peripheral vascular disease surgical presentation

5/20/2018 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

http://www.imagingpathways.health.wa.gov.au/includes/dipmenu/limb_is/summar

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