VASCULAR DISEASE

NICYELA JILLIEN
406182061
PERIPHERAL ARTERIAL DISEASE

Patients with peripheral arterial disease (PAD) have decreased lower extremity arterial perfusion
which is commonly referred to as “poor circulation.” In most cases of PAD, atherosclerotic plaques
narrow the arterial flow lumen which restricts blood flow to the distal extremity. Reduced blood
flow can cause thigh or calf pain with walking due to temporary ischemia of the leg muscles
during exertion.
Peripheral artery disease is usually caused by atherosclerosis. Other causes my abe inflammation of
the blood vessels, injury, or radiation exposure.
 Risk factors include:
 Diabetes
 Smoking
 Obesity (a body mass index over 30)
 High blood pressure
 High cholesterol
 Increasing age, especially after reaching 50 years of age
 A family history of peripheral artery disease, heart disease or stroke
 High levels of homocysteine, a protein component that helps build and maintain tissue
SIGN AND SYMPTOMS

 The most characteristic symptom of PAD is claudication which is a pain in the lower
extremity muscles brought on by walking and relieved with rest.
 Although claudication has traditionally been described as cramping pain, some patients
report leg fatigue, weakness, pressure, or aching. Symptoms during walking occur in the
muscle group one level distal to the artery narrowed or blocked by PAD.
 Patients with severe PAD can develop ischemic rest pain. These patients do not walk
enough to claudicate because of their severe disease. Instead, they complain of burning
pain in the soles of their feet that is worse at night. They cannot sleep due to the pain and
often dangle their lower leg over the side of the bed in an attempt to relieve their
discomfort.
DIFFERENTIAL DIAGNOSIS

 Deep vein thrombosis

 Low back pain
 Superficial thrombophlebitis
EVALUATION

 Ankle-brachial index (ABI)

 Doppler
TREATMENT

 Management strategies for PAD attempt to achieve two distinct goals: lower cardiovascular risk
and improve walking ability.
 Exercise therapy: walking until reaching pain tolerance, stopping for a brief rest, and walking
again as soon as the pain resolves.
 30-45 minutes, 3-4 times per week for at least 12 weeks
 Pharmacotherapy
 Cilostazol
 Pentoxyfilline
 Balloon angioplasty or stent placement (option for patients with PAD symptoms that do not
respond to exercise or medical therapy)
 Since PAD does not usually represent a life or limb threatening condition, surgery should be
reserved for highly selected patients who have significant symptoms despite treatment with
non-invasive and endovascular therapy. Surgical options for PAD include bypass grafts to divert
flow around the blockage or endarterectomy to segmentally remove the obstructive plaque.
COMPLICATIONS AND PROGNOSIS

 Ischemia/Gangrene
 Amputation
 Infection
 Ulceration
 Heart attack
 Stroke
 Blood clots
 Erectile Dysfunction
With treatment, the prognosis of PAD is generally good, however, due to a coexistence of
cerebrovascular or coronary artery disease the mortality rate is relatively high.
CHRONIC VENOUS INSUFFICIENCY

 Chronic venous insufficiency (CVI) typically refers to lower extremity edema, skin trophic
changes, and discomfort secondary to venous hypertension.
 The etiology of chronic venous insufficiency can also be classified as either primary or
secondary to deep venous thrombosis (DVT).
 Approximately 70% of patients have primary chronic venous insufficiency and 30% have
the secondary disease.
 Primary chronic venous insufficiency have identified reduced elastin content, increased
extra-cellular matrix remodeling and inflammatory infiltrate.
 Secondary chronic venous insufficiency occurs in response to a DVT which triggers an
inflammatory response subsequently injuring the vein wall.
SIGN AND SYMPTOMS

 Patients with chronic venous insufficiency commonly present initially with a combination of
dependent pitting edema, leg discomfort, and fatigue, and itching.
 Although there can be variation in presentation among patients, certain features are
more prevalent: pain, cramping, itching, prickling, and throbbing sensation.
 Patients may describe symptoms that improve with rest and leg elevation, and with no
association for exercise.
 Patients with advanced disease will present with a severe blanched skin lesion, dermal
atrophy, hyperpigmentation, dilated venous capillaries, and ulcer formation most
commonly overlying the medial malleolus.
EVALUATION

 Duplex ultrasonography
 Ankle-brachial index
TREATMENT

 Patients with chronic venous insufficiency should be treated based on their severity and
nature of the disease. The treatment goals include reducing discomfort and edema,
stabilizing skin appearance, removing painful varicose veins and healing ulcers.
 Most patients should initially be treated conservatively with leg elevation, exercise (which
improves calf muscle pump), weight management, and compression therapy.
 Ulcers are treated best with compression bandaging systems.
DEEP VEIN THROMBOSIS

