peripheral vascular disease

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  • Prof. Bo Yu MDVascular Surgery Department ,Huashan HospitalFudan University

    2013.12

  • Peripheral Vascular Disease (PVD) refers to diseases of vessels outside the heart and brain. It's often a narrowing of vessels that carry blood to the legs, arms, stomach or kidneys. * PVD definition is from the American Heart Association

  • Abdominal Aneurysm Aortoiliac Disease Upper Extremity Disease Carotid Artery Disease ClaudicationDeep Vein Thrombosis Diabetic Problems HyperlipidemiaLymphedema

    Mesenteric Ischemia Peripheral Aneurysm Peripheral Arterial DiseasePulmonary Embolism Renovascular Conditions Thoracic Aneurysm Thoracic Outlet Syndrome Varicose Veins Venous Insufficiency

  • Dilation: Aneurysm Stenosis /Obsturction

    Atherosclerosis obliterans (ASO) Thromboangiitis obliterans(TAO) Acute artery emoblism Polyarteritis(Takayasu Disease) Raynauds syndromeInjury of vessel/Arterio-venous fistulaVenous Diseases

  • Abdominal Aneurysm Aortoiliac Disease Upper Extremity Disease Carotid Artery Disease ClaudicationDeep Vein Thrombosis Diabetic Problems HyperlipidemiaLymphedema

    Mesenteric Ischemia Peripheral Aneurysm Arterio-venous fistula Pulmonary Embolism Renovascular Conditions Thoracic Aneurysm Thoracic Outlet Syndrome Varicose Veins Venous Insufficiency

  • NON-MODIFIABLE RISKS:

    Age. The risk of limb loss due to PAD increases with age. People 65 or older are two to three times more likely to have an amputation. Gender. Men with PAD are twice as likely to undergo an amputation as women. Race/ethnicity. Some racial and ethnic groups have a higher risk of amputation (i.e., African Americans, Latino Americans, and Native Americans). This is because they are at increased risk for diabetes and cardiovascular disease. Family history of heart disease. A family history of cardiovascular disease is an indicator for risk at developing PAD.

    MODIFIABLE RISKS:

    Cigarette smoking. Smoking is a major risk factor for PAD. Smokers may have four times therisk of PAD than nonsmokers.Obesity. People withaBody Mass Index (BMI)of 25 or higher are more likely to develop heart disease and stroke even if they have no other risk factors.Diabetes mellitus. Having diabetes puts individuals at greater risk of developing PAD as well as other cardiovascular diseases. Physical inactivity. Physical activityincreases the distance thatpeople with PAD can walk without pain and also helps decrease the risk of heart attack or stroke.Supervised exercise programsare one of the treatments for PAD patients. High blood cholesterol. High cholesterol contributes to the build-up of plaque in the arteries, which can significantly reduce the blood's flow. This condition is known as atherosclerosis.Managing cholesterol levelsis essential to prevent or treat PAD. High blood pressure. When blood pressure remains high, the lining of the artery walls becomes damaged. Many PAD patients also have high blood pressure. High levels of Homocysteine. This is an amino acid found in plasma (blood). Some recent studies show higher levels are associated with PAD.

  • Intermittent Pain

    Postexercise,locomotivePostural change Variation of temperature Persistent Pain (Rest pain) Artery Vein Imflammatory and ischemia and necrosis

  • IAsymptomaticIIIntermittent Claudication

    II a Claudication walking > 200mII bClaudication walking < 200mIIIRest/nocturnal painIVNecrosis/gangrene

  • Venous edemaLymphous edema

  • HeavyAbnomal sensation:numbparalysisneedlingformicationSensory deprivation

  • Up:

    Venous Obstruction Arterio-venous fistulaDown:

    Artery Obstruction

  • Normal and abnormal colorChange of Skin Color after: Finger pressed Locomotive Postual change

  • Artery Pulse :normal to weaken/disappear to enhance Murmur:trill Apperance and texture: flexion,harder,nodus

    Vein varicose ,murmur,etc.

