Problem Solving session PVD BLACK TOE

1. 30/07/2012 Problem Solving session “PVD” “BLACK TOE” Dr. Habib Tareif, FRCSI AGU Dr Habib Tareif, FRCSI 1

2. 30/07/2012 Dr Habib Tareif, FRCSI Peripheral Vascular Disease Arterial : Chronic : Atherosclerotic, Small vessels, Vasculitis Acute : Embolic, Thrombotic” Venous Neuropathic 2

3. 30/07/2012 Dr Habib Tareif, FRCSI ”Objectives of this problem” To provide an outline of PVD Discuss chronic arterial disease Aetiology Presentations Investigations Management Review acute arterial occlusion 3

4. 30/07/2012 History 65 y old patient presented with Black discoloration of left 2nd & 3rd toes He developed Painful left lower limb Exercise induced and progressive Marked pain after 10 meters in the last few weeks and rest pain for one week Heavy smoker & has Type II DM Past H/O acute AWMI 4 Dr Habib Tareif, FRCSI

5. 30/07/2012 History Any Further Questions in his History Dr Habib Tareif, FRCSI 5

6. 30/07/2012 History Dr Habib Tareif, FRCSI 6 Angina CVA/ TIA / Amaurosis fugax Medications Did he have any other surgery

7. 30/07/2012 Examination General condition is good Pulse= 80/min & regular, BP= 160/100 Bilateral carotid bruit. Systolic murmur grade 2/6 radiate to neck No abdominal scars or bruit 7 Dr Habib Tareif, FRCSI

8. 30/07/2012 Assessment of PVDIschaemic limb Dr Habib Tareif, FRCSI 8

9. 30/07/2012 Lower Limb AssessmentInspection Chronic Ischemic changes “Hair loss, shiny appearance & Trophic changes” Dry gangrene distal ½ of 2nd & 3rd toes Buerger’s critical angle 9 Dr Habib Tareif, FRCSI

10. 30/07/2012 Palpation Assessment of pulses Assess temperature Oedema Venous re-filling Capillary circulation 10 Dr Habib Tareif, FRCSI

11. 30/07/2012 Palpation Assessment of pulses Pulses (Grades 1-4) Pulse Fem Pop PT DP Right 4 4 1 1 Left 3 0 0 0 11 Dr Habib Tareif, FRCSI

12. 30/07/2012 Discuss The arteries of the lower limb The causes of black toe Pathology “Atherosclerosis” Pathogenesis of presentation Influence of DM on development of PVD 12 Dr Habib Tareif, FRCSI

13. 30/07/2012 Management Admission. Full history & physical examination. Blood tests. Non invasive investigations. Invasive investigations. Treatment. 13 Dr Habib Tareif, FRCSI

14. 30/07/2012 Treatment Medical treatment Angiography and PCI “Angioplasty and stents” Surgical Options “Fem-Pop Bypass, etc….” Prognosis. Life style modification. 14 Dr Habib Tareif, FRCSI

15. 30/07/2012 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” 15 Dr Habib Tareif, FRCSI

16. 30/07/2012 Etiology Atherosclerosis Vasculitis Burger's Disease (Thromboangiitis Obliterans) Extrinsic compression (neoplasm) 16 Dr Habib Tareif, FRCSI

17. 30/07/2012 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 17 Dr Habib Tareif, FRCSI

18. 30/07/2012 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” 18 Dr Habib Tareif, FRCSI

19. 30/07/2012 Risk Factors Hypertension Cigarette smokers Diabetics Hyperlipidaemia Increased age History of other atherosclerotic disease (coronary artery disease or carotid stenosis) 19 Dr Habib Tareif, FRCSI

20. 30/07/2012 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 20 Dr Habib Tareif, FRCSI

21. 30/07/2012 Pathophysiology As decreased blood flow or compromised integrity continues, tissues can become ischemic leading to: Pain at rest Poor wound healing Painful ulceration 21 Dr Habib Tareif, FRCSI

22. 30/07/2012 Pathophysiology As disease progresses patients are sometimes unable to ambulate and gangrene may set in with eventual need for amputation 22 Dr Habib Tareif, FRCSI

23. 30/07/2012 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) 23 Dr Habib Tareif, FRCSI

24. 30/07/2012 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 Dr Habib Tareif, FRCSI 24

25. 30/07/2012 Dr Habib Tareif, FRCSI Chronic Ischaemia Intermittent Claudication +/- Rest Pain Cold Peripheries Arterial Ulcers Wet/dry gangrene 25

26. 30/07/2012 Dr Habib Tareif, FRCSI Claudication Definition: Muscle pain which appears during exercise when there is an inadequate arterial flow Intermittent Claudication Claudicato = to limp 26

27. 30/07/2012 Dr Habib Tareif, FRCSI Intermittent Claudication Claudication Distance: The distance the patient is able to walk before onset of pain. Must be recorded accurately 27

28. 30/07/2012 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 28 Dr Habib Tareif, FRCSI

29. 30/07/2012 Dr Habib Tareif, FRCSI Intermittent Claudication Differential Diagnosis Nerve Root Compression Arthropathy Spinal Stenosis 29

