OPP Fellow DidacticsOnlinecom Peripheral Vascular Disease 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 ID: 1035928
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1. Rob Kawa, OMS IIIPredoctoral OPP FellowDidacticsOnline.comPeripheral Vascular Disease
2. 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
3. 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
4. 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!
5. 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)AtherosclerosisArteriolosclerosisLets Talk About The Terms
6. Atherosclerosis-Endothelial cell damage of muscular and elastic arteriesCauses of endothelial damage include smoking, hypertension, homocysteine, and LDL.Cell response to endothelial injuryMacrophage and platelets adhere to damaged endotheliumReleased cytokines cause hyperplasia of medial smooth muscle cells.Smooth muscle cells migrate to the tunica intimaCholesterol enters muscle cells and macrophages (foam cells)Smooth muscle cells release cytokines that produce extracellular matrixDevelopment of fibrous cap (plaque)Components include smooth muscle, foam cells, inflammatory cells, and ECMCap overlies a necrotic centerDisrupted plaque may extrude underlying necrotic material leading to vessel thrombosisFibrous plaque becomes dystrophically calcified and ulceratedSerum 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 LDLLets Talk About The Terms
7. AtherosclerosisPopular sites for atherosclerosis in descending orderAbdominal aortaCoronary arteryPopliteal arteryInternal carotid arteryComplications of atherosclerosisVessel weakness (aneurysm)Vessel thrombosisAcute MIStrokeSmall bowel infarctionHypertension (renal artery may activate RAAS)Cerebral atrophy (block circle of willis or internal carotids)Peripheral vascular diseaseIncreased risk of gangrenePain when walking (claudication)Lets Talk About The Terms
8. ArteriolosclerosisHardening of arteriolesHyaline 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” appearanceLets Talk About The Terms
9. A common disorder that usually affects men over 50Higher risk with history of:Abnormal cholesterolDiabetesHigh blood pressure (hypertension)Heart disease (coronary artery disease)Smoking Kidney disease involving hemodialysisStroke (cerebrovascular disease)Peripheral Vascular Disease
10. 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 nightSymptoms
11. Signs: What can the healthcare provider find on examination?Arterial bruits – a whooshing sound heard with the stethoscope over an affected arteryDecreased blood pressure in the affected limbLoss of hair on the legs or feetDecreased or absent pulses in the limb
12. 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 toenailsSigns in severe disease
13. Blood test – A blood test may show high cholesterol or diabetesAngiography of the arteries in the legs (arteriography)Blood pressure measurements in the arms and legs for comparisonDoppler ultrasonography Magnetic resonance angiography or CT angiographyPlethysmography – Tests a change in volume in the body, organs, or vessels.Tests
14. 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
15. 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 relieversTreatment
16. 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
17. TreatmentSurgery/ProceduresAngioplasty and stent placement – This procedure is similar to the technique used to open coronary arteries but is done in the affected leg.
18. TreatmentSurgery/Procedures:Arterial bypass surgery for vessels with significant blockage. Lower extremity vessels and the abdominal aorta are common sites.
19. TreatmentSurgery/Procedures:Endarterectomy – The surgical removal of plaque in a blocked vesselLimb Amputation – In severe cases where tissue becomes necrotic and gangrene is a concern.
20. TreatmentAn Osteopathic Consideration:MFR and Fascial Ligamentous ReleaseLASDiaphragmsLymphaticsFluid DynamicsMuscle Energy?
21. 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 ElsevierWolfsthal S. (2008) NMS Medicine Sixth Edition Baltimore: Lippincott Williams and WilkinsReferences