Peripheral Arterial Disease (PAD) - Surgery

what is PAD?
It is a progressive disorder characterized by stenosis and/or occlusion of large and medium-sized arteries supplying the limbs.

CORRECT

what is PAD?
WHAT ARTERIES ARE AFFECTED?

what is PAD?
It is a progressive disorder characterized by stenosis and/or occlusion of large and medium-sized arteries supplying the limbs.

LARGE ARTERIES pad?

COMMON ILLIAC

distal abdominal aortic

medium sized arteries?

femoral tibial poplitial

PAD is defined by which index?

It is defined by an ankle brachial index (ABI) of less than 0.90

PAD is defined by an ankle brachial index (ABI) of less than????

It is defined by an ankle brachial index (ABI) of less than 0.90

which vessels more affected lower or upper?

Lower extremity >> Upper extremity

risk factors Of PAD?

old age
smoker

IHD

Atherosclerotic PAD (90%)

correct

main cause of PAD?

Atherosclerotic PAD (90%)

Non-Atherosclerotic PAD (10%) to risk factor trigges

– Popliteal artery entrapment syndrome.

– Cystic adventitial disease of the popliteal artery. (congenital)

– Iliac artery Endo fibrosis

.– Fibromuscular dysplasia

– Large- and medium-vessel vasculitis (autimmune)

right

Non-Atherosclerotic PAD (10%) to risk factor trigges

Non-Atherosclerotic PAD (10%) to risk factor trigges

– Popliteal artery entrapment syndrome.

– Cystic adventitial disease of the popliteal artery. (congenital)

– Iliac artery Endo fibrosis

.– Fibromuscular dysplasia

– Large- and medium-vessel vasculitis (autimmune)

In Saudi Arabia, the prevalence of PAD is estimated at 12% of the population.

right

In Saudi Arabia, the prevalence of PAD is estimated at 1_________

In Saudi Arabia, the prevalence of PAD is estimated at 12% of the population.

The prevalence of PAD increases with the age of the population. • More common in black.

right

modfiable risk factors of PAD?
Smoking

Hypertension

Hyperlipidemia

Diabetes Mellitus

Obesity

Sedentary lifestyle

hypercoagbility

right

modfiable risk factors of PAD?

modfiable risk factors of PAD?
Smoking

Hypertension

Hyperlipidemia

Diabetes Mellitus

Obesity

Sedentary lifestyle

hypercoagbility

non-modifable risk factors?

Ageing

Family history of vascular disease

Known coronary, carotid or renal

atherosclerotic disease

Chronic kidney disease

how much asymptomatic patients of PAD?

Asymptomatic: 50 % of patients with PAD.

what is the symptom of the PAD?
Intermittent claudication (IC):
-Reproducible, ischemic, tight, aching, or squeezing pain in the co calf, thigh, or buttock that occurs with excretion.

• It occurs usually after the same amount of excretion and is relieved by rest (within 10 min).

right

Intermittent claudication (IC): is?

-Reproducible, ischemic, tight, aching, or squeezing pain in the co calf, thigh, or buttock that occurs with excretion.

Intermittent claudication (IC) wirse by?

what is the symptom of the PAD?
Intermittent claudication (IC):
-Reproducible, ischemic, tight, aching, or squeezing pain in the co calf, thigh, or buttock that occurs with excretion.

what is the symptom of the PAD?
Intermittent claudication (IC): better with?

• is relieved by rest (within 10 min).

what is classic symptom of PAD?

Only 35% of PAD patients have classic claudication; the remainder have atypical or no symptoms.

how much PAD have intermittent claudication?

Only 35% of PAD patients have classic claudication; the remainder have atypical or no symptoms.

Leriche syndrome, also known as aortoiliac occlusive disease, is a blockage of the lower abdominal aorta and/or iliac arteries, usually from atherosclerosis, causing a classic triad of symptoms:

1-claudication (leg pain with exercise),

2-impotence in men,

3- and absent or weak femoral pulses,

correct

what is leriche syndrome?

Leriche syndrome, also known as aortoiliac occlusive disease, is a blockage of the lower abdominal aorta and/or iliac arteries, usually from atherosclerosis, causing a classic triad of symptoms:

1-claudication (leg pain with exercise),

2-impotence in men,

3- and absent or weak femoral pulses,

leriche syndrome blockage of what?

Leriche syndrome, also known as aortoiliac occlusive disease, is a blockage of the lower abdominal aorta and/or iliac arteries, usually from atherosclerosis

triad of Leriche syndrome?

symptoms:

1-claudication (leg pain with exercise),

2-impotence in men,

3- and absent or weak femoral pulses,

4- muschle atrophy

1-claudication (leg pain with exercise),

2-impotence in men,

3- and absent or weak femoral pulses,

4- muschle atrophy

triad of Leriche syndrome

location of bloackage Leriche syndrome,?

