Peripheral Vascular Disease PDF

Peripheral vascular disease (PVD) 1 What is peripheral vascular disease? 1Peripheral vascular disease 2 bec of embolism or thrombus (PVD) is a circulation disorder that causes...

Peripheral vascular disease (PVD) 1 What is peripheral vascular disease? 1Peripheral vascular disease 2 bec of embolism or thrombus (PVD) is a circulation disorder that causes 3 narrowing, blockage, or spasms of blood vessels to parts of the body other than the brain and heart. end result for pvd tissue affected is in adequate supply so oxygen supply decrease too Peripheral vascular disease (PVD) is characterized by a reduction in blood flow and hence oxygen through the peripheral vessels. When the need of the tissue for oxygen exceeds the supply, areas of ischemia and necrosis will develop. 2 Causes of peripheral vascular disease include: Atherosclerosis : the most common cause. Blood clot: A blood clot can block a blood vessel (thrombus/emboli). Inflammation of the arteries: This condition is called arteritis and can cause narrowing or weakening of the arteries. Several autoimmune conditions can develop vasculitis. = inflammation bec of bacteria ex : rheumatoid , systemic lupus , sarcoidosis Infection: The inflammation and scarring caused by infection can block, narrow, or weaken blood vessels. Both salmonellosis (infection with Salmonella bacteria) and syphilis have been two infections traditionally known to infect and damage blood vessels. Structural defects: Defects in the structure of a blood vessel can cause narrowing. Most of these cases are acquired at birth, and the cause remains unknown. Takayasu disease is a vascular disease affecting the upper vessels of the body and affects usually Asian females. Injury: Blood vessels can be injured in an accident such as a car wreck or a bad fall. Hypercoagulable states. as coagulation factor is risky and hyperactive in patients with pvd as it get the chance to get thrombosis hyper coagulant state mainly depend on the viscosity of the blood specially in patients with polycythemia 3 The most common cause of peripheral vascular disease is atherosclerosis, or hardening of the arteries, a gradual process by which cholesterol plaques (material) builds up and causes inflammation in the inner walls of the arteries. This cholesterol plaque builds up over time and may block, narrow, or weaken the blood vessel walls, which results in restricted or blocked blood flow. 4 5  What are the risk factors for peripheral vascular disease? Positive family history of premature heart attacks or strokes. Old age: older than 50 years. With aging, blood vessels become less elastic, thin walled and calcified leading to increase peripheral vascular resistance with subsequent hypertension. bec of atherosclerosis changes Male gender bec female has estrogen which prevent the epithelial layer from damage to prevent atheroscelorosis Overweight or obesity Inactive (sedentary) lifestyle Cigarette smoking: nicotine causes vasoconstriction and spasm of the arteries + thermal effect which cause atherosclerosis Diabetes mellitus: Over the long-term, the high blood sugar level (hyperglycemia)of patients with diabetes can damage blood vesselsby(oxidative stress). This makes the blood vessels more likely to become narrowed or weakened (micro- & microvasculature). Also, patients with diabetes frequently also have high blood pressure and high cholesterol in the blood, which accelerates the development of atherosclerosis. High blood pressure (hypertension). chronic diseases can lead atherosclerosis Hypercholesterolemia: High cholesterol or LDL (the "bad cholesterol"), plus high triglycerides and low HDL (the "good cholesterol") can lead to atheroscelerosis People who have coronary heart disease or a history of heart attack or stroke generally also have an increased frequency of having peripheral vascular disease. What are the types of peripheral vascular disease? There are two types of peripheral vascular disease (PVD): (1) Functional PVD. no structural damage only spasm (2) Organic PVD. structural damage in wall of bv 7  types of peripheral vascular disease (1) Functional PVD: This type of PVD does not involve defects in the blood vessel structure, as the vessels are not damaged and the blood vessels are affected by external factors such as stress, temperature, or drugs. The spsm diseases of this type often have symptoms that come and go. The blood vessels naturally widen and narrow in response to the environment. But in functional PVD, the blood vessels exaggerate their response. Raynaud’s