Peripheral Vascular Disease

1. Peripheral Vascular Disease Rob Kawa, OMS III Predoctoral OPP Fellow DidacticsOnline.com

2. Peripheral Vacular 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 narrowing and hardening of the arteries occur. • The most common areas affected are the legs and feet.

3. Arteriosclerosis • 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.

4. Lets Back Up A Minute! • Why are there so many terms that all sound the same? (arteriosclerosis, atherosclerosis, arteriolosclerosis) • Where did the plaque come from?

5. Lets Talk About The Terms • 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) • Atherosclerosis • Arteriolosclerosis

6. 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

7. 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)

8. Lets Talk About The Terms • Arteriolosclerosis • Hardening 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 duplication • Arterioles have an “onion skin” appearance

9. Peripheral Vascular Disease • A common disorder that usually affects men over 50 • Higher risk with history of: • Abnormal cholesterol • Diabetes • High blood pressure (hypertension) • Heart disease (coronary artery disease) • Smoking • Kidney disease involving hemodialysis • Stroke (cerebrovascular disease)

10. Symptoms • 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 touch • Severe disease: • Impotence • Ulcers that do not heal • Worsening pain with leg elevation • Leg pain at night

11. 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

12. Signs in severe disease • Calf muscles that shrink • Hair loss over the toes and feet • Painful non-bleeding ulcers (usually black) that are slow to heal • Pale skin or a blue appearance (cyanosis) • Shiny tight skin • Thick toenails

13. Tests • 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 angiography • Plethysmography – Tests a change in volume in the body, organs, or vessels.

14. Treatment • 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 smoking • Reduce your weight • Keep your blood pressure under control • Take particular care with foot health, especially if diabetic • Monitor blood sugar • If your cholesterol is high eat a low cholesterol, low fat diet.

15. 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 medications • Pain relievers

16. Treatment Research • 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.

17. Treatment • Surgery/Procedures • Angioplasty and stent placement – This procedure is similar to the technique used to open coronary arteries but is done in the affected leg.

18. Treatment • Surgery/Procedures: • Arterial bypass surgery for vessels with significant blockage. Lower extremity vessels and the abdominal aorta are common sites.

19. Treatment • Surgery/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.

20. Treatment • An Osteopathic Consideration: • MFR and FascialLigamentous Release • LAS • Diaphragms • Lymphatics • Fluid Dynamics • Muscle Energy?

21. References • 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