peripheral vascular disease surgical presentation
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Peripheral Vascular
DiseaseAcute & Chronic Limb Ischemia
Lipi Shukla
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What is PVD?Definition:
Also known as PAD or PAOD.
Occlusive disease of the arteries of
the lower extremity.
Most common cause:
o Atherothrombosis
o Others: arteritis, aneurysm +embolism.
Has both ACUTE and CHRONIC Px
Pathophysiology:
Arterial narrowing Decreased
blood flow = Pain
Pain results from an imbalance
between supply and demand of
blood flow that fails to satisfy
ongoing metabolic requirements.
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The Facts:1. The prevalence: >55 years is 10%25%
2. 70%80% of affected individuals are asymptomatic
3. Pts with PVD alone have the same relative risk of death from
cardiovascular causes as those CAD or CVD
1. PVD pts = 4X more likely to die within 10years than pts withoutthe disease.
2. The anklebrachial pressure index (ABPI) is a simple, non-invasive
bedside tool for diagnosing PAD an ABPI
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Risk Factors:Typical Patient:
Smoker (2.5-3x)
Diabetic (3-4x) Hypertension
Hx of Hypercholesterolemia/AF/IHD/CVA
Age 70 years.
Age 50 - 69 years with a history of smoking or diabetes.
Age 40 - 49 with diabetes and at least one other risk factor for
atherosclerosis.
Leg symptoms suggestive of claudication with exertion orischemic pain at rest.
Abnormal lower extremity pulse examination.
Known atherosclerosis at other sites (eg, coronary, carotid, or
renal artery disease).
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Chronic PVD History:
3. Critical Stenosis = >60%, impending acute ischemic limb:
- rest pain
- ischemic ulceration
- gangrene
2. Other Symptom/Signs: A burning or aching pain in the feet (especially at night)
Cold skin/feet
Increased occurrence of infection
Non-healing Ulcers
Asymptomatic
1. INTERMITTENT CLAUDICATION
Derived from the Latin word to limp Reproducible pain on exercise which is relieved by rest
Pain can also be reproduced by elevating the leg
my legs get sore at night and feel better when I hang them over
the edge of the bed
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Thigh Claudication
60% Upper 2/3 Calf Claudication
Lower 1/3 Calf Claudication
Foot Claudication
30% Buttock & Hip Claudication
ImpotenceLeriches Syndrome
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DDx of Leg Pain1. Vascular
a) DVT (as for risk factors)
b) PVD (claudication)
2. Neurospinal
a) Disc Disease
b) Spinal Stenosis (Pseudoclaudication)
3. Neuropathic
a) Diabetes
b) Chronic EtOH abuse
4. Musculoskeletal
a) OA (variation with weather + time of day)
b) Chronic compartment syndrome
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Physical Examination:Examination: What do to:
Inspection
Expose the skin
and look for:
Thick Shiny Skin Hair Loss
Brittle Nails
Colour Changes (pallor)
Ulcers
Muscle Wasting
Palpation Temperature (cool, bilateral/unilateral) Pulses: ?Regular, ?AAA
Capillary Refill
Sensation/Movement
Auscultation Femoral Bruits
Ankle Brachial
Index (ABI)
= Systolic BP in ankle
Systolic BP in brachial artery
Buergers Test Elevate the leg to 45- and look for pallor
Place the leg in a dependent position 90& look
for a red flushed foot before returning to normal
Pallor at
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Pictures:
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What does the ABI mean?
ABI Clinical Correlation
>0.9 Normal Limb
0.5-0.9 Intermittent Claudication
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Investigations:
NON INVASIVE:
Duplex Ultrasoundnormal is triphasic biphasic monophasic absent
BLOOD TESTS:
1. FBE/EUC/Homocysteine Levels
2. Coagulation Studies
3. Fasting Lipids and Fasting Glucose
4. HBA1C
WHEN TO IMAGE:
1. To image = to intervene2. Pts with disabling symptoms where revascularisation is considered
3. To accurately depict anatomy of stenosis and plan for PCI or Surgery
4. Sometimes in pts with discrepancy in hx and clinical findings
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ANGIOGRAPHY:
Non-invasive:
CT Angiogram
MR Angiogram
Invasive:
Digital Subtraction Angiography
Gold Standard
Intervention at the same time
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Tardus et parvus = small amplitude + slow rising pulse
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CT Angiography Digital Subtraction Angiography
Value of angiography
Localizes the obstruction
Visualize the arterial tree & distal
run-off
Can diagnose an embolus:
Sharp cutoff, reversed meniscus or clotsilhouette
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Treatment:1. RISK FACTOR MODIFICATION:
a) Smoking Cessation
b) Rigorous BSL control
c) BP reduction
d) Lipid Lowering Therapy
3. MEDICAL MANAGEMENT:a) Antiplatelet therapy e.g.
Aspirin/Clopidogrel
b) Phosphodiesterase Inhibitor e.g.