disease, when stress and temperatures affect the blood flow, is an example of functional PVD. The most common causes of functional PVD are: - emotional stress - Cold temperatures - drugs 8 types of peripheral vascular disease there is damage (2) Organic PVD: This type of PVD is caused by structural changes to the blood vessels, such as inflammation or tissue damage, including: Organic PVD means there’s change in the structure of the blood vessels. For example, the plaque buildup from arteriosclerosis can cause the blood vessels to narrow. The primary causes of organic PVD are: smoking high blood pressure diabetes high cholesterol Additional causes of organic PVD include extreme injuries, muscles or ligaments with abnormal structures, blood vessel inflammation, and infection 9  example for pvd Raynaud syndrome btegey mcq or disease Raynaud syndrome, also known as Raynaud's phenomenon, is a medical condition in which spasm of arteries cause episodes of reduced blood flow. Typically, the fingers, and less commonly the toes, are involved. Rarely, the nose, ears, or lips are affected. The episodes result in the affected part turning white and then blue. Often, numbness or pain occurs. As blood flow returns, the area turns red and burns. The episodes typically last minutes, but can last several hours. in ct disorder = autoimmune disease which get vasculitis functional type : no structural damage only spasm in smooth muscle Episodes are often triggered by cold or emotional stress. The two main types are primary Raynaud's, when the cause is unknown, and secondary Raynaud's, which occurs as a result of ischemic another condition. Secondary Raynaud's can occur due to a connective-tissue disorder, such changes in as scleroderma or lupus, injuries to the hands, prolonged vibration, smoking, thyroid problems, both primary and secondary and certain medications, such as birth control pills. Diagnosis is typically based on the symptoms. The primary treatment is avoiding the cold. Other measures include the discontinuation of nicotine or stimulants use. Medications for treatment of cases that do not improve include calcium channel blockers and iloprost. Severe disease may rarely be complicated by skin sores or gangrene. Its pathophysiology includes hyperactivation of the sympathetic nervous system causing extreme vasoconstriction of the peripheral blood vessels, leading to tissue hypoxia. by releasing adrenaline and nor adrenaline 10 there is a RS between pvd and angina : the 2 are inadequate blood supply but in angina get pain with excretion bec on rest the demand= supply while on excretion demand increased than supply while pvd when sitting or resting the lower limb he is ok while when moving the lower limb it is painful = intermittent claudication Clinical manifestations of PVD The most common symptom of peripheral vascular disease in the legs is intermittent claudication. pain in one or both calves, thighs, or hips. The pain usually occurs on walking or climbing stairs and stops on rest. This is because the muscles' demand for blood increases during walking and other exercise. The narrowed or blocked arteries cannot supply more blood, so the muscles are deprived of oxygen and other nutrients. This pain is called intermittent (comes and goes) claudication. It usually is a dull, cramping pain. It may also feel like a heaviness, tightness, or tiredness in the muscles of the legs. Cramps in the legs have several causes, but cramps that start with exercise and stop with rest most likely are due to intermittent claudication. When the blood vessels in the legs are completely blocked, leg pain at night is very typical, and the individual almost always hangs his or her feet down to ease the pain. Hanging the legs down allows for blood to passively flow into the distal part of the legs. 11 Intermittent Claudication Intermittent Claudication is caused by narrowing or blockage in the main artery taking blood to the leg (femoral artery). This is due to hardening of the arteries (atherosclerosis). The blockage means that blood flow in the leg is reduced. Blood circulation is usually sufficient when resting, but when you start walking the calf muscles cannot obtain enough blood. This causes cramp and pain which gets better after resting for a few minutes. If greater demands are made on the muscles, such as walking uphill, the pain comes on more quickly. Claudication usually occurs in people aged over fifty years; however it can occur much earlier in people who smoke and those who have diabetes, high blood pressure or high levels of cholesterol in the blood. Unfortunately, the blockage which causes the claudication will not clear itself, but the situation can improve. Smaller arteries in the leg may enlarge to carry blood around the block in the main artery, this is called collateral circulation. Many people notice some improvement in their pain as the collateral circulation develops. This normally happens within six to eight weeks of the start of the claudication symptoms. 