiplatelet( reduce risks of MI ,
ischemic stroke and death from
vascular causes).
• Intervention ( Revascularization)
- Angioplasty +/- Stenting
- Plaque excision
- Surgical Bypass
- Rarely, sympathectomy is used.
- amputation is often a last resort to
stop infected ( In gangrene).
Angioplasty
Graded ambulation or bicycling
program
The patient should be encouraged to walk or bicycling
far as possible, without causing intermittent
claudicationas
carried out 3 to 5 days per week
mild warm-up activities before initiating ex. include stretching
calf ms , isometric pumping ex. For ankle & toes
Graded ambulation or bicycling
program
• Precautions:
avoid exercising outside during very
cold weather
wear shoes that fit properly and will
not cause skin irritations, blisters, or
sores
Patient with a history of cardiac
disorders , must be monitored closely
Graded ambulation or bicycling
program
• Contraindications: :
leg pain increased
over time
Patient with resting pain
ulcerations of the feet and wound or
fungal infections
Burger-Allen Exercise
• Procedure:
• A three-stage exercise procedure is carried out 3times /day.
• First position(stage)
Patient lies supine with legs elevated and
supported at a
45 to 60 degree angle.
Maintained position for 1 to 3 minutes,
or until
blanching of the extremity occurs
actively dorsiflex and planterflex the feet
Burger-Allen Exercis
Burger-Allen Exercise
• Second position(stage)
sits up and dangles his feet over
the edge of the bed..
actively dorsiflexes and planterflexes
his ankles for 3 minutes or until
rubor in
the feet develops.
Burger-Allen Exercise
• Third position(stage)
supine with his feet and legs
covered with a blanket for
warmth and rests for 5
minutes.
The
entire
three-stage
procedure is repeated 3 to 6
times during each treatment
session.
Burger-Allen Exercise
Termination:
Exercises and elevation of the
limbs are discontinued if pain
or cramping of the calf muscles
occurs.
Contraindications:
-Recent acute thrombosis or
embolus.
-Increased swelling in the lower
extremities
Prognosis
• Individuals with PAD have an elevated risk for
cardiovascular events and the majority will eventually
die of a cardiac ( 40%-60%) or cerebrovascular(10%20%) etiology
• prognosis is correlated with the severity of the PAD as
measured by the Ankle brachial index (ABI).
• In patients with intermittent claudication, the risk of
death from coronary events is three to four times
higher than matched controls without claudication.
• Severity of PAD is closely associated with risk of MI ,
ischemic stroke , and death from vascular cause .
Question
• Discuss the Strategies of Treatment for
patients with PAD?
Thank you