Leriche syndrome, also known as aortoiliac occlusive disease, is a blockage of the lower abdominal aorta and/or iliac arteries, usually from atherosclerosis

Critical limb ischemia (CLI):
-Ischemic rest pain: continuous, burning pain in the foot which is aggravated by lying down and is relieved by sitting or standing.

– Ulcers

– gangrene

correct

Critical limb ischemia (CLI):
charactrised by?
UGI

Critical limb ischemia (CLI):
-Ischemic rest pain: continuous, burning pain in the foot which is aggravated by lying down and is relieved by sitting or standing.

– Ulcers

– gangrene

what is ischimic rest pain?
where is found?

ischemic rest pain: continuous, burning pain in the foot which is aggravated by lying down and is relieved by sitting or standing.

• in critical limb ischimia

ischemic rest pain:
A - triggered by?
B- relived by?

C- found in?

ischemic rest pain:
A - triggered by? lying down
B- relived by? and is relieved by sitting or standing.

C- found in? and is relieved by sitting or standing.

• in critical limb ischimia

crititcal limb ischimia is?

Critical limb ischemia (CLI):
-Ischemic rest pain: continuous, burning pain in the foot which is aggravated by lying down and is relieved by sitting or standing.

– Ulcers

– gangrene

You see a 60-year-old man with a history of coronary heart disease, diabetes

and hyperlipidaemia in your clinic. The patient has found it increasingly hard

to walk due to the gradual increase in intensity of the cramping pain he experi-

ences in his right leg on walking, which is relieved by resting a few minutes.

In addition, he tells you that cramps have started to occur at night when he is

sleeping. On examination of the right leg, you notice that there is a 'punched out'

ulcer on the right heel. The right posterior tibial and dorsalis pedis pulses are

weak. You suspect that this patient has critical limb ischaemia. What is the most

appropriate next line investigation that would support your diagnosis?

A. Computed tomography angiography

B. Ankle-brachial pressure index

C. Radiograph the lower limbs

D.Magnetic resonance angiography

E. None of the above

B. Ankle-brachial pressure index

379. A 58-year-old man presents with pain in the left leg after walking

more than one block that is relieved with rest. On physical examination,

distal pulses are not palpable in the left foot and there is dry gangrene on

the tip of his left fifth toe. An ankle-brachial index on the same side is 0.5.

Which of the patient's symptoms or signs of arterial insufficiency qualifies

him for reconstructive arterial surgery of the left lower extremity?

a. Ankle-brachial index less than 0.7

b. Rest pain

c. Claudication

d. Absent palpable pulses

e. Toe gangrene

e. Toe gangrene

Burger test:
two part test
1- become white?
2- become red?

indicates PAD

correct

Burger test:

Burger test:
two part test
1- become white?
2- become red?

indicates PAD

• signs of PAD :

• Nonhealing wounds or Gangrene

• • Shiny skin • Loss of hair

• • Cool skin temperature •

• Pale or bluish skin

• • Reduced capillary refill time

• • Pallor on elevation and rubor on dependency

• • Weak or absent pulses

correct

Dependent rubor after doing

beurger test

The distal limb turn into reddish color due to

vasodilation by lactate (a waste product of anaerobic process)

correct

Dependent rubor after doing

Dependent rubor after doing

beurger test

The distal limb turn into reddish color due to

vasodilation by lactate (a waste product of anaerobic process)

• signs of PAD :

• Nonhealing wounds or Gangrene

• • ___skin • Loss of hair

• • ____skin temperature •

• ___or bluish skin

• • ____capillary refill time

• • _____on elevation and ____on dependency

• • Weak or absent pulses

• signs of PAD :

• Nonhealing wounds or Gangrene

• • Shiny skin • Loss of hair

• • Cool skin temperature •

• Pale or bluish skin

• • Reduced capillary refill time

• • Pallor on elevation and rubor on dependency

• • Weak or absent pulses

The Rutherford classification:

• Stage 0: asymptomatic

• Stage 1: mild claudication

• Stage 2: moderate claudication

• Stage 3: severe claudication

• Stage 4: rest pain (CLI)

• Stage 5: ischemic ulceration not exceeding the digits of the Toes foot.

• Stage 6: severe ischemic ulcers or frank gangrene. C

right

The Rutherford classification:

The Rutherford classification:

• Stage 0: asymptomatic

• Stage 1: mild claudication

• Stage 2: moderate claudication

• Stage 3: severe claudication

• Stage 4: rest pain (CLI)

• Stage 5: ischemic ulceration not exceeding the digits of the Toes foot.

