PERIPHERAL VASCULAR DISEASE

1. PERIPHERAL VASCULAR DISEASE Dr.P.S.MAmeer Ali M.S Professor Of Surgery YMCH

2. Most common cause of morbidity & death in developed countries. • Adverse events are due to impaired circulation to critical end organs or extremities. • Atherosclerosis & Thromboangitis Obliterans(TAO) are the main culprits. • Smoking,hypercholestrolemia,fatty diet,diabetes mellitus,hypertension are the most important causes.

3. CLINICAL FEATURES • Intermittent claudication definition : It is a cramp like pain felt in the muscles that is brought on by walking and not present on taking the first step and relieved by standing still. usual site : calf ( also in thigh / buttock) LERICHE SYNDROME - Buttock claudication with impotence Grade 1 : pain starts on walking & on continuing to walk it disappears Grade 2 : pain persists but patient walks with effort Grade 3 : pain compels patient to take rest Grade 4 : rest pain

4. Coldness,paraesthesia & colour change common in moderate & severe ischaemia. Affected limb blanches on elevation (buerger’s postural test) and turns cyanotic on dependency • Ulceration presents as a painful erosion or as shallow non healing ulcers on dorsum of feet,malleoli & on the shins.

5. Gangrene Defined as macroscopic death of tissue with superadded putrefaction. TAO commonly presents with dry gangrene whereas diabetes presents with wet gangrene. Pre – gangrene : rest pain,colour changes,oedema,hyperaesthesia with or without ulceration Critical limb ischaemia : persistently recurring rest pain due to ischaemia with ulceration/gangrene with ankle pressure of <50mm hg or toe systolic pressure of <30mm hg

6. TAO is exclusively in male smokers of younger age group (20-40yrs) but atherosclerosis affects both sexes & occurs at age >50 • Pathology : TAO = panarteritis atherosclerosis = atheroma formation • Small & medium sized vessels involved in TAO , large vessels in atherosclerosis • Arterial bruits auscultable in atherosclerosis but not in TAO

7. INVESTIGATIONS Blood parameters : CBC , blood sugars (usualy elevated in diabetes patients) , fasting lipid profile (elevated in atherosclerosis patients). Minor tests : ankle-brachial index (ABPI) ABPI = ankle BP / brachial artery BP Normal value : 1 <0.9 :moderate ischaemia <0.4 :critical limb ischaemia ECG , echocardiogram ,chest x-ray

8. Doppler & duplex ultrasonography B-mode ultrasound is used and doppler shift can be used to obtain vessel flow,turbulence,change in flow direction & velocity of flow thereby determining presence or absence of stenosis. Angiography appropriate if intervention is being planned. SELDINGER technique. either DSA(digital subtraction angiography) or CT / MRI angiography is done.

9. TREATMENT • General advice 1.Life style modification 2.Stop smoking 3.Encourage exercise 4.Dietary modification (reduce red meat) 5.Care of ischaemic foot

10. Medical therapy 1.Lipid lowering drugs(statins) 2.Anti platelet therapy(aspirin,clopidogrel) 3.Diabetic control(OHA’s & insulin) 4.Disease modifying agents (Trental = pentoxyphilline) 5.Fibrinolytics{heparins, Tissue Plasminogen Activator (TPA)} only in case of acute occlusions

11. Surgery (TAO) 1.Lumbar sympathectomy : it’s a preganglionic sympathectomy where the trunk is divided below L1 and removed upto L4. it does not reduce the pain but reduces ulcer formation. 2.Conservative amputation 3.Below knee amputations are last resort.

12. Atherosclerosis 1.Transluminal angioplasty & stenting (successful in iliac artery occlusions) 2.Endarterectomy (preferred in carotid bifurcation stenosis,short segment lesion) 3.Bypass grafting Aortoiliac disease - aortofemoral graft Iliofemoral disease – iliofemoral graft Femoropopliteal disease – femoropopliteal graft Profunda femoris artery – profundoplasty NOTE : graft materials (reversed saphenous vein,dacron,PTFE)

13. THANK YOU • References : 1.bailey & love (25th edn) 2.sabiston (18th edn)