Peripheral arterial disease
Ahmad Osailan
Pathophysiology
• Form of atherosclerosis
• Progressive disease
May occur suddenly if an embolism occurs or
when a blood clot rapidly develops in a blood
vessel restricted by an atherosclerotic plaque, and
the blood flow is quickly cut off.
Peripheral arterial disease
• Atherothrombosis = thrombus formation on top of
existing atherosclerosis
• Occurs in multiple arterial beds
Cerebrovascular disease
(ischaemic stroke, transient ischaemic attack)
Coronary artery disease
(stable/unstable angina, myocardial infarction)
PAD (intermittent claudication, critical leg
ischaemia, amputation, gangrene, necrosis)
Introduction
Peripheral arterial disease arises when there is significant narrowing of
arteries distal to the arch of the aorta.
Incidence (Including asymptomatic- assessed by non-invasive tests)
PAD affects 20% of people >70years age(Cochrane 2007).
• 13.9-16.9% in men
• 11.4-20.5% in women over 55 years of age
Usually about 60% of affected will be asymptomatic.
Mechanisms
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Atherosclerosis
Vasospasm
Inflammation/ vasculitis
Thrombosis/ Embolism
Case Presentation
• ID/CC: 83 yo Caucasian female with HTN, s/p
aortic valve replacement in generally excellent
health who complains of one year of right
thigh pain with “ambulation around the
grocery store but not around the house.”
Symptoms of PAD
• Leg or hip pain during walking (intermittent
claudication).
• The pain stops when you rest.
• Numbness, tingling or weakness in the legs.
• Burning or aching pain in feet or toes when
resting.
• Sore on leg or foot that won’t heal.
• Cold legs or feet.
• Color change in skin of legs or feet.
• Loss of hair on legs.
Claudication
DEFIt is the ischaemic pain due to decompensation of the blood supply
typically occurring with physical activity. Determining how much
physical activity is needed before the onset of pain is crucial.
It is most common with the distal superficial femoral artery (located
just above the knee joint), which corresponds to claudication in the
calf muscle area (the muscle group just distal to the arterial
disease).
If proximal vessels are involved, pain might be felt in thighs and
buttocks too.
There should be no weakness or numbness. Pain resolves quickly on
rest(<5mins).
Spinal pain( nerve root irritation, spinal stenosis) usually gives
symptoms localised to a muscle group, accompanied by weakness
Risk Factors
Risk Factors
Smoking biggest risk factor.
DM is a close second.
Rest are hypertension,
hyperlipidaemia,
family history,
sedentary lifestyle
Noninvasive diagnosis of PAD
• Ankle Brachial Index (ABI)
• ABPI = Ankle systolic pressure/ Brachial systolic pressure.
• In the absence of significant stenosis or occlusion in these vessels the two
values are usually within 10 mmHg of each other even in the presence of more
proximal disease.
• The maximum cuff pressure at which the pulse can just be heard with the
probe is recorded .
• BP measures in both arms and the higher of both used.
Interpretation of values
• Symptom free
- 1 or more
• Intermittent claudication - 0.95 - 0.5
• Rest pain
- 0.5 - 0.3
• Gangrene and ulceration - <0.2
How to do an ABPI?
• http://www.youtube.com/watch?v=bTVYl9UR
dSI&feature=related
Critical limb ischaemia
Treatments
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Risk factor reduction
Exercise
Medications
Percutaneous translumenal angioplasty (PTA)
Arterial bypass surgery
Exercise
• Numerous studies demonstrating clear
benefits
• A meta-analysis in JAMA (1995) showed an
increase of 179% (from 125 to 350 meters) to
onset of claudication pain and an increase of
122% (from 325-723 meters) to maximal
claudication pain
• Equal to an additional 4 blocks by treadmill
• P<.001
Exercise Prescription
• Training Intensity
Initial
• Set by result of peak treadmill.
• Starting exercise work load brings on
claudication pain.
Subsequent
• Speed or grade increased if patient walks >
10 minutes.
• Grade increased first if speed > 2 mph.
• Speed increased first if < 2 mph.
Exercise Prescription
• Duration
Initial
• 35 minutes (intermittent walking)
Subsequent
• Add 5 minutes every session until 50 minutes
(intermittent walking) is possible
Exercise Prescription
• Frequency
3-5 times per week.
• Specificity of Activity
Treadmill walking is the recommended exercise.
Surgical Treatments for PVD
• Thrombectomy
• Bypass Grafts
Peripheral venous diseases
Peripheral venous disease
• Peripheral venous disease is a term describing damage,
defects or blockage in the veins that carry blood from the
hands and feet to the heart. Peripheral venous disease can
occur almost anywhere in the body but is mostly seen in
the arms and legs.
• The most common cause of peripheral venous disease is a
blood clot that blocks a vein. A clot forms when vein walls
become weak and blood flow slows. When the clot is in a
vein deep within the body, it is called deep vein
thrombosis. When the clot is in a vein closer to the skin, it
is called superficial thrombophlebitis.
Deep Venous Thrombosis
• A blood clot in a deep vein.
• May form on the valves within the vein, and may
subsequently increase in size to totally occlude the vein.
• Sometimes parts of the clot may break off and travel in
the bloodstream to the lungs and cause serious health
problems (pulmonary embolism).
•
• DVT is perhaps the most dangerous problem.
Varicose Veins
• Caused because either the blood flow is too slow making
the vein pile up with blood or the valve in the vein is not
working well so the blood falls down due to gravity and
piles up in the veins of the legs.
• Sclerotherapy: Irritant chemical is injected into the veins,
causing them to scar and seal off. This “detours” the
blood to nearby healthier veins.
• Stripping: Procedure used to remove larger varicose
veins. Parts of the vein can be removed or tied off, or the
entire vein can be removed.
Phlebitis
• Inflammation of the leg veins.
• Two types:
Inflammation of the veins on the surface of the leg
(more common).
Inflammation of the deep veins of the leg.
• Phlebitis is caused by an infection or injury.
• Can cause a blood clot to form and this clot can then
embolize and result in pulmonary embolism. This is the
worst thing that can happen if you have phlebitis.
Physical therapy treatment
• For varicos veins:
• Elevating the affected leg above your heart to help
pooled blood drain properly.
• Avoiding long periods of standing or sitting. If you must
sit for a long period, stretch and flex your legs every 5
minutes or so to keep blood flowing.
• Wearing elastic compression stockings that squeeze the
veins and keep the blood flowing in your legs, which
makes it more difficult for blood clots to form.
Physical therapy treatment
• For DVT:
• There is no specific Exercises for DVT BUT
there are precautions to exercise patients
with DVT, they are:
1. Never elevate the affected extremities to assisted
gravity position for blood flow.
2. Do not exercise patient in supine position, always
perform exercises while sitting
3. never do any massage technique on the affected
extremity
4. Encourage walking more than anything else.