PERIPHERAL VASCULAR DISEASE Revision session

1. PERIPHERAL VASCULAR DISEASE Revision session  Dr. Habib Tareif, FRCSI AGU

2. Peripheral Vascular Disease Arterial Chronic : Atherosclerotic, Small vessels, Vasculitis Acute : Embolic, Thrombotic�

3. �Objectives� To provide an outline of PVD Discuss chronic arterial disease Aetiology Presentations Investigations Management Review acute arterial occlusion

4. Peripheral vascular disease of the lower extremitiesDefinition �Decreased patency� of the arterial supply to the lower extremities leading to Intermittent Claudication Ischemic rest pain potentially limb loss �Compromised�

5. Etiology Atherosclerosis Vasculitis Burger's Disease (Thromboangiitis Obliterans) Extrinsic compression (neoplasm)

6. Atherosclerosis Thickening and hardening of arteries Some hardening is normal with age Plaque may partially or totally block the blood's flow through an artery

7. Atheroma Plaques can form from damage to arterial walls by Increase levels of cholesterol and triglyceride in the blood Increase in blood pressure Tobacco smoking �Cellular debris will adhere to plaques (cholesterol etc.) �Endothelium becomes thick and the diameter of the artery is reduced�

8. Risk Factors Hypertension Cigarette smokers Diabetics Hyperlipidaemia Increased age History of other atherosclerotic disease (coronary artery disease or carotid stenosis)

9. Pathophysiology �Narrowing of the arterial lumen leads to� Decreased blood flow resulting in. Decreased O2 supply leading to Anaerobic metabolism Increased Lactic Acid Pain with increased muscle use

10. Pathophysiology As decreased blood flow or compromised integrity continues, tissues can become ischemic leading to: Pain at rest Poor wound healing Painful ulceration

11. Pathophysiology As disease progresses patients are sometimes unable to ambulate and gangrene may set in with eventual need for amputation

12. Acute Complication of Atheroma Two things that can happen where plaque occurs are: Hemorrhage into the plaque Plaque ruptures and a blood clot (thrombus) forms on surface (Affects large and medium-sized arteries)

13. Consequence of arterial block Heart attack = reduced blood supply to heart Stroke = reduced blood supply to brain Gangrene = reduced blood supply to arms and legs

14. Chronic Ischaemia Intermittent Claudication +/- Rest Pain Cold Peripheries Arterial Ulcers Wet/dry gangrene

15. Claudication Definition: Muscle pain which appears during exercise when there is an inadequate arterial flow Intermittent Claudication Claudicato = to limp

16. Intermittent Claudication Claudication Distance: The distance the patient is able to walk before onset of pain. Must be recorded accurately

17. Clinical Presentation Claudication requires a sustained walk cramping/burning muscular pain localized to a muscle group (calf) reproducible relieved with rest Distribution of pain may suggest anatomic location of disease

18. Intermittent Claudication Differential Diagnosis Nerve Root Compression Arthropathy Spinal Stenosis

19. Clinical Presentation �Differentiate Claudication from pseudoclaudication� Character location is the same as cramp and tightness Location of pain is the same BUT Claudication is Exercise induced. The Distance to symptoms is reproducible It is Relieved by Stop walking not by Change of position No Symptoms with standing Character and location is the same as cramp and tightness

20. Intermittent Claudication 30% are Diabetics Increased relative risk of death x3 50%-heart disease 15%-stroke

21. Rest Pain Pain caused by critical Ischaemia worse at night May be present throughout the day and night Continuous, aching & severe Located in toes and forefoot. (Patient hangs the leg over the side of the bed)

22. Don�t forget other relevant history Angina CVA/ TIA / Amaurosis fugax Medications Did he have any other surgery

23. Examination General condition Pulse/ BP= 160/100 Carotid bruit. Cardiac/ Respiratory assessment Abdominal scars or bruit

24. Assessment of PVDIschaemic limb

25. Lower Limb AssessmentInspection Chronic Ischemic changes �Hair loss, shiny appearance & Trophic changes� Presence of Gangrene Ulcers Buerger�s critical angle 20%

26. Vascular Assessment Temperature: Often cool Oedema: un usual Capillary circulation Venous re-filling

27. Lower Limb AssessmentInspection Buerger�s critical angle 20%

28. PHYSICAL EXAMINATION Pulse exam Palpable vs. non-palpable Audible by Doppler vs. not audible Compare limbs Pulse exam helps define level of disease May also examine pulses after exercise

29. Vascular Assessment Pulses (Grades 1-4) Pulse Fem Pop PT DP Right Left

30. INVESTIGATION OF PVD Assess risk factors: Fasting lipids & glucose, HbA1c Non-Invasive Doppler Ankle/Brachial Index & Duplex Invasive CT Angiogaphy/ MRI Angiography

