Dr.AbdulAziz Al Muzaini
PAD
Students
Arterial Disease
Anatomy
Dr.A.Al-Muzaini
Arterial Disease
Risk Factors for PAD
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Family H/O CAD, PAD, CVA.
Personal H/O CAD, MI.
Known arterial disease.
Stroke.
Diabetes.
Hypertension.
Hyperlipidemia.
Tobacco Abuse.
Dr.A.Al-Muzaini
Arterial Disease
Mode of Examination
• History and physical examination
• Physiological testing (ABI, Pressure
measurements and Doppler waveforms).
• Duplex Sonography.
• Angiography (Catheter, MRA and CTA).
Dr.A.Al-Muzaini
Arterial Disease
History and Physical Examination
• Sensitive- moderate and sever arterial
insufficiency.
• Limited localization of obstruction.
Dr.A.Al-Muzaini
Arterial Disease
Patient History & Examinations
Dr.A.Al-Muzaini
Arterial Disease
Physiological Testing
(ABI, Pressure Measurements and Doppler
Waveforms)
• Very sensitive for arterial insufficiency (especially
with exercise).
• Specific – answer question: are symptoms due to
arterial insufficiency?
• Semi – quantitative (severity).
• Detect progression over time.
• Limited localization of obstruction.
Dr.A.Al-Muzaini
Arterial Disease
Peripheral Lower Limb Ischemia
Acute
on top
of chronic
Most common
Chronic
Critical
Acute
5 Ps
Rest pain > 2 weeks + trophic
changes or low ankle and toe
pressure
Dr.A.Al-Muzaini
Arterial Disease
Claudication “To Limp”
• Mild to moderate disease.
• Progressive muscular cramping pain with
exertion.
• Typically in calf, but may be thigh
or buttock.
• Location dependent upon the site
of the lesion(S).
• Relieved by rest.
• Consistent onset and severity.
• Not joint pain.
Dr.A.Al-Muzaini
Arterial Disease
Severe Disease
1•
Ischemic rest pain
2
Ulceration
3
Tissue Necrosis
4
Gangrene
Dr.A.Al-Muzaini
Arterial Disease
Physical Examination
• Thick to nails + crack.
• Depended rubber.
• Ulcer.
• Dry scale skin
Dr.A.Al-Muzaini
Dr.A.Al-Muzaini
Arterial Disease
Noninvasive Assessment of Arterial Disease
• Physiological Testing:
- Indirect testing evaluates hemodynamics.
- Determine physiological impairment.
• Duplex Ultrasound:
- Morphologic and physiologic information.
- Identifies changes in blood flow patterns
due to pathology.
- Define location of disease more precisely.
Dr.A.Al-Muzaini
Arterial Disease
Normal Waveform
Dr.A.Al-Muzaini
Arterial Disease
Waveforms
Biphasic
Monophasic
Dr.A.Al-Muzaini
Arterial Disease
Waveform
Dr.A.Al-Muzaini
Arterial Disease
Segmental Pressure (SLP)
• Compare to contralateral limb same level
(Horizontal).
• Compare to adjacent segments (Vertical).
• ≥ 20 mm/hg pressure gradient (drop) is
significant if the ABI is normal.
• Can determine region of disease.
Dr.A.Al-Muzaini
Arterial Disease
Physiological Arterial Testing
•
Segmental Limb Pressures
(SLP):
 Compare to brachial
pressure
 Compare to
contralateral limb.
 Compare to adjacent
segments.
Dr.A.Al-Muzaini
Arterial Disease
Segmental Limb Pressure SLP
Dr.A.Al-Muzaini
Arterial Disease
Ankle Brachial Index (ABI)
• Normal individual in a supine position, ankle
systolic pressure is ≥ Brachial.
• Highest ankle pressure divided by the higher
brachial pressure.
Dr.A.Al-Muzaini
Arterial Disease
Pressure Measurements and Doppler
• Semi-quantitative:
 Normal
 Claudications
- Mild
- Moderate
- Sever/Multi level
 Rest pain
 Tissue loss- gangrene
0.90 / 1.25
0.75 - 0.90
0.50 - 0.75
0.30 - 0.50
< 0.30
0.0
Dr.A.Al-Muzaini
Dr.A.Al-Muzaini
Physiological Arterial Testing
•
Toe Brachial Index:
 Used on patients
with incompressible
vessels.
 Diabetics, chronic
renal failure.
 Toe BI= 0.7 or
greater (normal).
 CW Doppler or
photocell.
Arterial Disease
Exercise Testing
• Useful in patients with mildly abnormal
resting studies, unusual
presentations/symptoms (borderline normal
from abnormal).
• Differentiate true vascular claudication from
“pseudo-claudication’.
• Confirm or exclude presences of arterial
disease.
Dr.A.Al-Muzaini
Arterial Disease
Vasculogenic claudication Criteria
• Drop in ankle pressure > 20 mm/hg
configuring vascular etiology for claudication.
• Larger the drop/ longer return to baseline
corresponds to lesion severity.
Dr.A.Al-Muzaini
Arterial Disease
Duplex (Mapping)
Dr.A.Al-Muzaini
Arterial Disease
Case Study
Dr.A.Al-Muzaini
Arterial Disease
Case Study
Dr.A.Al-Muzaini
Arterial Disease
Case Study
Dr.A.Al-Muzaini
Arterial Disease
Case Study
Dr.A.Al-Muzaini