peripheral vascular disease · 2015-07-07 · 전남대학교병원순환기내과 김계훈...

전남대학교병원 순환기내과

김 계 훈

Peripheral Vascular Disease

혈관연구회 연수강좌 - 2007

CC Cramping pain in left calf at walking (D: 6 Mo)

PH HT, DM: medication for 10 years

SH Smoking : 50 PYs, Current smoker

PI Progressively worsened over the past 6 months

Interfering with his ability to perform his job

Should rest after walking half a block

Case 1: 서 O O (69/M)

병력상 이 환자에서 가장 의심되는 질환은?

1) Spinal stenosis

2) Peripheral vascular disease of the lower extremity

3) Compartment syndrome

4) Arthritis


D/D of Claudication from Pseudoclaudication

VS BP 150/95 mmHg PR 92/min

BT 36.4℃ RR 20/min

PE Bruit on left inguinal area

Right Left

Brachial & radial pulse Normal Normal

Femoral pulse Normal Decreased

Popliteal pulse Decreased Decreased

Dorsalis pulse Decreased Absent


Lab findings CBC: WNL LFT & RFS: WNL

UA: microalbuminuria (+)

Lipid profiles

TC: 256 mg/dL

TG: 210 mg/dL

HDLC: 38 mg/dL

LDLC: 180 mg/dL


▶ Broadly encompasses the vascular diseases

▶ Caused primarily by atherosclerosis and thromboembolic

pathophysiologic processes

▶ Alter the normal structure and function of the aorta, its visceral

branches, and the arteries of the lower extremities

▶ Denote stenotic, occlusive, and aneurysmal diseases of the aorta

and its branch arteries, exclusive of the coronary arteries

Definition of PAD

ACC/AHA guideline 2005. JACC 2006

Natural History of PAD

Diagnostic Workup

• Carefully history taking

• D/D from pseudoclaudication

Examined with shoes

and socks off

With attention to pulses,

hair loss, skin color,

trophic skin changes

이 환자의 진단을 위해 시행할 initial screening test로 적절한 것은?

1) Lumbar CT or MRI

2) Duplex ultrasound

3) CT angiography of the lower extremities

4) Ankle-brachial index (ABI)

Diagnostic Workup

Diagnostic Workup

Diagnostic Workup: ABI


▶ Initial screening test of PAD

▶ ≤ 0.9 : confirm the diagnosis of PAD

▶ Normal resting ABI, abnormal post-exercise ABI

: toe raise, standing flat-footed and raising the heels off the

ground repeatedly, or post treadmill

=> large vessel inflow disease of distal aorta or iliac artery

PAD의 anatomic location과 significant stenosis의 여부 평가를

위해 다음으로 시행 할 imaging study는?

1) CT angiography

2) MR angiography

3) Conventional contrast angiography

Diagnostic Workup: Imaging Study

Diagnostic Workup: Imaging Study

Case 1: CT Angiography

이 환자의 시술이나 수술 전후로 시행할 치료 방침으로 적절한 것은?

1) Statin을 사용하여 LDLC를 70 mg/dL 이하로 낮춘다

2) 항고혈압제를 사용하여 혈압을 140/90 mmHg 이하로 유지한다

3) 항혈소판제로 aspirin이나 clopidogrel을 투여한다

4) 혈류 개선을 위해 oral vasodilator prostaglandins를 투여한다

5) Claudication 증상의 개선을 위해 cilostazol을 투여한다

Treatment of PAD

▶ Risk factor modification

▶ Exercise program

▶ Antiplatelet theraphy

▶ Revascularization

Treatment of PAD

▶ Target goal of LDLC

: Less than 100 mg/dL (I)

: Less than 70 mg/dL in very high risk patients (IIa)

▶ Very high risk in patients with established PAD

: Multiple major risk factors (especially, DM)

: Severe and poorly controlled risk factors (especially, smoking)

: Multiple risk factors of metabolic syndromes

: Individuals with acute coronary syndromes

CV Risk Reduction: Lipid Lowering Therapy


▶ Target goal of BP (I)

: Less than 140/90 mmHg in nondiabetics

: Less than 130/80 mmHg in diabetics and chronic renal disease

▶ Beta adrenergic blocking agents (I)

: Not contraindicated in patients with PAD

: Do not adversely affect walking capacity

: Reduce the risk of MI and death in CAD

▶ ACE inhibitors (IIa)

: Reasonable for symptomatic patients with PAD

: To reduce the risk of adverse cardiovascular events

CV Risk Reduction: Antihypertensives


▶ Control of DM

: Reduce the HgbA1C to less than 7% (IIa)

