rob kawa, oms iii predoctoral opp fellow didacticsonline.com
TRANSCRIPT
Peripheral vascular disease (PVD) can really be a vascular pathology of either the veins or arteries.
PVD is also known as peripheral artery disease (PAD) because it is generally thought of as a disease of the blood vessels in which narrowing and hardening of the arteries occur.
The most common areas affected are the legs and feet.
Peripheral Vacular Disease
Arteriosclerosis is “the hardening of the arteries” and is the process of fat build up on the walls of the arteries in the form of plaques.
The artery becomes narrow, the walls become stiff, and together this blocks the dilation of arteries when there is increased demand for blood and oxygen in working tissues.
As a result, your legs can not receive blood when walking or running and pain develops. Eventually , due to disease progression, there may not be enough blood available during rest.
Arteriosclerosis
Why are there so many terms that all sound the same? (arteriosclerosis, atherosclerosis, arteriolosclerosis)
Where did the plaque come from?
Lets Back Up A Minute!
Arteriosclerosis-A broad term describing thickening and loss of
elasticity of arterial walls. Three main types:
Medial calcification which is dystrophic calcification and of no clinical concern unless associated with atherosclerosis (Ex: calcification in uterine arteries)
AtherosclerosisArteriolosclerosis
Lets Talk About The Terms
Atherosclerosis- Endothelial cell damage of muscular and elastic arteries Causes of endothelial damage include smoking, hypertension, homocysteine, and
LDL. Cell response to endothelial injury
Macrophage and platelets adhere to damaged endothelium Released cytokines cause hyperplasia of medial smooth muscle cells. Smooth muscle cells migrate to the tunica intima Cholesterol enters muscle cells and macrophages (foam cells) Smooth muscle cells release cytokines that produce extracellular matrix
Development of fibrous cap (plaque) Components include smooth muscle, foam cells, inflammatory cells, and ECM Cap overlies a necrotic center Disrupted plaque may extrude underlying necrotic material leading to vessel thrombosis Fibrous plaque becomes dystrophically calcified and ulcerated
Serum C-reactive peptide (CRP) is increased in patients with disrupted inflammatory plaques. Plaques rupture, produce vessel thrombosis, and cause acute MI. CRP may be a stronger predictor of cardiovascular events than LDL
Lets Talk About The Terms
Atherosclerosis Popular sites for atherosclerosis in descending order
Abdominal aorta Coronary artery Popliteal artery Internal carotid artery
Complications of atherosclerosis Vessel weakness (aneurysm) Vessel thrombosis
Acute MI Stroke Small bowel infarction
Hypertension (renal artery may activate RAAS) Cerebral atrophy (block circle of willis or internal carotids) Peripheral vascular disease
Increased risk of gangrene Pain when walking (claudication)
Lets Talk About The Terms
ArteriolosclerosisHardening of arterioles
Hyaline arteriolosclerosis: Increased protein deposited in the vessel walls occludes the lumen. Associated conditions include diabetes mellitus and hypertension.
Hyperplastic arteriolosclerosis: Renal arteriole effect from an acute increase in blood
pressure (Ex: malignant hypertension)Smooth muslce cell hyperplasia and basement
membrane duplicationArterioles have an “onion skin” appearance
Lets Talk About The Terms
A common disorder that usually affects men over 50
Higher risk with history of:Abnormal cholesterolDiabetesHigh blood pressure
(hypertension)Heart disease
(coronary artery disease)Smoking Kidney disease involving hemodialysisStroke (cerebrovascular disease)
Peripheral Vascular Disease
Pain, achiness, burning, fatigue, discomfort of the calves, feet, or thighs. These symptoms usually appear with exercise and go away with rest (Claudication).
Numbness, pale skin, cool to the touchSevere disease:
ImpotenceUlcers that do not healWorsening pain with leg elevationLeg pain at night
Symptoms
Signs: What can the healthcare provider find on examination?Arterial bruits – a
whooshing sound heard with the stethoscope over an affected artery
Decreased blood pressure in the affected limb
Loss of hair on the legs or feet
Decreased or absent pulses in the limb
Calf muscles that shrink Hair loss over the toes and feetPainful non-bleeding ulcers (usually black)
that are slow to healPale skin or a blue appearance
(cyanosis)Shiny tight skinThick toenails
Signs in severe disease
Blood test – A blood test may show high cholesterol or diabetes
Angiography of the arteries in the legs (arteriography)
Blood pressure measurements in the arms and legs for comparison
Doppler ultrasonography Magnetic resonance angiography or CT
angiographyPlethysmography – Tests a change in volume
in the body, organs, or vessels.
Tests
Self-care:Balance exercise and rest: If you exercise to the
point of pain and follow with rest over time you can improve circulation as new, small (collateral) blood vessels form.
Stop smokingReduce your weightKeep your blood pressure under controlTake particular care with foot health, especially if
diabeticMonitor blood sugarIf your cholesterol is high eat a low cholesterol, low
fat diet.
Treatment
Medications:Aspirin or a medication called clopidogrel
(plavix) keep your blood from clotting in the arteries by affecting platelets.
Cilostazol is also an anti-platelet medication but works to dilate arteries in moderate to severe cases where surgery is not an option. The dilated arteries can improve blood flow to areas of claudication.
Cholesterol medicationsPain relievers
Treatment
Prostanoids for treating people with severe peripheral arterial disease of the legs
First published: January 20, 2010; This version published: 2010. Review content assessed as up-to-date: October 28, 2009.
The question is whether specific drugs such as prostanoids reduce mortality and progression of the disease, including amputations, more than placebo or other treatments. This review of 20 trials did not find any evidence that prostanoids provided long‐term benefit.
Prostanoids seem to have efficacy regarding rest‐pain relief and ulcer healing.
Treatment Research
TreatmentSurgery/Procedures
Angioplasty and stent placement – This procedure is similar to the technique used to open coronary arteries but is done in the affected leg.
TreatmentSurgery/
Procedures:Arterial bypass
surgery for vessels with significant blockage. Lower extremity vessels and the abdominal aorta are common sites.
TreatmentSurgery/Procedures:
Endarterectomy – The surgical removal of plaque in a blocked vessel
Limb Amputation – In severe cases where tissue becomes necrotic and gangrene is a concern.
TreatmentAn Osteopathic
Consideration:MFR and Fascial
Ligamentous Release
LASDiaphragmsLymphaticsFluid DynamicsMuscle Energy?
Websites: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001224/ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001223/ http://www.fashion-writings.com/peripheral-vascular-disease-test/ http://www.endovascularsurgery.com/patient-vascular.html http://www.acu-heal.com/vascular-progress.html http://www.vascularweb.org/vascularhealth/pages/peripheral-artery-disease-(-
pad-)-.aspx
http://jama.ama-assn.org/content/291/7/809.extract http://www.alexkolesar.com/diabetic-foot/peripheral-vascular-disease.html http://www.podiatricresidency.com/insight/insight9.html http://www.tobaccolabels.ca/gallery/hongkong/hongko~9 http://www.osteoworks.com.au/1-services/osteopathy-brisbane
Books: Goljan E. (2010) Rapid Review Pathology Third Edition
Philadelphia: Mosby Elsevier Wolfsthal S. (2008) NMS Medicine Sixth Edition
Baltimore: Lippincott Williams and Wilkins
References