12 Intermittent Claudication - Most common. - Pain in the extremity that develops in a muscle that has an inadequate blood supply during exercise. - The cramping pain disappear within 1-2 minutes after stopping the exercise or on resting. - The femoral artery is often affected- pain in the calf muscle- common symptom. 13 Clinical manifestations of PVD (Cont.) Other symptoms of peripheral vascular disease include the following: Buttock pain Numbness, tingling, or weakness in the legs Burning or aching pain in the feet or toes while resting A sore on a leg or a foot that will not heal One or both legs or feet feel cold or change color (pale, bluish, dark reddish) Loss of hair on the legs Impotence Having symptoms while at rest is a sign of more severe disease. 14 What tests diagnose peripheral vascular disease? Rose criteria: A test used by many medical professionals to screen for peripheral vascular disease is a series of 9 questions called the Rose criteria. The answers to these questions indicate whether patients have peripheral vascular disease and how severe it is. 15 Ankle/brachial index: One of the most widely used tests for a person who has symptoms suggesting intermittent claudication is the Ankle/Brachial Index (ABI). This test compares the blood pressure in the arm (brachial) with the blood pressure in the legs. In a person with healthy blood vessels, the pressure should be higher in the legs than in the arms. The blood pressure is taken in both arms in the usual way. It is then taken at both ankles. The pressure at each ankle is divided by the higher of the 2 pressures from the arms. An ABI above 0.90 is normal; 0.70-0.90 indicates mild peripheral vascular disease; 0.50-0.70 indicates moderate disease; and less than 0.50 indicates severe peripheral vascular disease. 16 Treadmill exercise test: If necessary, the ABI will be followed by a treadmill exercise test. Blood pressures in the arms and legs will be taken before and after exercise (walking on a treadmill, usually until patients have symptoms). A significant drop in leg blood pressures and ABIs after exercise suggests peripheral vascular disease. If the leg pulses are not palpable, the use of a portable Doppler flow probe will quickly reveal the absence or presence of an arterial flow. 17 Imaging tests for peripheral vascular disease To help locate blockages in the blood vessels, any of several tests, such as angiography, ultrasonography, or MRI (magnetic resonance imaging), can be used. 18 Tests to diagnose peripheral vascular disease include: Ankle/brachial index (ABI), Treadmill exercise test, Angiography (a type of X-ray), Ultrasonography, MRI (magnetic resonance imaging), + rose criteria 19 Treatment of PVD Lifestyle changes to treat or prevent peripheral vascular disease. Medications. Interventional procedures. 20 Lifestyle changes to treat or prevent peripheral vascular disease include: Quitting smoking, Getting regular exercise, exs in pvd is imp to open the collateral circulations to increase the blood supply to that area + decrease the weight + control the chronic diseases Eating a low-fat and healthy diet, Maintaining a healthy weight, Controlling high blood pressure and high cholesterol, Keeping blood sugar optimal. 21 Treatment of PVD Two medications have been approved by the United States Food and Drug Administration (FDA) for direct treatment of the symptom of intermittent claudication. to relive the severe pain Pentoxifylline (Trental): It improves blood flow by making red blood cells more flexible. With these alterations, the blood can move more easily past obstructions in the blood vessel. Cilostazol (Pletal): This drug keeps platelets from clumping together. This clumping promotes formation of clots and slows down blood flow. The drug also helps dilate, or expand, the blood vessels, encouraging the flow of blood 22 Sudden blockage of an artery by a blood clot (thrombus) has been treated with medication for many years. Choices include antiplatelet agents, anticoagulants, and "clot-busters" (thrombolytics). Antiplatelet agents include aspirin ,ticlopidine, and clopidogrel. These agents do not get rid