Transcript Peripheral Vascular Disease

VASCULAR DISEASES AND
SURGERY
Khaled Daradka
Faculty of Medicine / University of Jordan
General Surgery Department
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Peripheral Arterial Disease
Definition:
• Also known as PVD.
• 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
PAD
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.
Introduction
Atherosclerotic changes
Normal Artery
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Diseased Artery
Introduction
Disease evolution
• Claudication
• Rest pain
• Ulceration
• Gangrene
• Limb loss
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Risk Factors
• Tobacco abuse
• Diabetes
• Hypercholesterolemia
• Hypertension
• Obesity
• Sedentary lifestyle
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Diagnosis
• Patient history
• Physical examination
• Laboratory values
• Noninvasive vascular studies
• Angiography
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Patient History
• Risk factors
• Exercise-induced symptoms
• Rest pain
• Ulceration
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Patient History
Historical clues to the diagnosis of
intermittent claudication
Variable Symptom Complex
Symptoms in the legs that are provoked
by walking and relieved by rest
Pain
Tightness
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Aches
Soreness
Tiredness
Weakness
Numbness
Patient History
Is it vascular limb pain?
Historical
Clue
Vascular
Etiology
Neurogenic
Etiology
Onset
Predictable
Variable
Only with
walking?
Yes
No
Yes
Variable
Variable
Variable
Relief with
stopping or
standing?
Absent pedal
pulses at rest
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Patient History
Differential diagnosis of PAD
• Intermittent claudication
– Atherosclerosis
– Non-atherosclerotic


Buerger’s
Vasculitis
• Neurogenic causes
– Lumbar canal stenosis
– Peripheral neuropathy
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• Venous claudication
• Musculoskeletal causes
– Arthritis
– Bursitis
– Tendonitis
• Pediatric causes
– Plantar fasciitis
Physical Examination
• Pulses
• Bruits
• Ankle-Brachial Index (ABI)
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Physical Examination
Ankle-Brachial Index
• Simple, painless, accurate, highly
reproducible examination
• Clinically useful
– Identifies patients with PAD
– Major indicator of premature MI, CVA, mortality
• Indications
– Any patient with suspicion for PAD
– Any patient at risk of PAD


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Age 50 or greater with history of DM or tobacco use
Age 70 or greater regardless of risk factors
Physical Examination
Ankle-Brachial Index
• How to perform
– Patient resting supine
for 5-10 minutes
– Continuous wave,
hand-held Doppler
– Measure systolic BP in
both arms

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Left Arm
Pressure:
Pressure:
Pressure:
Higher value is
DENOMINATOR of ABI
– Measure systolic BP in
DP and PT

Right Arm
Pressure:
Higher value is
NUMERATOR of ABI
PT
PT
DP
DP
Physical Examination
ABI = Ankle Systolic Pressure
Brachial Systolic Pressure
>0.9 = Normal
>0.4-0.9 = Moderate disease
<0.4 = Severe disease
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Physical Examination
Interpretation and limitations of ABI
ABI Interpretation
Above 0.90 — Normal
0.71-0.90 — Mild
Obstruction
0.41-0.70 — Moderate
Obstruction
0.00-0.40 — Severe
Obstruction
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Two Main Limitations
Calcified ankle vessels
result in artificially
“normal” ABI (DM, RF)
Normal ABI in patient
with Aortoiliac Disease—
only becomes abnormal
with exercise testing
Noninvasive Vascular Studies
• Vascular ultrasound
• CT angiography
• Magnetic resonance angiography
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Noninvasive Vascular Studies
Post-intervention iliac imaging
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Noninvasive Vascular Studies
MRA in PAD
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Noninvasive Vascular Studies
Left
SFA
Stenosis
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Right
Fem-Pop
BPG
CTA
DSA
(Pre-PTA)
Invasive Vascular Studies
Diagnosis−angiography
Normal
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Abnormal
Treatment
• Risk factor modification
• Medical management
• Minimally invasive techniques
• Surgical intervention
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Goals
PAD Therapeutic Goals
Improve functional
status and quality
of life
Identify and treat
systemic
atherosclerosis
Preserve the limb
Prevent
progression of
atherosclerosis
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Risk Factor Modification
• Tobacco cessation
• Exercise
• Weight reduction
• Pharmacologic intervention
– Hypercholesterolemia
– Hypertension
– Diabetes
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Minimally Invasive Techniques
• Percutaneous transluminal angioplasty (PTA)
• Stenting
• Thrombolysis
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Minimally Invasive Techniques
Guidewire placement
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Minimally Invasive Techniques
Guidewire advanced past lesion
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Minimally Invasive Techniques
Balloon dilatation
Percutaneous Transluminal Angioplasty
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Minimally Invasive Techniques
Stent expansion by a balloon
catheter over a guidewire
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Minimally Invasive Techniques
Post-PTA/stent placement
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Minimally Invasive Techniques
Thrombolysis
Post-thrombolytic infusion
revealing stenosis
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Case Study #1
Aorto/iliac disease
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Case Study #1
Aorto/iliac disease
pre-PTA stenting
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Aorto/iliac disease
post-PTA stenting
Case Study #2
Pre-thrombolysis
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Post-thrombolysis
Case Study #2
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Angioplasty
post-thrombolysis
Surgical Intervention
• Bypass grafts
• Amputation
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Surgical Intervention
• Bypass grafts
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What are the features of an
acute ischemic limb?
REMEMBER THE 6 P’S:
1. PAIN
1. PALLOR
1. PULSELESNESS
1. PERISHING COLD (POIKILOTHERMIA)
1. PARASTHESIAS
1. PARALYSIS
Venous Disease (CVI)
Simple spider veins to complex
dermal sclerosis and ulcer
formations.
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Venous Valves
Presence of
valves prevent
reflux
Pressure
generated in
deep veins by
the calf
muscles are
prevented
from
transmission
to superficial
veins by the
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valves
Venous Pathology
Obstruction
Reflux and/or incompetence
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Venous Obstruction
 As a result of DVT or superficial
phlebitis
 As a result of extrinsic compression
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Venous Reflux
Spider Veins
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Varicose Veins
Venous Reflux
Edema
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Venous Statis w/wo Ulcer
Venous History of Patient
Pain
Edema
Ulcers
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Physical Exam of Patient
Supine and Standing
Objective findings of spider or
varicose veins
Skin changes (hyperpigmentation
to atrophic blanch)
Edema (typically pitting)
Ulcer formation
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Diagnostic Testing
Duplex Scan
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Treatment
Medical Management
1. Leg elevation
2. Compression therapy
3. Exercise
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Interventional Therapy
Sclerotherapy
Endovenous Ablation
Surgical
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Sclerotherapy
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Similarities and Differences
Arterial symptoms produced by
exercise and relieved by resting
Venous symptoms worsened by
standing and improved by exercise and
leg elevation
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THANK YOU
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