Peripheral artery diseases - PowerPoint Presentation

Slide1

Peripheral artery diseases

Jakub

Honěk

Kardiologická klinika

2.LF UK a FN Motol

Slide2

Diagnostic methodsPeripheral artery diseases

(limb ischemia)Chronic PADAcute limb ischemiaCompressive syndromesVasospastic disordersSpecific localization of PADVasculitis

Slide3

Diagnostic methodsMedical

history, physical examinationMeasurement of peripheral arterial pressure (+ ABI, TBI) at rest, after exercise

P

lethysmographic

examination

TcpO2

Teadmill

walking

test

Color

duplex

sonography

X-

ray

based

methods

- DSA

, CTA, MRA

Slide4

Peripheral BP (mmHg

)

ankle >100…, 50-100 … (claudication), <50 … (critical ischemia)toe

< 30 …

 (

critical

ischemia)

ABI

TBI

> 1,25

mediokalcinosis

0,9- 1,25

Normal

values

≥ 0,8

0,7- 0,9

Mild

stenosis

0,4-0,8

0,5- 0,7

Significant

stenosis

≤ 0,4

< 0,5

Severe

disease

(

multiple

stenoses

)

≤ 0,3

Slide5

tcpO2 T

esting

peripheral skin perfusion on the capillary level; testing skin nutritionClosely corresponds to the capillary pressure of O2→ To determine the degree of perfusion (ischemia)

,

evaluate the effectiveness of revascularization,determine amputation line

,

predict effect of hyperbaric oxygen therapy

Slide6

tcpO2 (transkutánní měření parciálního tlaku kyslíku ve tkáni)

tcpO2

> 50

mmHg

normal

> 30

mmHg

satisfactory

> 20

mmHg

prediction of healing

of

amputation stump

< 10

mmHg

critical

ischemia

Slide7

Plethysmography

Photopletysmography

- emitted infrared light is reflected Hb, while in tissues without Hb is absorbed or released (decay curve)→ detection of acral

blood circulation disorders

;

examination patients with DM (

mediocalcinosis

);

dif.dg. TOS; cooling test

Slide8

Duplex ultrasound

Bifurcation

Atherosclerotic plaque

Slide9

X-ray based methods

Slide10

Peripheral artery diseases (PAD)

Peripheral artery disease (PAD) generally refers to a disorder that obstructs the blood supply to the lower or upper extremities

90-95 % atherosclerosis

5-10%

thrombosis

, embolism, vasculitis,

fibromuscular dysplasia, entrapment Impcact

on

quality

of life + mortality (cardiovascular)> 50% patients with PAD at the same time suffer from coronary atherosclerosis, 15-40% and carotid atherosclerosis

Slide11

Prevalence of PAD

Slide12

Cigarette smoking

Dyslipidemia

DiabetesArterial hypertensionModifiable risk factors(atherosclerosis

)

Slide13

Less frequent causes of PAD

Coarctation

of the aortaVasculitidesTromboangiitis obliterans (Buergers disease)

Peripheral

embolisation

from various originsEntrapment

sy

APCystic adventitial degeneration APfibromuscular dysplasiaIliac artery

endofibrosis

of

cyclists

Primary

vascular tumorsCompression (tumors etc.)

Vascular

trauma

Iatrogenic vascular disease (

percutaneous

and surgical procedures)

Irradiation

arterial

disease

Slide14

Patophysiology

Slide15

Chronic diseaseClaudication – muscle ischemiaSite of stenosis

correlates

with site of painintermittent claudication – on exertionCritical limb ischemia Acute vs. chronicLimb/life threatening disease

paresthesia, pain at rest

Symptoms

Slide16

Peripheral arterial disease -

classification

Fontain

stage

symptoms

I. (

asymptomatic

stage

)noII. (claudication

stage

)

a

claudication

> 200 m

b

claudication

< 200 m

c

claudication

< 50 m

III. (

stage

with

rest

pain

)

a

rest

pain

with

ankle

pressure

>

50

mmHg

b

rest

pain with ankle pressure < 50 mmHgIV.(stage with trophic defects)abounded defectsbsurface defects

Rutheford

stage

category

symptoms

0

0

no

I

1

mild

claudication

2

moderate

claudication

3

limiting

claudication

II

4

rest

pain

III

5

small

tissue

defect

6

large

tissue

defect

Slide17

Metabolic demands of

muscle not met during exercise Higher demand (muscle work)Flow limitation (pressure gradient)

Impaired

vasomotion

Steal syndromePain one level

bellow

stenosisTredmill test – determines walking capacity, ABI after exercise (pain + 25% decrease in ABI confirms diagnosis)

Intermittent

claudication

Slide18

Chronic critical limb ischemia

Persistent pain at

rest requiring analgesics and continuing > 2 weeksTrophic defects or gangrene of the toes or feet