of an existing clot. They prevent further clots from forming by keeping blood cells and platelets from clumping together. Anticoagulant agents include heparin ,warfarin (Coumadin, Jantoven), or low- molecular-weight heparin such as enoxaparin (Lovenox). These agents also do not remove an existing clot. They interfere with the sequence of blood clotting factors that causes a clot to form. Thrombolytics: These are powerful drugs that can actually dissolve an existing clot. They can be used only under certain circumstances and are given only in the hospital. They can be injected directly into the blocked artery under angiographic guidance. To be effective, they have to be administered intravenously within the first 4-8 hours after a patient develops symptoms 23 What interventional procedures treat peripheral vascular disease? Percutaneous (through the skin) balloon angioplasty, or just "angioplasty," is a technique for enlarging an artery that is blocked or narrowed without surgery. A diagnostic angiogram is done first to locate the blockage or narrowing and determine the severity, because, for instance, minor blockages are treated medically. A thin plastic tube called a catheter is inserted into the affected artery through a needle under local anesthesia. X-ray dye or contrast is injected, X-ray films are taken and studied by the doctor. If the obstruction is significant, especially in a larger more proximal artery, angioplasty may be reasonable. The angioplasty catheter has a tiny balloon attached to the end. The balloon is inflated, pushing aside the plaque and widening the artery so that it no longer restricts blood flow. The balloon is then deflated and removed from the artery. 24  Angioplasty is not a permanent solution for most people. Stenting is a technique for arteries that are very severely blocked or begin to close up again after angioplasty. 25  Generally, after the stent is placed, angioplasty is carried out. Stenting and angioplasty are very useful if the obstructive lesions are localized and involve a small portion of the vessel. The majority of peripheral vascular lesions can be managed by placement of a stent, a small metal mesh sleeve that is fixed inside the narrowed artery. The stent holds the artery open. Eventually, new tissue grows over the stent. A bare metal stent was the initial approach. However, development of restenosis or fibrous scar tissue growth inside the stent leads to recurrent obstruction. A new generation of drug-eluting stents is especially exciting, since a drug is attached to the metal sleeve that dissolves into the blood and prevents growth factors acting to develop scar tissue. The rate of restenosis has decreased. Atherectomy is removal of an atherosclerotic plaque. A tiny cutting blade is inserted into the artery to cut the plaque away. 26 27 28 What about surgery for peripheral vascular disease? When the obstructive lesions are long and involve most of the vessel, surgery is the best alternative. The most widely used operation for a blocked or damaged artery is called a bypass. This is similar to the artery bypass operation done on the heart. A piece of vein, harvested from another part of the body, or a piece of synthetic artery is used to bypass or detour the obstructed segment of disease, therefore restoring blood flow to the downstream or distal portion of the artery. Surgery is required less often today, as better preventative anti- atherosclerotic medications and techniques have become available for treating blocked or damaged arteries. With modern treatments, surgery is required only for very severe atherosclerosis unresponsive to medications and angioplasty. 29  Treatment for peripheral vascular disease includes angioplasty, which is a technique for enlarging an artery that is blocked or narrowed without surgery. Stenting may be performed for arteries that are very severely blocked locally or begin to close up again after angioplasty. A procedure called atherectomy is removal of an atherosclerotic plaque. Types of medications commonly used to treat peripheral vascular disease include antiplatelet agents, anticoagulants, and "clot-busters" (thrombolytics). Drugs approved to help treat intermittent claudication include pentoxifylline (Trental) and cilostazol (Pletal). Lifestyle changes to treat or prevent peripheral vascular disease include quitting smoking, getting regular exercise, eating a low-fat and healthy diet, maintaining a healthy weight, controlling high blood pressure and high cholesterol, and if patients have diabetes, keeping blood sugar optimal. 30