32. Digital Pressures: useful in Diabetes Mellitus. Why?

33. Duplex Ultrasound Advantages Noninvasive Fast/cheap Few complications Disadvantages Dependent on ultrasonographers ability Poor visualization below the knee

34. Arteriography Advantages Gold standard for demonstrating anatomy of disease Provides therapeutic opportunities: eg.PTA Disadvantages Invasive risk of hemorrhage, aneurysm, infection Contrast load is nephrotoxic

35. CT ANGIOGRAPHY & Magnetic Resonance Advantages Good resolution Allows visualization of surrounding structures Noninvasive with few complications Disadvantages No intervension Efficacy has not been completely demonstrated Cost/availability

36. Claudication Treatment STOP SMOKING Exercise program Control diabetes, lower cholesterol Pentoxyphylline Cilostazole �75% improve with non-operative management�

37. Treatment of critical ischemia�Ischemic rest pain/ulcer/gangrene� Must first determine how patient uses limb Angioplasty vs. Surgery �Gangrene or blackened toes require amputation but revascularization may preserve level and use of limb�

38. ARTERIAL ULCERS PAINFUL! PUNCHED OUT �NOT SUPERFICIAL LIKE VENOUS� SURROUNDING EVIDENCE OF ARTERIAL DISEASE pale, loss of hair, decreased capillary refill, decreased or absence of pulses

39. Burger's Disease (Thromboangiitis Obliterans) Clinical Features Males <45 years Upper and lower limb involvement Heavy smokers Angiogram Normal proximal arteries Distal occlusions

40. The Diabetic Foot Pathophysiology Ischaemia (Microangiopathy/Macroangiopathy) Neuropathy Sepsis

41. Chronic IschaemiaConservative Management Increasing exercise tolerance Pharmacotherapy's: Decrease rate of progression i.e.; Anti Platelet agents & Statins. STOP SMOKING! ACE I {esp. in Diabetics } Avoidance of minor trauma esp. in those with neuropathy / PVD => Lower amputation rates

42. Surgical Management Endovascular options: to increase inflow if suitable for femoral angioplasty or stenting Surgical bypass of diseased segment using vein or prosthetic graft If un-reconstructable: Try Prostacyclin infusion (Iloprost) Last option is amputation

43. Amputations 50% of major amputations die within 3 yrs. Why? Post Amputation: 39 %totally wheelchair bound at 5 yrs 5% wheelchair free 56% undergo limb fitting 85% of these are walking at 1 year 30 % are walking at 5 years Amputation Levels as distal as possible in interest of mobility The key to social reintegration

44. Arterial Ulcer

45. Dry Gangrene: No infection

46. Wet Gangrene: Infected!

47. Femoral Angiography

48. Neuropathic Ulcers

49. NEUROPATHIC ULCER

50. Acute Ischemia presentation Sudden Severe Agonizing Pain Parasthesia Discoloration Loss of movement Cold Limb

51. Acute Ischaemia Clinical Features Pain Pallor Parasthesia. Paralysis Pulselessness Perishing Cold Pistol Shot onset

52. Acute Limb Ischaemia Embolus Thrombus Trauma

53. Acute Limb Ischaemia Source of Emboli Heart - 90% - Arrhythmias - Valvular heart disease - Prosthetic heart valves - Mural thrombus post MI - Ventricular aneurysm

54. Acute Limb Ischaemia Source of Emboli Great Vessels (9%) Atherosclerotic aorta Aortic aneurysm Popliteal artery aneurysm Other (1%) Paradoxical

55. Acute Limb Ischaemia Thrombus Thrombus on a pre-existing atherosclerotic lesion Patient has history of intermittent Claudication

56. Acute Ischaemia Treatment Urgent Treatment, Heparin Heparin Investigations Intervention ? Thrombolytic

57. Acute Limb Ischaemia Vascular Trauma

59. Trash Foot- Late Presentation

60. Summary Arterial Disease => acute vs. chronic Venous Disease Diabetes

61. FINAL MEDREVISIONVaricose Veins Habib Tareif FRCSI AGU 2010

62. What we�ll cover Some Definitions A bit of anatomy What your looking for? Examination techniques Doppler Questions

63. What is a varicose vein? Long, tortuous and dilated veins of the superficial varicose system Commonly legs but where else? Abdominal Wall Anus Vulva Oesophagus

64. Pathogenesis of Varicose Veins Increased pressure in the superficial venous system Normally blood flows from superficial system to deep If the valves protecting the superficial veins become incompetent there is higher pressure in the superficial veins and they become varicose

66. Causes Primary Congenital abnormality, most common cause Secondary Anything that raises intra-abdominal pressure or raises pressure in superficial/deep venous system so�: Pregnancy Abdominal/pelvic mass Ascites obesity constipation thrombosis of leg veins