Associated

ankle

systolic pressure < 50 mmHg

Systolic pressure o

n

the thumb < 30 mmHgTcpO2 in the ischemic area < 10 mmHg

Slide19

Acute limb ischemia

←70-80%

embolic closure (sudden PAD)←30-20% thrombotic occlusion (mostly thrombus

on

ruptured

plaque - acute worsening of existing PAD)Clinical picture

-

incomplete

X complete ischemic sy (6Ps)PainPalenessPulselessness

Paresthesias

Paralysis

Prostration

Slide20

Treatment of acute limb

ischemia

i.v. Heparin, i.v. analgesics → urgent revascularization (DSA)Surgical

embolectomy

-

pelvic

arteries, arm and forearm arteriesEndovascular

therapy

-

LTL, thrombus aspiration, mechanical revascularizationCombination of both

Slide21

Treatment of chronic

PAD

Cardiovascular mortality preventionantiplatelet drugs (ASA)risk factor

modification

(

statins

!, antihypertensives…)Lifestyle changes, exercise

QoL

improvement – control of claudicationsVasocative

agents

(

cilostazol

2x100

mg,

naftidrofuryl

3x200 mg)Few clinical data supporting effectivity of

vasoactive

drugs

Prostanoids

–

critical

limb

ischemia

Exercise

Revascularization

Slide22

Treatment of chronic PAD

Methods

of revascularization Endovascular (percutaneous, invasive

)

PTA (DEB; BMS, DES);

stentgrafts

; SIR; thrombolysissurgery bypass,

endarterectomy

,

amputationStimulation of angiogenesis (stem cells) ??Lumbar

sympathectomy

Slide23

Claudication in buttocks, hypotrophy of thighs,

impotence

in ♂ Treatment - aorto-bifemoral bypassLerich`s syndrom

e

(

total

subrenal occlusion of aorta)

Slide24

Compressive syndromes

compression

of arteries, veins, nerves (or all 3 systems) –- anatomical structures (costocl

avicular

sy

)- anatomical anomalies (cervical rib)

-

d

ifferent course (medial course of a.poplitea)

Slide25

Thoracic outlet syndrome

compression

of neurovascular bundlebetween scalenous musclesIn

costoclavicular

space

at the insertion of m

.

pectoralis

minor

Slide26

Thoracic outlet syndrome

symptomatology

- neurogenic 95%                               - arterial 3-5%                               - venous 2%symptom

s

-

carrying an umbrella, washing windows, painting walls, driving…Therapy

-

rehabilitation

→ improvements up to 70% within a few months - surgical (resection of the first rib) in severe disability

Slide27

Costoclavicular syndrome

represents

80% of all TOScompression of neurovascular bundle (a., v., n.) between the clavicle and the first rib

Slide28

Entrapment syndrome of popliteal

arterydg. MR- relation of vascular bundle with the

surrounding muscle or

connective structuresth. s

urgery

(LTL and PTA only to improve the outflow tract for surgical reconstruction)

the most common cause of limb ischemia in patients under 35 years

←

abnormal

course

of

PA

←

non-physiological hypertrophy of the surrounding structures

←

presence of abnormal structures

(fibrous bands

)

Slide29

Specific localization of PAD

Visceral

ischemiaCarotid artery diseaseRenal arteries

Slide30

Vasospastic disorders

U

sually reversible localized narrowing of small arteriesprimary disorders do not lead to trophic changesRaynauds phenomenon

Primary

:

morbus

Raynaud- etiology is not clearly known, suspected failure of regulation at the level of the terminal vascular bedSecondary: Raynaud´s

syndrome

–

secondary to another underlying disease

Slide31

Raynaud's phenomenon

1st

phase: ischemia → morbidly pale fingers, paresthesia,

5-60 min.

2nd

phase

: stasis

of blood in the capillaries and veins → cyanosis

3rd

phase: reactive hyperemia → reddening

Slide32

Primary Raynaud's syndrome

paroxysmal

character, symmetrically, except thumbwomen 5x more often than

men

♀

between puberty and 30

years old, after pregnancy or menopause problems often disappear

Slide33

Secondary Raynaud's syndrome

Connective tissue disorders

SLE, RA, sclerodermia…PADBuergers disease, atherosclerosis, TOS…DrugsOccupational diseasesVibration – drilling, cold exposureMalignancyOther causes

Slide34

Take home messages

PAD –

occlusive diseases of peripheral (limb) arteries90% atherosclerosis (modfiable risk factors

– smoking!, CV mortality)

Imaging

– DUS, CT (MR),

angiographyChronic PAD (claudication, crtitical limb ischemia

) vs.

Acute

limb ischemiaTreatment – CV risk modification + revascularization (endovascular, surgical)Many other disorders

(

vasculitides

,

compression

sy

., vasospastic

disorders…)