Cilostazol
c) Foot Care
2. EXERCISE:a) Claudication exercise
rehabilitation program
b) 45-60mins 3x weekly for 12 weeks
c) 6 months later +6.5mins walking
time (before pain)
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PCI/Surgery:Indications/Considerations:
Poor response to exercise rehabilitation + pharmacologic therapy.
Significantly disabled by claudication, poor QOLThe patient is able to benefit from an improvement in claudication
The individuals anticipated natural hx and prognosis
Morphology of the lesion (low risk + high probabilty of operation
success)
PCI:
Angioplasty and Stenting
Should be offered first to patients with significant comorbidities who are
not expected to live more than 1-2 years
Bypass Surgery:Reverse the saphenous vein for femoro-popliteal bypass
Synthetic prosthesis for aorto-iliac or ilio-femoral bypass
Others = iliac endarterectomy & thrombolysis
Current Cochrane review = not enough evidence for Bypass>PCI
Amputation:Last Resort
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Some Bypass Options:
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Mr. X presents with an acutely
painful leg:
You have had a busy day in the ED and the next
patient to see is:
Mr. X a 60 yr old gentleman with a very painful leg.
He tells you that he woke up this morning with an
excruciating pain in his left leg and has never felt
this pain before.
? Embolism (AF/Recent Infarct/Anuerysm)
? Thrombosis of native vessel or graft
?Trauma
MUST RULE OUT ACUTE LIMB ISCHEMIA
Wh h f f
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What are the features of an
acute ischemic limb?
REMEMBER THE 6 PS:
1. PAIN
1. PALLOR
1. PULSELESNESS
1. PERISHING COLD (POIKILOTHERMIA)
1. PARASTHESIAS
1. PARALYSIS
Fixedmottling &
cyanosis
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History & Exam FindingsFurther Hx: Smokes 20cigs/day for 30 years
4 months of leg cramps in BOTH legs 2-3 weeks of intermittent chest palpitations
Has not seen a Dr. in the last month
Examination:
Inspection:o LLL: below the knee is pale/cool
Palpation:
o Irregularly irregular pulse
o LLL Capillary return is sluggish
o No pulses palpable below L femoral artery
o All pulses palpable but appear reduced in R lego Normal Sensation + Movement bilaterally
Impression?60yo male with a L Acute Ischemic limb on the background of heavy
smoking, untreated AF and symptomatic PVD.
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What will you do now?
1. CALL THE VASCULAR REGISTRAR
2. ORDER INVESTIGATIONS
a) FBE
b) EUC
c) Coagulation Studiesd) Group and Hold
e) 12 Lead ECG
f) Chest XR
3. INITATE ACUTE MANAGEMENT:
a) Analgesiab) Commence IV heparin
c) Call Radiology for Angiography if limb still viable
d) Discuss with registrar:
i) Thrombotic cause ?cathetar induced thrombolysis
ii) Embolic cause ?embolectomy
iii) All other measures not possibleBypass/Amputation
Simple measures to improve
existing perfusion:
Keep the foot dependant
Avoid pressure over the heel
Avoid extremes of temperature(cold induces vasospasm)
Maximum tissue oxygenation
(oxygen inhalation)
Correct hypotension
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Mr. Xs Complication- Angiogram is done in radiology
- Shows acute thrombosis of L popliteal artery
- Cathetar induced urokinase and heparin infusion is started
. 3-4 hours later
-Severe calf pain in the reperfused limb
-All pulses are present-Leg is swollen, tense and +++ tender
REPERFUSION INJURY!
-Restored blood flow can lead to unwanted local + systemic effects
1) Washout =
oMetabolic Acidosis
oHyperkalemia
oARF (myoglobinuria)
oNon-cardiac APO
2) Compartment Syndrome =
oMay need fasciotomy
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Learning Outcomes1. Risk factors for PVD
2. Recognise signs and symptoms of chronic ischemia of the lower limbs
3. Differential diagnosis for leg pain
4. Examine a chronic ischemic limb
5. Understand medical/surgical of management of PVD
6. Recognise an acute ischemic limb
7. Know it is important to call the vascular registrar ASAP
8. Know what investigations to order in the ED
9. Be aware of the manifestations of reperfusion injury
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Questions?
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References:Uptodate Articles:
- Clinical features, diagnosis & natural history of lower extremity PAD- Treatment of chronic critical limb ischemia
- Indications for surgery in the patient with lower extremity claudication
Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the
Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl S:S5
McDaniel MD, Cronenwett JL. Basic data related to the natural history ofintermittent claudication. Ann Vasc Surg 1989; 3:273.
Lane DA, Lip GYH. Treatment of hypertension in peripheral arterial disease.
Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD003075. DOI:
10.1002/14651858.CD003075.pub2
Murabito JM, Evans JC, Nieto K, et al. Prevalence and clinical correlates of
peripheral arterial disease in the Framingham Offspring Study. Am Heart J 2002;143:961
Peripheral arterial disease: prognostic significance and prevention of
atherothrombotic complicationsPaul E Norman, John W Eikelboom and Graeme J
HankeyMJA 2004; 181 (3): 150-154
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