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Lower Extremity Arterial Disease
Dr Dharmaraj Rajesh Babu Consultant National University Heart Center
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Lower Extremity Arterial Disease Dr Dharmaraj Rajesh Babu - - PowerPoint PPT Presentation
Lower Extremity Arterial Disease Dr Dharmaraj Rajesh Babu - - PowerPoint PPT Presentation
Lower Extremity Arterial Disease Dr Dharmaraj Rajesh Babu Consultant National University Heart Center Topic and date goes here 1 Introduction Epidemiology Natural History Diagnosis Management Topic and date goes here 2 Introduction
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Introduction
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Introduction
Chronic lower limb ischemia secondary to peripheral arterial disease is most common limb pathology seen by vascular specialist Due to increasing age, increasing prevalence of DM and other risk factors the prevalence is on the rise Patient present with asymptomatic disease, intermittent claudication, rest pain, or tissue loss
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Epidemiology
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Epidemiology
Best method of assessing the prevalence is to record the ABI and correlate it with risk factors ABI less than 0.9 and higher than 1.4 is abnormal ABI correlated well with the mortality risk associated with PAD, regardless of whether leg symptoms are present Overall prevalence is 4.3%
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Epidemiology
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Prevalence based on risk factors
Hypertension increases risk by 2.5 fold PAD prevalence is 20% to 30% higher in DM Severity of arterial occlusive is proportional to number of cigarettes smoked
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Odds ration for risk factors for symptomatic PAD
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Natural History
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Natural history
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One year outcomes
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Diagnosis
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Diagnosis
Complete History and detailed physical examination Classical Risk factors and less commonly associated risk factors should be identified and defined Diagnostic tests
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Diagnostic Studies
Hematological investigations Cardiac and cerebrovascular Evaluation Exclusion of
- ther associated
pathology like aneurysm Vascular laboratory and imaging studies
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Hematological Studies
Full blood count Fasting Blood Sugar Serum creatinine Fasting Lipid profile Hypercoagulable states Homocysteine
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Vascular Laboratory
ABI Toe Pressure tcPO2 Exercise ABPI Ultrasound Duplex
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Imaging
CT Angiogram MR Angiogram Conventional Angiogram
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Treatment
Control Cardiovascular Risk factors Specific therapies
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Control Cardiovascular Risk Factors
Smoking Diabetes mellitus Hypertension Dyslipidemia Platelets and Thrombosis Homocysteinemia
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Smoking
Smoking cessation has been shown to reduce the risk of MI and death in patients with pad and delay the progression of lower extremity symptoms from claudication to CLI and Limb loss Three fold increased risk of graft failure in smokers
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Smoking Cessation
Education Emotional Support Pharmacological aids
Education Emotional Support Pharmacological aids
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Smoking Cessation
Bupropion Varenicline
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Diabetes Mellitus
1% increase in glycosylated hemoglobin is associated with 28% increase in risk of PAD DM leads to alteration in nitric oxide availability and stimulation of proatherogenic activity in vascular smooth muscles DM enhances platelet aggregation=n, increased blood viscosity and elevation of fibrinogen levels
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Diabetes Mellitus
American Diabetes association guidelines recommend hemoglobin A1c levels less than 7% Goal should be maintain glucose control close to normal without significant hypoglycemia
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Hypertension
2 to 3fold increased risk of PAD Target blood pressure of 140/90 mmHg in high risk groups Target bloos pressure of 130/80 mm Hg in patients who also have Dm or renal insufficiency
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Dyslipidemia
Total Serum cholesterol levels greater than 5.18 mmol/l are associated with an increased risk of cardiac related events, especially in combination with a low HDL fraction Statins have lipid lowering properties Statins also works by stabilizing existing atherosclerotic plaques, decreasing oxidative stress and reducing vascular inflammation Statin also protects against thrombosis by altering the lipid content
- f platelets, thereby decreasing platelet aggregability
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Platelets and thrombosis
Antiplatelet therapy reduces the risk of non fatal MI, ischemic stroke and vascular related death Asiprin, Clopidrogrel and newer drugs are available All patients with diagnosed PVD should be started on antiplatelets. No evidence of it in patients at-risk
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Claudication
Exercise Therapy Pharmacologic treatment Revascularization in disabling claudication
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Pharmacological treatment
Pentoxifyline Cilostazol
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Critical lower limb ischemia
Need tertiary care Control of risk factors Revascularization and debridement
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