A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins usually of the leg but can occur in
the veins of the arms and the mesenteric and cerebral veins.
 Risk Factors
 Following are the risk factors and are considered as causes of deep venous thrombosis:
 Reduced blood flow: Immobility (bed rest, general anesthesia, operations, stroke, long-haul flights)
 Increased venous pressure: Mechanical compression or functional impairment leading to reduced flow in the
veins (neoplasm, pregnancy, stenosis, or congenital anomaly which increases outflow resistance)
 Mechanical injury to the vein: Trauma, surgery, peripherally inserted venous catheters, previous DVT, intravenous
drug abuse.
 Increased blood viscosity: Polycythaemia rubra vera, thrombocytosis, dehydration
 Increased Risk of Coagulation
 Genetic deficiencies: Anticoagulation proteins C and S, antithrombin III deficiency, factor V Leiden mutation
 Acquired: Cancer, sepsis, myocardial infarction, heart failure, vasculitis, systemic lupus erythematosus and lupus
anticoagulant, Inflammatory bowel disease, nephrotic syndrome, burns, oral estrogens, smoking, hypertension,
diabetes
 Constitutional Factors
 Obesity, pregnancy, Increasing age
SIGN AND SYMPTOMS

 Symptoms
 Pain (50% of patients)
 Redness
 Swelling (70% of patients)
 Physical Examination
 Limb edema may be unilateral or bilateral if the thrombus is extending to pelvic veins
 Red and hot skin, with dilated veins
 Tenderness
 Pain on dorsiflexion of the foot (the Homans sign)
EVALUATION

 D-dimers (very sensitive but not very specific)

 Proximal leg vein ultrasound (when positive, indicates that the patient should be treated
as having a DVT)
TREATMENT

 Treatment of DVT aims to prevent pulmonary  Rivaroxaban is an oral factor Xa inhibitor which
embolism, reduce morbidity, and prevent or has recently been approved by the FDA and
minimize the risk of developing the post- NICE and is attractive because there is no need
thrombotic syndrome. The cornerstone of for regular INR monitoring
treatment is anticoagulation. NICE guidelines  Thrombolysis: Following are the indications for
only recommend treating proximal DVT (not the use of thrombolytics:
distal) and those with pulmonary emboli. In
each patient, the risks of anticoagulation  Symptomatic iliofemoral DVT
need to be weighed against the benefits.[  Symptoms of less than 14 days duration
 Anticoagulation  Good functional status
 Low-molecular-weight heparin or fondaparinux  Life expectancy of 1 year or more
for 5 days or until INR is greater than 2 for 24
hours (unfractionated heparin for patients with  Low risk of bleeding
renal failure and increased risk of bleeding)  Compression hosiery: Below-knee graduated
 Vitamin K analogs for 3 months compression stockings with an ankle pressure
greater than 23 mm Hg for 2 years (if there are
 In patients with cancer, consider no contraindications)
anticoagulation for 6 months with low-
molecular-weight heparin  Inferior vena cava filters: If anticoagulation is
 In patients with unprovoked DVT consider contraindicated or if emboli are occurring
vitamin K analogs beyond 3 months despite adequate anticoagulation
COMPLICATIONS AND PROGNOSIS

 The following are the two major complications of DVT;

 Pulmonary emboli (paradoxical emboli if an atrioseptal defect is present)
 Post-thrombotic syndrome
 Bleeding from use of anticoagulants
 Prognosis:
 Many DVTs will resolve with no complications.
 Post-thrombotic syndrome occurs in 43% 2 years post-DVT (30% mild, 10% moderate, and severe in
3%).
 Risk of recurrence of DVT is high (up to 25%).
 Death occurs in approximately 6% of DVT cases and 12% of pulmonary embolism cases within one
month of diagnosis.
 Early mortality after venous thromboembolism is strongly associated with the presentation as
pulmonary embolism, advanced age, cancer, and underlying cardiovascular disease.
ACUTE LIMB ISCHEMIA

 Acute limb ischemia is defined as a sudden loss of limb perfusion for up to 2 weeks after
the initiating event.
 The most common cause of acute limb ischemia is in situ thrombotic occlusion. It is more
common in the lower extremities, and the initiating event is a preexisting history of
peripheral artery disease (PAD). Thrombotic occlusions can occur in any segment of the
upper and lower extremities but most commonly affects the superficial femoral artery.
Patients who have a preexisting history of PAD tend to have the well-established
development of collateral vessels creating variability in symptoms and severity. Other
causes include embolic occlusion from the left heart, aorta, and iliac vessel, as well as
penetrating or blunt trauma.
SIGN AND SYMPTOMS

 The classic presentation of limb ischemia is known as the "six Ps"; they are as follows: pallor,
pain, paresthesia, paralysis, pulselessness, and poikilothermia.
 These clinical manifestations can occur anywhere distal to the occlusion.
 Most patients initially present with pain, pallor, pulselessness, and poikilothermia.
 Pain is often localized and less severe when the limb is in the dependant position.
 As the ischemia prolongs, paresthesia replaces pain and the final stages of injury cause
paralysis.
EVALUATION

 Bilateral pulse exam (manual palpation and arterial Doppler exam)

 Muscle strength and sensation test
TREATMENT

 Cases of limb-threatening ischemia require emergent vascular surgery consult.

 The surgical approach is directed at reperfusion of the affected extremity. This can be
accomplished by the surgical bypass, endarterectomy, or embolectomy.
COMPLICATIONS

 Compartment syndrome
 Amputation
 Necrosis and gangrene
 Bleeding
 Stroke
 MI
 Death