  • Dystrophia skin changeUlcer,gangreneLonger , bigger extremity

  • Apperance:Varicose

    Color:PigmentationTexture:HarderUlcer

  • Gangrene

  • Non-invasiveABIsSegmental limb pressuresLimb plethysmographyExercise testingDoppler & duplex ultrasoundCT angiographyMR angiographyInvasiveContrast arteriography

  • Comparison of ankle pressure to brachial SBP Reproducible, useful for long term surveillanceNormal 0.85-1.2Claudicants 0.5-0.7Critical ischemia < 0.4May be falsely elevated in calcified vessels (DM)

  • Simple, reliable means for diagnosing PAD. Blood pressure measurements are taken at the arms and ankles using a Doppler. The ABI test is simple enough to be performed in any doctor's office. Inexpensive equipment and reimbursable tests.

  • 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.

  • Duplex Scanning = a combination of real-time and Doppler ultrasonographyPurpose: to evaluate arterial and venous disorders noninvasively. The most common application for the examination is to determine the presence of deep vein thrombosis (DVT) in the extremity, usually because of leg swelling.The deep veins are examined every 1-2 cm and gentle pressure is applied with the scan head to demonstrate that the walls of the vein can be easily collapsed. When thrombus is present there is little if any compressibility. The flow patterns are also assessed with Doppler recording. The presence or absence of venous valve insufficiency is assessed with compression maneuvers of the extremity.

    TYPES OF DUPLEX SCANS:Extracranial CerebrovascularAbdominalRenalAortoiliac Mesenteric Arterial Venous Duplex Scan Upper and Lower Extremities

  • Risk factor managementLipid-lowering therapySmoking cessationExercise regimenAntiplatelet therapy - ASA, clopidogrelVasoactive - Cilostazol (Pletal), pentoxyfilline (Trental)

  • Bypass

    Endarterectomy

    PTA/Stenting

    Stenosis vs. Occlusion

    Either

    Stenosis > occlusion

    Stenosis > occlusion

    Length of segment

    Not a factor

    Preferably short

    Preferably short

    Vessel caliber

    > 2 mm

    Preferably > 5-6 mm

    Preferably > 4 mm

    Most suitable anatomic sites

    Aortic arch through distal femoral

    Carotid bifurcation

    Distal abdominal aorta and iliacs

  • GraysAnatomy: The Anatomical Basis of Clinical Practice, 40th edition (2008), Churchill-Livingstone, Elsevier

    *

  • Predilection Sites: Bifurcation of Common Carotid Artery (CCA)Origin of Common Carotid ArteryCarotid SiphonMiddle Cerebral Artery (MCA) and Anterior Cerebral Arteries (ACA)

    Bilateral Lesion is mostly Seen

  • Atherosclerosis , >90%Takayasu Disease, Fibromuscular DysplasiaRare:Trauma, Artery Reversion, Congenital Artery Atresia, Tumors, Inflammation around the artery , Fibrosis after Radiotherapy

  • Stroke is the first cause of disability and death in China, the incidence has increased every year150-200 million new cases in China, the recurrence rate is more of an average annual rate of 7.6%China has 700 million existing patients with cerebrovascular disease, of which about 70% of Ischemic Stroke.2 / 3 of ischemic stroke is caused by Carotid Artery Atherosclerosis Stenosis

  • Carotid plaques mainly caused by cerebral ischemia in two waysSevere stenosis of the carotid artery caused hemodynamic changes, leading to the corresponding parts of the brain hypoperfusion Micro-emboli or plaques in the plaque surface micro-thrombosis leading to cerebral embolism

  • Symptomatic Carotid StenosisBrain ischemic symptoms: Tinnitus, Vertigo, Amaurosis, Blurred vision, Dizziness, Headache, Insomnia, Memory loss, dreams and Ocular ischemic manifestations.TIA (transient ischemic attack): clinical manifestation is one side of limb sensory or motor function disorders, transient monocular blindness, or aphasia, etc., generally lasted only a few minutes, within 24h after the onset of full recovery. Imaging without focal lesions. Ischemic stroke: common clinical symptoms limb sensory disturbances, hemiplegia, aphasia, brain damage, coma and other serious and nervous system with the appropriate signs and imaging features

    Asymptomatic Carotid Stenosis Patients with carotid stenosis without any clinical signs or symptoms

    Asymptomatic Vs Symptomatic 3-41

  • BUS,TCDConvenient and easy to repeatCTA: Accurate and important tool for screeningCTP Assess cerebral ischemia and vascular reserveMRDWI/PWI: Assess indications for thrombolysisMRA: TOF/PC MRA3D-CEMRADSA: Gold Standard

  • Blackshear WM,.,Strandness DE.Stroke 1980; 11:67.

    *

  • *

  • *

  • VR MPR MIP

  • CT Ang