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 depe