2. OUR CASE
A 62 yo male complain of pain in right leg.
Past medical history: Ischemic stroke, HT, DM2.
Present medical history: Severe cramps in right calf on excersize,
after walking 100 meter, no rest pain.
Medication: Metformin 500mg twice daily, hydrochlorothizide 25
mg once daily.
Intoxication: Smoking 25 cig/day during 45y.
Family history: Father had MI (58y), mother had stroke (75y).
3. CON..
Physical examination:
• Body weight 80 Kg, BMI 28 Kg/m, BP=160/100 mmHg.
• Yellow-colored papules on eyelids and skin surrounding eyes
• Heart: Normal tones, no bruit
• Abdomen: Bruit umbilical region.
• L L: Normal pulses femoral arteries, bruit right groin, no pulses
of right popliteal a, posterior tibial a, dorsalis pedis a, atrophic,
dry skin, lack of hair on right lower leg and foot, low skin
tempreture.
4. QUESTIONS
Which investigation do you recommend to evaluate P.A.D?
Which other tests would you like to perform?
How would you treat the complains of this patient with peripheral
arterial disease?
What other medical treatments should this patient receive?
5. INTRODUCTION
What’s Atherosclerosis??
Is chronic progressive degenerative disease affect vascular wall.
Atherosclerosis-Related Diseases??
Atherosclerosis can affect any artery in the body. As a result,
different diseases may develop based on which arteries are affected.
Such as:
Coronary Heart Diseases.
Peripheral Artery Disease.
Chronic Kidney Disease.
6. Q1) WHICH INVESTIGATION DO YOU
RECOMMEND TO EVALUATE
PERIPHERAL ARTERIAL DISEASE?
Q2) WHICH OTHER TESTS
WOULD YOU LIKE TO
PERFORM?
7. GENERAL INFORMATION ABOUT
P.A.D
(P.A.D.) is atherosclerosis of the extremities (virtually always lower)
causing ischemia.
Medical
history
• Risk factor for P.A.D ( diabetes, smoking, older age, hypertension,
stroke).
• Symptoms (Weak or no pulses in the legs or feet, lower
temperature in one leg, decreased hair growth on the legs,
intermittent claudication symptoms).
Family
history
• Family history of heart and blood vessels diseases.
• Father had MI (58y), mother had stroke (75y).
Physical
examination
• Checking pulses by stethoscope (weak or absent pulses in legs or
feet),
• Lower temperature in one leg, atrophic leg or feet.
8. INVESTIGATION OF P.A.D
Ankle-Brachial Index (ABI):
• It compares blood pressure in the ankle to blood pressure in the
arm.
• This test shows how well blood is flowing in limbs.
• A normal ABI ( range between 0.90 - 1.30).
• Can be classified as:
• Mild (0.71 to 0.90),
• Moderate (0.41 to 0.70), or severe (≤ 0.40).
• The test takes about 10 to 15 minutes.
9. CON..
Doppler Ultrasound:
• Looks at blood flow in the major arteries and veins.
• Handheld device is placed on:
• UE: over the axillary, brachial, ulnar, and radial arteries.
• LE: over the femoral, popliteal, dorsalis pedis, and
posterior tibial arteries.
• A computer converts sound waves into a picture of blood
flow in the arteries and veins.
• Provides details of the location and extent of arterial
stenoses or occlusion
10. CON..
Treadmill Test:
• The patient walks on a treadmill while the BP and EKG are
mentored
• A treadmill test can show the severity of symptoms and the
level of exercise.
Magnetic Resonance Angiogram (MRA):
• Uses magnetic and radio wave energy to take pictures of blood
vessels.
• Provides details of the location and extent of arterial stenosis or
occlusion.
11. CON…
Arteriogram:
• Provides a "road map" of the arteries.
• Dye is injected through a needle into one of arteries. After that an x ray
is taken.
• it show the location, type, and extent of the blockage in the artery.
• tiny ultrasound camera to take picture (Intravascular ultrasound).
Computed tomography (CT):
• can be of use to the emergency physician in that it does not have the
time.
12. CON…
Transcutaneous oximetry:
• Is a local, non-invasive measurement reflecting the amount of
O2 that has diffused from the capillaries, through the epidermis.
Electrocardiogram (ECG):
• Used to look for evidence of dysrhythmia, prior cardiac injury, or
even acute myocardial infarction.
14. Q1) Name 2 tests that we can use in the investigation of P.A.D??
QUIZ TIME !