• Stage 6: severe ischemic ulcers or frank gangrene. C

the distance that delineates mild, moderate and severe claudication is not specified in the Rutherford classification, but is mentioned in the Fontaine classification as 200 meters.

correct

the distance that delineates mild, moderate and severe claudication is not specified in the Rutherford classification, but is mentioned in the ___________classification as ______-meters.

the distance that delineates mild, moderate and severe claudication is not specified in the Rutherford classification, but is mentioned in the Fontaine classification as 200 meters.

The Rutherford classification:

The Rutherford classification:

• Stage 0: asymptomatic

• Stage 1: mild claudication

• Stage 2: moderate claudication

• Stage 3: severe claudication

• Stage 4: rest pain (CLI)

• Stage 5: ischemic ulceration not exceeding the digits of the Toes foot.

• Stage 6: severe ischemic ulcers or frank gangrene. C

outcome of crititcal limb ischimia?

• Alive with two limbs 50%

• Amputation25%

• Cardiovascular mortality 25%

claudicatyion outcome?
Stable claudication 70-80%

Worsening claudication 10-20%

CLI 1-2% —> Amputation

correct

claudication outcome? limb outcome?
most outcome?

claudicatyion outcome?
Stable claudication 70-80%

Worsening claudication 10-20%

CLI 1-2% —> Amputation

cardiovascular mortality of limbs?
claudication

cardiac causes 75%

Diagnostic tools of PAD?

1- ankle brachial index
2- toe brachial index
3- pulse volume
4- segmental pressures

Duplex Ultrasonography.

•CTA/ MRA

•Angiography

correct

ankle brachial pulse normal?

0.9 —> 1.3

ankle brachial pulse PAD?

x < 0.9

ankle brachial pulse > 1.3 —.

calcification of the arteries (DM)

akle brachial ratioi is?

80/100

brachial > ankle
brachial 100
ankle 80
80/100

abkle brachial index
A/B = 80 /100

CORRECT

< 0.4

Severe PAD

0.9-1.3

Normal finding

if patient comes with pain in claudication but the
ankle brachila index is normal .. what to do?

G in its Exercise treadmill ABI

Must be ordered in symptomatic patients when resting ABIs are normal or borderline

Exercise treadmill ABI —> measure functional limitations attributable to leg symptoms

Exercise treadmill ABI

Must be ordered in symptomatic patients when resting ABIs are normal or borderline

Limitations of ABI:
- False elevation in patients with calcified arterial vessels (DM, CKD and Dialysis)

• ABI does not localize disease within the lower extremities

• -30%of Patients with CLI have Normal ABI

• ABI might be normal if there is isolated inflow disease

correct

Limitations of ABI:
- False elevation in patients with ???

Limitations of ABI:
- False elevation in patients with calcified arterial vessels (DM, CKD and Dialysis)

how much critical ill ischimai have normal ABI?

• -30%of Patients with CLI have Normal ABI

Toe Brachial Index (TBI):
Performed when the ABI is abnormally high due to calcification. •Normal TBI > 0.65

• Abnormal TBI < 0.65

correct

when we do Toe Brachial Index (TBI):?

Toe Brachial Index (TBI):
Performed when the ABI is abnormally high due to calcification.

normal Toe Brachial Index (TBI):

Toe Brachial Index (TBI):
Performed when the ABI is abnormally high due to calcification. •Normal TBI > 0.65

• Abnormal TBI < 0.65

• Abnormal TBI

• Abnormal TBI < 0.65

Duplex, CTA, MRA or angiography:

These studies are ordered for anatomic imaging assessment. Jf • They are generally reserved for highly symptomatic patients in whom revascularization is being considered

intact pulse do?

US

NO PULSE?
GOOD KIDNEY?

do CTA

NO PULSE?
BAD KIDNEY?

DO MRA

Management of PAD:
- Non CLI patient

– Structured Exercise therapy –

Guideline Directed Medical Therapy (GDMT)– Revascularization if persistent lifestyle-limiting claudication despite GDMT and structured exercise therapy for 12 weeks.

correct

a 23 y.o. non-CLI patient —> treatment?

Management of PAD:
- Non CLI patient

– Structured Exercise therapy –

Guideline Directed Medical Therapy (GDMT)– Revascularization if persistent lifestyle-limiting claudication despite GDMT and structured exercise therapy for 12 weeks.

CLI patient –

Guideline Directed Medical Therapy (GDMT)– Revascularization to provide in-line blood flow to the foot through at least 1 patent artery to preserve a functional limb.

Amputation

increases morbidity and mortality

• 40 % dead at 2 years

. • 50% deadat 5 years.

correct

Amputation

increases morbidity and mortality

• ___ % dead at 2 years

. • ____ % deadat 5 years.

Amputation

increases morbidity and mortality

• 40 % dead at 2 years

. • 50% deadat 5 years.