Few important notes on PAD

1. Peripheral Vascular Disease-
Legs
By,
Kriti Chakrabarty,
6th year

2. Overview
• Commonly referred to as peripheral
arterial disease (PAD) or peripheral
artery occlusive disease (PAOD),
• A disease of the peripheral blood vessels
Characterized by narrowing and
hardening of the arteries that supply the
legs and feet
• The decreased blood flow results in
nerve and tissue damage to the
extremities

3. Incidence
• PVD is a very
common disorder
• Most common in
men over 50 years
of age.

4. Epidemiology
• The prevalence of peripheral vascular
disease in the general population is 12–
14%, affecting up to 20% of those over
70,70%–80% of affected individuals are
asymptomatic; only a minority ever
require revascularization or amputation.
Peripheral vascular disease affects 1 in 3
diabetics over the age of 50.
• The incidence of symptomatic PVD
increases with age, from about 0.3% per
year for men aged 40–55 years to about
1% per year for men aged over 75 years.
The prevalence of PVD varies considerably
depending on how PAD is defined, and the
age of the population being studied

6. In India
• A population-based study in South
India reported a prevalence of PAD
of 6.3% amongst diabetics
compared to 3.2% in the whole
population.
• This contrasts with a population-
based study from the United States
which reported the PAD prevalence
to be 22% in its diabetic cohort as
compared to 3% in people with
normal glucose tolerance

7. Onset
• PVD has a gradual
onset
• Initially asymptomatic
until secondary
complications develop
such as:
Claudication - pain,
weakness, numbness,
or cramping in muscles
after walking or
exercise.

8. • Sores, wounds, or ulcers that heal
slowly or not at all

9. Noticeable change in color
(blueness or paleness) or
temperature (coolness) when
compared to the other limb
Diminished hair and nail growth
on affected limb and digits.
When peripheral artery disease
becomes severe, you may have:
Impotence(Leiriche syndrome)
Pain and cramps at night

10. The 5 P’s
• Pulselessness
• Paralysis
• Paraesthesia
• Pain
• Pallor

11. Claudication

12. Classification
• Peripheral artery occlusive disease is
commonly divided in the Fontaine stages:
1. Mild pain when walking
(claudication), incomplete blood vessel
obstruction;
2. Severe pain when walking relatively short
distances (intermittent
claudication), stage IIa : pain triggered by
walking "after a distance of >150 m
stage II-b after <150 m
3. Rest pain, mostly in the feet, increasing
when the limb is raised;
4. Biological tissue loss (gangrene) and
difficulty walking.

13. A more recent classification by
Rutherford consists of three
grades and six categories
• Mild claudication
• Moderate claudication
• Severe claudication
• Ischemic pain at rest
• Minor tissue loss
• Major tissue loss

14. Pathophysiology:
• PVD, also known as arteriosclerosis
obliterans, is primarily the result of
atherosclerosis. The atheroma
consists of a core of cholesterol
joined to proteins with a fibrous
intravascular covering.
• Vascular disease may manifest
acutely when thrombi, emboli, or
acute trauma compromises
perfusion.

15. Atherosclerosis

16. • Pain, Change in
color and
temperature ,
ultimately
nerve damage

18. Gait stance

19. Dx:
• Patient History-HTN ,DM , Family history ,
pain?
• Physical Examination:
Habitus , Constitution of the person
,Discoloration , Mass of muscle , Hair and
nail growth on the limb area , Temperature
Ausculatation: Over the precordium and the
affected limb of region.
• A whooshing sound with the stethoscope
over the artery (arterial bruits)
• Decreased blood pressure in the affected
limb
• Weak or absent pulses in the limb

20. Physical Assessment
• Femoral pulses: check above the
inguinal fold
• Popliteal pulse is behind the knee
• Doralis Pedis is on the top of the
foot and the posterior tibial pulse
in on the medial aspect of the
ankle

21. Buerger's test -You can illicit elevation pallor
by elevating the leg while the patient is on the
exam table. The skin becomes very pale. Have
the patient sit up and you see the leg go from
pale to hyperemic as depicted
Brodie-Trendelenburg Test (assessment of
valvular competence if varicose veins)

22. DDx:
• Aneurysm, Abdominal
• Ankle Injury, Soft Tissue
• Back Pain, Mechanical
• Deep Venous Thrombosis and
Thrombophlebitis
• Lumbar (Intervertebral) Disk
Disorders
• Venous disease
• Trauma, Peripheral Vascular Injuries