30. 30/07/2012 Clinical Presentation “Must 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 30 Dr Habib Tareif, FRCSI

31. 30/07/2012 Intermittent Claudication 30% are Diabetics Increased relative risk of death x3 50%-heart disease 15%-stroke

32. 30/07/2012 Dr Habib Tareif, FRCSI 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) 32

33. 30/07/2012 Physical Examination Skin Thin, brittle, shiny with thick opaque toes Often cool No hair Poor capillary refill 33 Dr Habib Tareif, FRCSI

34. 30/07/2012 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 34 Dr Habib Tareif, FRCSI

35. 30/07/2012 Dr Habib Tareif, FRCSI INVESTIGATION OF PVD Assess risk factors: Fasting lipids & glucose, HbA1c Non-Invasive Doppler Ankle/Brachial Index & Duplex Invasive CT Angiogaphy/ MRI Angiography 35

36. 30/07/2012 Dr Habib Tareif, FRCSI 36

37. 30/07/2012 Dr Habib Tareif, FRCSI Digital Pressures: useful in Diabetes Mellitus. Why? 37

38. 30/07/2012 Duplex Ultrasound Advantages Noninvasive Fast/cheap Few complications Disadvantages Dependent on ultrasonographers ability Poor visualization below the knee 38 Dr Habib Tareif, FRCSI

39. 30/07/2012 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 39 Dr Habib Tareif, FRCSI

40. 30/07/2012 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 40 Dr Habib Tareif, FRCSI

41. 30/07/2012 Claudication Treatment STOP SMOKING Exercise program Control diabetes, lower cholesterol Pentoxyphylline Cilostazole “75% improve with non-operative management” 41 Dr Habib Tareif, FRCSI

42. 30/07/2012 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” 42 Dr Habib Tareif, FRCSI

43. 30/07/2012 Dr Habib Tareif, FRCSI 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 43

44. 30/07/2012 Dr Habib Tareif, FRCSI Burger's Disease (Thromboangiitis Obliterans) Clinical Features Males <45 years Upper and lower limb involvement Heavy smokers Angiogram Normal proximal arteries Distal occlusions 44

45. 30/07/2012 Dr Habib Tareif, FRCSI The Diabetic Foot Pathophysiology Ischaemia (Microangiopathy/Macroangiopathy) Neuropathy Sepsis 45

46. 30/07/2012 Dr Habib Tareif, FRCSI 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 46

47. 30/07/2012 Dr Habib Tareif, FRCSI 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 47

48. 30/07/2012 Dr Habib Tareif, FRCSI 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 48

49. 30/07/2012 Dr Habib Tareif, FRCSI Arterial Ulcer 49

50. 30/07/2012 Dr Habib Tareif, FRCSI Dry Gangrene: No infection 50

51. 30/07/2012 Dr Habib Tareif, FRCSI Wet Gangrene: Infected! 51

52. 30/07/2012 Dr Habib Tareif, FRCSI Femoral Angiography 52

53. 30/07/2012 Dr Habib Tareif, FRCSI Neuropathic Ulcers 53

54. 30/07/2012 Dr Habib Tareif, FRCSI NEUROPATHIC ULCER 54

55. 30/07/2012 Acute Ischemia presentation Sudden Severe Agonizing Pain Parasthesia Discoloration Loss of movement Cold Limb 55 Dr Habib Tareif, FRCSI

56. 30/07/2012 Dr Habib Tareif, FRCSI Acute Ischaemia Clinical Features Pain Pallor Parasthesia. Paralysis Pulselessness Perishing Cold Pistol Shot onset 56

57. 30/07/2012 Dr Habib Tareif, FRCSI Acute Limb Ischaemia Embolus Thrombus Trauma 57

58. 30/07/2012 Dr Habib Tareif, FRCSI Acute Limb Ischaemia Source of Emboli Heart - 90% - Arrhythmias - Valvular heart disease - Prosthetic heart valves - Mural thrombus post MI - Ventricular aneurysm 58

59. 30/07/2012 Dr Habib Tareif, FRCSI Acute Limb Ischaemia Source of Emboli Great Vessels (9%) Atherosclerotic aorta Aortic aneurysm Popliteal artery aneurysm Other (1%) Paradoxical 59

60. 30/07/2012 Dr Habib Tareif, FRCSI Acute Limb Ischaemia Thrombus Thrombus on a pre-existing atherosclerotic lesion Patient has history of intermittent Claudication 60

61. 30/07/2012 Acute Ischaemia Treatment Urgent Treatment, Heparin Heparin Investigations Intervention ? Thrombolytic 61 Dr Habib Tareif, FRCSI

62. 30/07/2012 Dr Habib Tareif, FRCSI Acute Limb Ischaemia Vascular Trauma 62

63. 30/07/2012 Dr Habib Tareif, FRCSI 63

64. 30/07/2012 Dr Habib Tareif, FRCSI Trash Foot- Late Presentation 64

65. 30/07/2012 Dr Habib Tareif, FRCSI Summary Arterial Disease => acute vs. chronic Venous Disease Diabetes 65

66. 30/07/2012