15. Q3/HOW WOULD YOU TREAT THE
COMPLAINTS OF THIS PATIENT
WITH P.A.D?
Q4/WHAT OTHER MEDICAL
TREATMENTS SHOULD THIS
PATIENT RECEIVE?
16. TREATMENT OF P.A.D
Risk factor modification.
Exercise.
Antiplatelet drugs.
Sometimes pentoxifylline or cilostazol for claudication.
Cholesterol lowering medication.
ACE inhibitors.
PTA or surgery for severe disease.
17. TREATMENT OF P.A.D
Risk factor modification, include:
• Smoking cessation.
• Control of diabetes: Metformin 500mg twice daily.
• Control of HT: hydrochlorothiazide 25 mg once daily. (ACE).
• Dietary changes:
Less saturated fat<20 g/day.
More fruits and vegetables.
More fiber (decrease LDL 5%).
Eat fish (EPA inhibit platelet aggregation).
Eat less red meat (homocystin).
18. TREATMENT OF P.A.D
Exercise:
• 35 to 50 min of treadmill or track walking 3 to 4 times/wk. (with
underused treatment).
• Mechanisms:
• Increased collateral circulation.
• Improved endothelial function with microvascular vasodilation.
• Decreased blood viscosity.
• Increase HDL.
19. CON..
Antiplatelet drugs:
• lessen symptoms, improve walking distance and modify
thermogenesis.
• Aspirin 81 to 162 mg taking by mouth, once/day. (low dose).
• Aspirin 25 mg plus dipyridamole 200 mg taking by mouth
once/day,
• Action of aspirin:
• Inhibit TXA2.
• Maintain activity of prostacyclin.
20. CON..
To relief of claudication:
• Pentoxifylline 400 mg, taken by mouth, three time daily.
• or cilostazol 100 mg, taken by mouth, twice daily.
• Mechanisms:
• Relieve intermittent claudication by improving blood flow and
enhancing tissue oxygenation in affected areas.
21. CON…
ACE inhibitors:
• Ramipril 10 mg, taking by mouth once/day.
• Mechanisms:
• They are antiatherogenic.
• Promoting the degradation of bradykinin and the release of nitric oxide.
23. CON…
Percutaneous transluminal intervention:
• Is a minimally invasive procedure to open up blocked arteries.
• Work best in large arteries with high flow (iliac and renal).
• They are less useful for smaller arteries and for long
occlusions.
• Indications:
• Intermittent claudication that inhibits daily activities.
• Rest pain.
• Gangrene.
24. CON…
Surgery:
• Thromboendarterectomy: (surgical removal of an occlusive lesion).
• Revascularization: uses synthetic or natural materials (often the saphenous
or another vein) to bypass occlusive lesions.
• Amputation: is a procedure of last resort, indicated for uncontrolled
infection, unrelenting rest pain, and progressive gangrene.
25. SUMMARY
Atherosclerosis Is chronic progressive degenerative disease affect
vascular wall.
Atherosclerosis can associated with other disease like P.A.D.
General information about P.A.D.
Investigation.
Treatment.
26. QUIZ TIME !
Q1) to treat P.A.D and Atherosclerosis we used:
1- Aspirin with low dose.
2- Aspirin with high dose.
29. REFERENCE
Kumar & Clark’s Clinical Medicine Book (Ninth Edition), (Page
1049- 1056).
BNF (65 Edition), (Page 138).
Merk Manual (19 Edition), (Page 2218-2220).
Peripheral Vascular Disease Workup. MD, E. S. (2016, Dec. & jan.).
Retrieved February 19, 2017, from
http://emedicine.medscape.com/article/761556-workup#showall
How Is Peripheral Artery Disease Diagnosed? (2016, June & july).
Retrieved February 19, 2017, from
https://www.nhlbi.nih.gov/health/health-
topics/topics/pad/diagnosis.
Notas del editor
Peripheral artery disease : Narrowing in the arteries of the legs from plaque causes poor circulation. This makes it painful for you to walk. It’ll also cause wounds not to heal as well. Severe disease may lead to amputations.
Atherosclerosis is a disease in which plaque builds up inside your arteries. Arteries are blood vessels that carry oxygen-rich blood to your heart and other parts of your body.
including arteries in the heart, brain, arms, legs, pelvis, and kidneys.
Atherosclerosis can affect any artery in the body, including arteries in the heart, brain, arms, legs, pelvis, and kidneys. As a result, different diseases may develop based on which arteries are affected.