67. A bit of anatomy Superficial System arises from foot and ends at Sapheno- femoral junction or Sapheno- popliteal junction Long saphenous vein- medial leg up to SFJ Short saphenous vein- lateral malleoulus round back of ankle, up calf to meet popliteal vein behind knee Sapheno- femoral junction- 4 cm lateral and 4cm below the pubic tubercle

69. So the examination Inspection Palpation cough test tap test Ausculation Tourniquet Tests Trendelenberg Tourniquet test Perthes Doppler Sapheno-femoral junction Sapheno-popliteal junction

70. Inspection Start with patient standing-both legs exposed to the groin �I am looking along the distribution of the Long saphenous vein� Medial side, length of the leg �Next I am looking along the distribution of the Short Saphenous vein� Below knee, posterior and lateral aspects of leg Remember!!! when describing veins they arise at the bottom of the leg and go upwards to the groin!

71. Inspection- other features Venous Stars- blueish vessels that distend above the skin surface Thrombophlebitis- superficial red painfull lump Brown pigmentation- haemosiderin deposition Venous Eczema Venous Ulcers- over medial ankle or �gaiter area� Lipodermatosclerosis-progressive sclerosis of cutaneous fat- ankle becomes thin and hard- area above becomes oedematous Scars from previous surgery

72. Palpation Palpate the veins to confirm they are infact veins- will refill if if gently pressed and released Next- find the sapheno-femoral junction (SFJ) Find Pubic Tubercle just lateral to pubic symphisis 4 cm lateral then 4cm below Palpate for a sapheno varix- localised distension of the long saphenous vein in the groin Cough Test- Fingers over SFJ, ask patient to cough can you feel a thrill, if yes suggest incompetence Tap Test- tap over the SFJ and feel further down long saphenous vein for any transmitted sounds, if yes suggest incompetence

73. Ausculation Auscultate over any varicosites for bruits Due to A-V malformation

74. Trendelenberg/Tourniquet tests Aim- to localise the valve/s that are incompetent Trendelenberg Lie patient down and raise leg attempting to drain varicosities of blood. Using either a tourniquet or fingers put pressure over SFJ to occlude it Ask patient to stand If varicosities DO NOT refill indicates SFJ incompetence If DO refill the leaky valve is lower down �I will now try and locate the incompetent perforator using the tourniquet test�

75. Tourniquet test continued Same as before - lie down, raise and drain leg Place tourniquet approximately over area of each perforator( mid thigh, sapheno-popliteal, calf perforators) If varicosities DO NOT refill that perforator is incompetent If varicosities DO refill continue down leg

76. Perthes test � I will now check the patency of the deep venous system� important for theatre as if superficial veins removed and deep veins occluded- problem Ask patient to stand up tourniquet round mid thigh raised onto toes 10 times ( pumps blood up leg) if veins empty- deep system fine if veins swell and become painful- ? deep vessel occlusion

77. Doppler! Must practise with a Doppler before LOCAS or you will look like a fool Has taken over from tourniquet test as gold standard �I would like to use a Doppler to check for incompetence at the Sapheno femoral junction and Sapheno popliteal junction�

78. Doppler continued Find SFJ Place doppler over it Squeeze either thigh of calf One whoosh as blood goes up � good second whoosh if blood comes back down bad! means SFJ is incompetent, the quicker the second whoosh the more incompetent the valve Remember one whoosh good two whoosh bad! Exactly the same in Sapheno- popliteal junction in popliteal fossa

79. To complete my examination I would like to� Perform a full Abdominal Examination Scrotal examination ( on males!) Arterial Examination Investigations Duplex Ultrasonography- maps valve incompetence Venography

80. Complications of varicose veins Most varicose veins are relatively benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.

81. Complications of varicose veins Pain, heaviness, inability to walk or stand for long hours thus hindering work Skin conditions / Dermatitis which could predispose skin loss Bleeding�: life threatening bleed from injury to the varicose vein Ulcer�: non healing varicose ulcer could threaten limb amputation

82. Complications of varicose veins Coagulation of blood in varicose veins cause superficial thrombosis, deep vein thrombosis (DVT), Pulmonary Embolism (PE)

83. Some questions: Causes of varicose veins Management options: Conservative- reassurance, exercise, avoid long stands, weight reduction, elevation of legs, compression stockings Surgical- injection sclerotherapy, ligation of SFJ (trendelenberg procedure), Stripping of tributaries, isolated removal of small varicosities Symptoms of varicose veins: aching leg pain tired/heavy legs worse as day progresses and long periods of standing skin changes-hair loss, itching, eczema etc swellings

84. Thank you Any Questions???