peripheral arterial disease : pad

Peripheral Arterial Disease :PAD

นพ. ธรพล เกาะเทยนนายแพทยชำานาญการพเศษ

ศลยแพทยโรคหวใจ หลอดเลอด และทรวงอก โรงพยาบาลสรรพสทธประสงค อบลราชธาน

Introduction

PAD caused by atherosclerotic occlusion of arteries to legs Prevalence 12% and increases to 20% if persons older than 70 yr. Affects men and women equally pt. with PAD , even absence of Hx of MI or ischemic stroke have same relative risk of death from CVS cause as pt. with Hx of CAD or CVD

Introduction

Rate of death of all causes equal in men and women and is elevated even in asymptomatic pt. Severity of PAD is closely associated with risk of MI , ischemic stroke , and death from vascular cause Lower ABI – greater risk of CVS events Critical leg ischemia – mortality of 25%

RISK FACTOR

Smoking DM HT Hypercholesterolemia

Normal Artery and Artery With Plaque Buildup

PAD in THAILAND

Male 4% Female 8%

Risk Factor Age DM > 12 yrs HT

A Life Threatening Condition

The REACH (Reduction of Atherothrombosis for Continued Health) Registry has expanded mortality associated with PAD

At one year, 19% of the PAD population had experienced either an MI, a stroke or were hospitalised for an atherothrombotic event or had died from CV causes compared to 10% of the CAD population and 7% of CVD population.

PAD vs DM

DM ทำ�ใหเพมคว�มชกของ PAD 2เท�

1.5% ของผปวย DM จะถกตดนว ข�

50% จะถกตดเพม 50% ถกตดอกข�ง ภ�ยใน 2 ป 50% ทถกตดข� เสยชวต ภ�ยใน

5 ป

Clinical Staging of LEAD

Screening for PAD

ABI

Selection of patient high risk

DM

Age 50 years.

Ankle-Brachial Index (ABI)

INTERPRETATION

NORMAL 0.9 -1.30

MILD 0.7-0.89

MODERATE 0.4-0.69

SEVERE < 0.4 POORLY COMPRESSIBLE > 1.3

TREATMENT

งดสบบหร ออกกำาลงกาย ควบคม ความดน (140/90 mmHg) LDH < 100 Medication Endovascular treatment Surgery

ก�รประเมนผปวยทมอ�ก�ร Claudication

ผปวยทมอาการแบบ classic claudication

ตรวจรางกายระบบหลอดเลอด

ตรวจ resting ankle - brachial index (resting ABI)

ABI ≤ 0.90 ABI > 0.90

- Exercise ABI - Toe-brachial index - Segmental pressure measurement - Duplex ultrasound exam.

Confirmation of

PAD diagnosis

Abnormal results

Normal results

No PAD or consider arterial entrapment syndrome

- Risk factors normalization - Pharmacological risk

การรกษาภาวะclaudication

Intervention of PAD

Toe gangrene in a patient with diabetes

AORTO-ILIAC LESIONS

Lesion type

Type A

Type B

Description

* Unilateral or bilateral stenosis of CIA

* Unilateral or bilateral single short (≤3cm) stenosis

of EIA

* Short (≤3cm) stenosis of infrarenal aorta* Unilateral CIA Occlusion

* Single or multiple stenosis totaling 3-10cm. Involving the EIA occlusion not involving the origins of internal iliac of

CFA

AORTO-ILIAC LESIONS

Lesion type

Type C

Type D

Description* Bilateral CIA occlusion

* Bilateral EIA stenosis 3-10cm long not extending into the CFA

* Unilateral EIA stenosis extending tnto the CFA* Unilateral EIA occlusion that involves the

origins of internal iliac and/or CFA* Heavily calcified unilateral EIA occlusion with

or without involvement of origins of internal iliac and/or CFA

* Infra-renal aorto-iliac occlusion* Diffuse disease involving the aorta and both iliac arteries

requiring treatment* Diffuse multiple stenosis involving the unilateral CIA, EIA

and CFA* Unilateral occlusions of both CIA and EIA

* Bilateral occlusion of EIA* Iliac stenosis in patients with AAA requiring treatment and

not amenable to endograft placement or other laesions requiring open aortic or iliac surgery

FEMORAL-POPLITEAL LESIONS

Lesion type

Type A

Type B

Description

* Single stenosis ≤10cm in length

* Single occlusion ≤5cm in length

* Multiple lesions (stenoses or occlusion),each ≤5cm

* Single stenosis or occlusion ≤15cm not involving the infra geniculate popliteal artery

* Single or multiple lesions in the absence of continuous tibial vessels to improve inflow for a distal bypass

* Heavily calcified occlusion ≤5cm inlength* Single popliteal stenosis

FEMORAL-POPLITEAL LESIONS

Lesion type

Type C

Type D

Description

* Multiple stenoses or occlusions totaling >15cm with or without

heavy calcifications* Recurrent stenoses or occlusion

that need treatment after two endovascular interventions

* Chronic total occlusion of CFA of SFA (>20cm, involving

the popliteal artery)* Chronic total occlusion of popliteal

artery and proximal trifurcation vessels

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