Coronary heart disease (CHD), also called coronary artery disease, occurs when plaque builds up in the coronary arteries. These arteries supply oxygen-rich blood to your heart,, If blood flow to your heart muscle is reduced or blocked, you may have angina (chest pain or discomfort) or a heart attack.
Peripheral artery disease (P.A.D.) occurs if plaque builds up in the major arteries that supply oxygen-rich blood to your legs, arms, and pelvis.
If blood flow to these parts of your body is reduced or blocked, you may have numbness, pain, and, sometimes, dangerous infections.
Chronic kidney disease can occur if plaque builds up in the renal arteries. These arteries supply oxygen-rich blood to your kidneys.
Over time, chronic kidney disease causes a slow loss of kidney function. The main function of the kidneys is to remove waste and extra water from the body.
Mild PAD may be asymptomatic or cause intermittent claudication; severe PAD may cause rest pain with skin atrophy, hair loss, cyanosis, ischemic ulcers, and gangrene.
Peripheral arterial disease (PAD) occurs almost always in the lower extremities.
Your doctor may ask:
Whether you have any risk factors for P.A.D. For example, he or she may ask whether you smoke or have diabetes.
About your symptoms, including any symptoms that occur when walking, exercising, sitting, standing, or climbing.
Whether anyone in your family has a history of heart or blood vessel diseases.
People who have P.A.D. may have symptoms when walking or climbing stairs, which may include pain, numbness, aching, or heaviness in the leg muscles. Symptoms also may include cramping in the affected leg(s) and in the buttocks, thighs, calves, and feet. Symptoms may ease after resting. These symptoms are called intermittent claudication.
Your doctor also may check the pulses in your leg arteries for an abnormal whooshing sound called a bruit. He or she can hear this sound with a stethoscope. A bruit may be a warning sign of a narrowed or blocked artery.
Your doctor may compare blood pressure between your limbs to see whether the pressure is lower in the affected limb. He or she also may check for poor wound healing or any changes in your hair, skin, or nails that may be signs of P.A.D.
It show whether P.A.D. is affecting limbs, but it won't show which blood vessels are narrowed or blocked.
You may have an ABI test before and after the treadmill test.
This test is a type of magnetic resonance imaging (MRI).
Some doctors use a newer method of arteriogram that uses tiny ultrasound cameras. These cameras take pictures of the insides of the blood vessels. This method is called intravascular ultrasound.
electrolyte studies help evaluate for signs of end-organ injury and for factors that might lead to worsening of peripheral perfusion.
Homocystin is amino acid which will make damage to endothelium.
Exosa pentose acid
Antiplatelet drugs may modestly lessen symptoms and improve walking distance; more importantly, these drugs modify atherogenesis and help prevent acute coronary syndromes and transient ischemic attack.
Inside platlet there is facror called TXA2 which increase platelet depose in vascular wall so aspirin it will inhibit thrombxan.
In the vessels wall there is factor called prostacyclin which inhipit platlets activation and also have vasodilator effect.
For relief of claudication, pentoxifylline 400 mg po tid with meals or cilostazol 100 mg po bid may be used to relieve intermittent claudication by improving blood flow and enhancing tissue oxygenation in affected areas; however, these drugs are no substitute for risk factor modification and exercise. Use of pentoxifylline is controversial because evidence of its effectiveness is mixed. A trial of ≥ 2 mo may be warranted, because adverse effects are uncommon and mild. The most common adverse effects of cilostazol are headache and diarrhea. Cilostazol is contraindicated in patients with severe heart failure.
nitric oxide, are potent vasodilators.
Angioplasty and Stent Placement
Your doctor may recommend angioplasty to restore blood flow through a narrowed or blocked artery.
During this procedure, a catheter (thin tube) with a balloon at the tip is inserted into a blocked artery. The balloon is then inflated, which pushes plaque outward against the artery wall. This widens the artery and restores blood flow.
A stent (a small mesh tube) may be placed in the artery during angioplasty. A stent helps keep the artery open after angioplasty is done. Some stents are coated with medicine to help prevent blockages in the artery.
انسداد
Surgery is indicated for patients severe symptoms do not respond to noninvasive treatments.
Other Types of Treatment
Researchers are studying cell and gene therapies to treat P.A.D. However, these treatments aren’t yet available outside of clinical trials. Read more about clinical trials.
Thromboendarterectomy (surgical removal of an occlusive lesion) is used for short, localized lesions in the aortoiliac, common femoral, or deep femoral arteries.