Download Clinical Features

PERIPHERAL VASCULAR DISEASE
Dr .Ghazi F.Haji
Senior lecturer of Cardiology
Al-Kindy College of Medicine/Baghdad university
06/07/2017
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”Objectives”
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Definition
Aetiology
Presentations
Investigations
Management
Acute arterial occlusion
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Peripheral vascular disease of the lower
extremities
Definition
“Decreased patency” of the arterial supply to the lower
extremities leading to
 Chronic ischemic: (Claudication ,critical limb)
Atherosclerotic, Vasculitis,Burger's Disease
(ThromboangiitisObliterans),Extrinsic compression
(neoplasm)
Acute Ischemic : Embolic, Thrombotic”
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Risk Factors
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Hypertension
Cigarette smokers
Diabetics
Hyperlipidaemia
Increased age
History of other atherosclerotic disease
(coronary artery disease or carotid stenosis)
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Pathophysiology
“Narrowing of the arterial lumen leads to”
Decreased blood flow resulting in.
 Decreased O2 supply leading to
 Anaerobic metabolism
 Increased Lactic Acid
leading to:
Pain at rest
Poor wound healing
Painful ulceration
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Chronic Ischaemia
Intermittent Claudication
Muscle pain which appears during exercise
when there is an inadequate arterial flow
 critical limb -Rest Pain
 Cold Peripheries
 Arterial Ulcers
 Wet/dry gangrene
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Clinical Presentation
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Cramping/burning muscular pain
Localized to a muscle group (calf)
Reproducible
Relieved with rest
Distribution of pain may suggest anatomic
location of disease
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Lower Limb Assessment
Features of Chronic Ischemic changes
“Hair loss, shiny appearance & Trophic changes
Pulses: diminished or absent
Bruits:”
 Presence of Gangrene
 Ulcers
 Pallor on elevation and rubor on dependency
(Buerger's sign)
Muscle-wasting
Skin and nails: dry, thin and brittle
Temperature: Often cool
 Oedema: un usual
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Intermittent Claudication
Differential Diagnosis
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Spinal Stenosis
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Pain caused by critical Limb
Ischemia
Rest Pain
worse at night
May be present throughout the day and night
Continuous, aching & severe
Located in toes and forefoot.
(Patient hangs the leg over the side of the bed)
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INVESTIGATION OF PVD
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Assess risk factors:
Fasting lipids & glucose, HbA1c
Non-Invasive
Doppler Ankle/Brachial Index
Invasive
CT Angiogaphy/ MRI
Angiography
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Chronic Ischaemia
Conservative Management
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STOP SMOKING!
Increasing exercise tolerance
 Pharmacotherapy's:
 Aspirin 75 mg daily or clopidogrel 75 mg daily
 Statins.
 The peripheral vasodilator(Pentoxyphylline)
, cilostazol, has been shown to improve walking
distance
 ACE I {esp. in Diabetics }&control of DM
 Avoidance of minor trauma esp. in those with
neuropathy
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Surgical Management
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Endovascular options: to increase inflow if
suitable for femoral angioplasty or stenting
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Surgical bypass of diseased segment using
vein or prosthetic graft
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If un-reconstructable: Try Prostacyclin infusion
(Iloprost)
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Last option is amputation
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Treatment of critical ischemia
“Ischemic rest pain/ulcer/gangrene”
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Angioplasty vs. Surgery
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Femoral Angiography
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Acute Limb Ischaemia
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Embolus
Thrombus
Trauma
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Source of Emboli
Heart - 90%
- Arrhythmias, Valvular heart disease
- Prosthetic heart valves, Mural thrombus
post MI, Ventricular aneurysm
 Great Vessels (9%)
 Atherosclerotic aorta
Other (1%) --Paradoxical
Thrombus--- Thrombus on a pre-existing
atherosclerotic lesion
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Clinical Features
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Pain
Pallor
Parasthesia.
Paralysis
Pulselessness
Perishing Cold
Treatment------ Urgent Treatment
Heparin
 Investigations
 Intervention
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 ? Thrombolytic
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Clinical features
Embolism
Thrombosis in situ
Severity
Complete (no collaterals) Incomplete (collaterals)
Onset
Seconds or minutes
Hours or days
Limb
Leg 3:1 arm
Leg 10:1 arm
Embolic source
Present (usually AF)
Absent
Bruits
Absent
Present
Diagnosis
Clinical
Treatment Embolectomy, warfarin
thrombolysis
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Angiography
-Medical, bypass,
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Upper limb diseases
1-Arm claudication
2-Atheroembolism (blue finger syndrome).
3-Subclavian steal. When the arm is used, blood is 'stolen'
from the brain via the vertebral artery. This leads to
vertebro-basilar ischaemia, which is characterised by
dizziness, cortical blindness and/or collapse.
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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.
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Primary Raynaud's phenomenon (or disease):
 This affects 5-10% .
 Young age women aged 15-30 years may be familial
 Not progress to ulceration or infarction
 NO significant pain
 NO underlying cause .
 No investigation is necessary.
The patient should be reassured and advised to avoid
exposure to cold. Long-acting nifedipine may be
helpful
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Secondary Raynaud's phenomenon (or syndrome)
Occur in older people
Association with connective tissue disease (most
commonly systemic sclerosis or the CREST syndrome, ),
vibration-induced injury (from the use of power tools) and
thoracic outlet obstruction (e.g. cervical rib).