: To reduce microvascular complications

: Potentially improve CV outcomes

▶ Smoking cessation (I)

▶ Homocysteine lowering drugs (folic acid and Vitamin B12)

: Not well established (IIb)

: To reduce the risk of adverse cardiovascular events


CV Risk Reduction: Others


Claudication Management: Exercise Program

▶Warm-up and cool down period

of 5-10 min each

▶Types of exercise

: Treadmill and track walking

▶Intensity

: Set to a grade and speed that

elicits claudication symptoms

within 3 to 5 minutes

Claudication Management: Medications

Revascularization (Endovascular or Surgical)

Case 1: Percutaneous Transluminal Angioplasty

▶ ABI within 1 week after PTA

▶ Re-evaluated at 3 month intervals for 1st year

: History, P/E, ABI

▶ Should be performed in the immediate post-PTA period at

intervals for at least 2 years


CV Risk Reduction: Surveillance Program

이 환자의 향후 follow-up은 어떻게 하시겠습니까?

Post-stenting ABI

CC Left leg pain and color change

PH HT: medication for 8 years

SH Smoking : None

PI 1달 전부터 left leg pain 있어 인근 병원에서 치료했으나 호전

없었음. 1주전 신경외과에서 MRI상 HNP(L4-5)로 진단 후 수술 예정.

2일전부터 leg pain이 갑자기 심해지고 left foot에 skin color

change 및 ulcerative lesion 발생되어 전원

Case 2: 심 O O (66/F)

VS BP 140/90 mmHg PR 80/min

BT 36.4℃ RR 20/min

PE Color change, paresthesia, decreased sensation, and

ulcerative skin lesion on the left lower leg (more than ankle)

Right Left

Brachial & radial pulse Normal Normal

Femoral pulse Normal Normal

Popliteal pulse Normal Absent

Dorsalis pulse Normal Absent


CBC

WBC 14,700 /mm3

Hgb 14.9 g /dL

PLT 189 x 103 /mm3

LFT

AST 40 U/L

ALT 55 U/L

RFS and electrolytes

BUN 35.1 mg/dL

Cr 1.3 mg/dL

Na/K/Cl 132/3.5/97

Acute phase reactant

CRP 5.7 mg/dL

Lipid profiles

TC 139 mg/dL

TG 105 mg/dL

HDLC 39 mg/dL

LDLC 80 mg/dL

Glucose 210 mg/dL

HgbA1C 8.7%

Case 2: Laboratory Findings

병력상 이 환자에서 가장 의심되는 질환은?

Acute limb ischemia (ALI)


이 환자의 ALI의 심한 정도 (clinical categories)는?

1) Viable

2) Threatened marginally

3) Threatened immediately

4) Irreversible

Acute Limb Ischemia: Clinical Categories


이 환자의 치료 방침을 결정하기 위해 고려해야 할 사항은?

1) Site and extent of occlusion

2) Embolus versus thrombus

3) Duration of ischemia

4) Patient co-morbidities

5) Contraindications to thrombolysis or surgery


Case 2: Percutaneous Transluminal Angioplasty

Case 2: FU Angiography after 3 Days

▶ Initial assessment : ABI

▶ Imaging study (duplex US, CTA, MRA, DSA)

▶ Risk factor assessment and modification

: Smoking cessation, dietary adjustment, lipid, BP, and glucose control

▶ Exercise program

▶ Anti-platelet therapy: aspirin or clopidogrel

▶ Cilostazol

▶ Revascularization (endovascular or surgical)

▶ Regular follow-up

Summary (I): Chronic PAD

Summary (II): Acute Limb Ischemia

Rapid or sudden decrease in limb perfusion

Threatens tissue viability

History and physical examination

Determine time of onset of symptoms

Emergent assessment of severity of ischemia:

Loss of pulses

Loss of motor and sensory function

Vascular lab assessment

ABI, TBI

Duplex ultrasound

Summary (II): Acute Limb Ischemia

ABI, TBI, or duplex ultrasound

No or minimal PAD Severe PAD documented

: ABI less than 0.4

: Flat PVR waveform

: Absent pedal flowConsider

: Atheroembolism

: Thromboembolism

: Phlegmasia cerulia dolens

Evaluation of source

: ECG or Holter

: TTE or TEE

: Abdominal US, MRA, or CTA

Treatment of ALI

: Immediate anticoagulation

: Assess etiology and severity

: Revascularization (thrombolysis,

endovascular, or surgical)

peripheral vascular disease · 2015-07-07 · 전남대학교병원순환기내과 김계훈...

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