23. Lab Studies
• Routine blood tests generally are
indicated in the evaluation of
patients with suspected serious
compromise of vascular flow to an
extremity.
• CBC, BUN, creatinine, and
electrolytes studies help evaluate
factors that might lead to
worsening of peripheral perfusion..
• Lipid Profile, Coagulation etc

24. • An ECG may be
obtained to look for
evidence of
dysrhythmia, chamber
enlargement, or MI.
• Elevated levels of
inflammatory blood
markers such as D
dimer, C-reactive
protein, interleukin 6,
and homocysteine
have been linked to
decreased lower
extremity tolerance of
exercise

25. Imaging Studies
• Doppler ultrasound exam of an extremity-to
determine flow status. Lower extremities are
evaluated over the femoral, popliteal, dorsalis
pedis, and posterior tibial arteries. Note the
presence of Doppler signal and the quality of the
signal (ie, monophasic, biphasic, triphasic)
• Magnetic resonance angiography or CT
angiography
• Modern multislice computerized tomography (CT)
scanners provide direct imaging of the arterial
system as an alternative to angiography

26. Other tests
• Blood pressure measured in the arms and
legs for comparison (ankle/brachial
index, or ABI)
• Treadmill test-to confirm PAD
• Transcutaneous oximetry affords
assessment of impaired flow secondary to
both microvascular and macrovascular
disruption.

27. Doppler and ABI

28. • Angiography of the
arteries in the legs
(arteriography)

29. Risk factors
• Smoking.
• Diabetes mellitus
• Dyslipidemia
• Hypertension
• Risk of PAD also increases in individuals
who are over the age of 50,
• male,
• obese, or
• with a family history of vascular
disease, heart attack, or stroke.
• Other risk factors which are being
studied include levels of various
inflammatory mediators such as C-
reactive protein, homocysteine

30. Treatment
• Emergency-ABC, Heparin
• Lifestyle Changes
• Smoking cessation
• Management of diabetes-feet
• Management of hypertension.
• Management of cholesterol, and medication
with antiplatelet drugs. Medication with
aspirin, clopidogrel and statins, which
reduce clot formation and cholesterol
levels, respectively
• Regular exercise for those with claudication
helps open up alternative small vessels
(collateral flow)

31. Cont.
• Cilostazol or pentoxifylline treatment to
relieve symptoms of claudication.
• Treatment with other drugs or vitamins
are unsupported by clinical evidence, "but
trials evaluating the effect of folate and
vitamin B-12 on
hyperhomocysteinaemia, a putative
vascular risk factor, are near completion".

32. Revascularization
• After a trial of the best medical treatment
outline above, if symptoms remain
unacceptable, patients may be referred
to a vascular or endovascular surgeon.
• Angioplasty (PTA or percutaneous
transluminal angioplasty) can be done on
solitary lesions in large arteries, such as
the femoral artery, but angioplasty may
not have sustained benefits.
• Plaque excision, in which the plaque is
scraped off of the inside of the vessel
wall.

33. • Occasionally, bypass grafting is needed to
circumvent a seriously stenosed area of
the arterial vasculature. Generally, the
saphenous vein is used, although artificial
(Gore-Tex) material is often used for large
tracts when the veins are of lesser quality.
• Rarely, sympathectomy is used - removing
the nerves that make arteries
contract, effectively leading to
vasodilatation.
• When gangrene of toes has set
in, amputation is often a last resort to stop
infected dying tissues from causing
septicemia.
• Arterial thrombosis or embolism has a
dismal prognosis, but is occasionally
treated successfully with thrombolysis.

35. Guidelines
• Several different guideline
standards have been
developed, including:
• TASC II Guidelines
• ACC/AHA Guidelines

36. Prognosis
• Individuals with PAD have an "exceptionally elevated
risk for cardiovascular events and the majority will
eventually die of a cardiac or cerebrovascular etiology";
• prognosis is correlated with the severity of the PAD as
measured by the Ankle brachial pressure index (ABPI).
Large-vessel PAD increases mortality from cardiovascular
disease significantly. PAD carries a greater than "20% risk
of a coronary event in 10 years".
• There is a low risk that an individual with claudication
will develop severe ischemia and require amputation,
but the risk of death from coronary events is three to
four times higher than matched controls without
claudication. [
• Of patients with intermittent claudication, only "7% will
undergo lower extremity bypass surgery, 4% major
amputations, and 16% worsening claudication", but
stroke and heart attack events are elevated, and the "5-
year mortality rate is estimated to be 30% (versus 10% in
controls)"

37. Thank you