Progress to fingertip ulceration, and necrosis .
Significant pain
Need investigation
Need treatment :avoid exposure to cold
The fingers must be protected from trauma,
Antibiotics requires to treatment infection
Sympathectomy .
Prostacyclin infusions
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Burger's Disease
(Thromboangiitis Obliterans)
Clinical Features
- Males <45 years
- Upper and lower limb involvement
- Heavy 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
- Disease also affects the veins, giving rise to superficial
thrombophlebitis
Diagnosis: Angiogram
Major limb amputation is the most frequent outcome if patients
continue to smoke(Choice cigarette or your limb)
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Diseases of the aorta
Aneurysm, dissection
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Aneurysm: This is an abnormal dilatation of the
aortic lumen; a true aneurysm involves all the layers
of the wall, whereas a false aneurysm does not
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06/07/2017
Dr Habib Tareif, FRCSI
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Aetiology
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Atherosclerosis
Hypertension
-Families and genetic factors
-Infection -syphilis (saccular aneurysms) .
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aortitis include Takayasu's disease , Reiter's syndrome
giant cell arteritis and ankylosing spondylitis
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Marfan's syndrome (autosomal dominant trait and is
caused by mutations in the fibrillin gene on chromosome
15. Affected systems include the skeleton (arachnodactyly,
joint hypermobility, scoliosis, chest deformity and high
arched palate), the eyes (dislocation of the lens) and the
cardiovascular system (aortic disease and mitral
regurgitation).
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Types of aneurysm, investigation & treatment
Types : abdominal(mass) ,thoracic(high pressure +aortic
regurgitation)
Investigations:.
Chest X-ray, ultrasound , echocardiography, MRI or CT
Treatment with β-blockers reduces the rate of aortic dilatation
and the risk of rupture.
Elective replacement of the ascending aorta
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Dr Habib Tareif, FRCSI
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Abdominal aortic aneurysms (AAAs)
AAAs are present in 5% of men aged over 60 years and 80% are
confined to the infrarenal segment.
Men are affected three times more commonly than women.
The usual age at presentation is 65-75y
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Ultrasound is the best way of establishing the diagnosis and of
following up
CT provides more accurate information about the size and extent
of the aneurysm,.
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06/07/2017
Dr Habib Tareif, FRCSI
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Aortic dissection
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A tear of the aortic wall(intima) allows arterial blood to
enter the media, which is then split into two layers,
creating a 'false lumen' alongside the existing or 'true
lumen'. The aortic valve may be damaged and the
branches of the aorta may be compromised.
Disease of the aorta and hypertension are the most
important aetiological factors..
It may also rupture into the left pleural space or
pericardium with fatal consequences..
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The peak incidence is in 60-70 y (Occur in younger in
marfan sydrome,pregnancy ,truma )
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Men
are twice as frequently affected as women.
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Dr Habib Tareif, FRCSI
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Types
Aortic dissection is classified anatomically and for
management purposes into type A and type B
( regarding debakey and stanford classification)
Type A dissections account for two-thirds of cases and
frequently also extend into the descending aorta.
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Dr Habib Tareif, FRCSI
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Factors that may predispose
to aortic dissection
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Hypertension (80% of cases)
Aortic atherosclerosis
Aortic coarctation
Collagen disorders (e.g. Marfan's syndrome, Ehlers-Danlos
syndrome)
Fibromuscular dysplasia
Previous aortic surgery (e.g. CABG, aortic valve replacement)
Pregnancy (usually third trimester)
Trauma
Iatrogenic (e.g. cardiac catheterisation, intra-aortic balloon
pumping)
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Clinical features
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Involvement of the ascending aorta typically gives rise to
anterior chest pain, and involvement of the descending
aorta give rise to intrascapular pain.
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The pain is typically described as 'tearing' and very abrupt
in onset; collapse is common..
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There may be asymmetry of the brachial, carotid or femoral
pulses and signs of aortic regurgitation. Occlusion of
aortic branches may cause MI (coronary), stroke (carotid)
paraplegia (spinal), mesenteric infarction with an acute
abdomen (coeliac and superior mesenteric), renal failure
(renal) and acute limb (usually leg) ischaemia.
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Investigations
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The chest X-ray (wide medistinum ,left-sided pleural
effusion )
The ECG -left ventricular hypertrophy in patients with
hypertension, or rarely changes of acute MI (usually
inferior).
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Doppler echocardiography ( aortic regurgitation, a dilated
aortic root and, occasionally, the flap of the dissection).
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Transoesophageal echocardiography
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CT and MRI angiography are both highly specific and
sensitive.
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Management
The early mortality of acute dissection is approximately
1-5% per hour so treatment is urgently required.
 Initial management comprises pain control and
antihypertensive treatment(labetelol alfa and beta
,sodium nitruoprusside ,nicardipin ,ACEI.)
 Endoluminal repair or implanting a stent graft placed
from the femoral artery
 Type A dissections require emergency surgery to replace
the ascending aorta.
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Type B aneurysms are treated medically unless there is
actual or impending external rupture, or vital organ (gut,
kidneys) or limb ischaemia, as the morbidity and
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mortality associated with surgery is very high.
Thank you
Any Questions???