Lecture 1-PVD Part 1 0518-1.pdf

Peripheral Vascular System Part 1 – Backround &Arterial Disorders Jacqueline Gil, MS, PA-C Clinical Coordinator Touro College PA Program https://www.youtube.com/watch?v=itn_MRGqaY8 1 Vascular components Arteries Veins Lymphatics 2 Arteries  3 concentric layers: intima, media and adventitia...

Peripheral Vascular System Part 1 – Backround &Arterial Disorders Jacqueline Gil, MS, PA-C Clinical Coordinator Touro College PA Program https://www.youtube.com/watch?v=itn_MRGqaY8 1 Vascular components Arteries Veins Lymphatics 2 Arteries  3 concentric layers: intima, media and adventitia  Injury to the vascular endothelial cells can result in thrombus formation and atheroma's  Intima: Single layer endothelial cells with many metabolic properties:  Synthesize regulators of thrombosis like prostacyclin, plasminogen activator and heparin-like molecules  Produces: Von Willebrand factor and plasminogen activator inhibitor  Modulates blood flow via vasoconstrictors (endothelin, ACE) and vasodilators (Nitrous oxide and prostacyclin)  Regulates immune response: interleukins, adhesion molecules and histocompatibility antigens 3 Arteries  Temporal Lower Extremities  Carotid  Aorta Upper Extremities  Brachial  Radial  Ulnar  Femoral  Popliteal  Dorsalis pedis  Posterior tibia 4 VEINS  Thin-walled, highly distensible  Can hold 2/3 circulating blood flow  Venous intima composed of non-thrombogenic endothelium  Valves promote directional venous return to heart  Prevents pooling and venous stasis  * calf muscles act as a venous pump  Deep veins of legs=90% venous return from LE  Well supported by surrounding Connective Tissue  Superficial Veins of legs=10% of venous return from LE (Greater and lesser saphenous veins) 5 6 7 Distribution of Lymphoid Tissues Epitrochlear nodes Medial surface arm 3 cm above elbow Drain fluid from ulna surface forearm and hand, And part of 3rd, 4th and 5th digits Superficial Inguinal nodes Horizontal : Drains superficial portions lower abdomen and buttock Vertical Group: Drains upper part leg near superficial saphenous vein 8 Arterial Conditions  Cerebrovascular  Carotid artery disease  Aortoiliac  Femoral-popliteal MACROvascular  Renal  Aortic occlusive  Aneurysmal diseases  MICROvascular: Diabetes Mellitus 9 Venous Conditions Venous stasis Thrombotic disorders  Pulmonary embolism: 200,ooo deaths annually in US  Sudden death = 1st symptom in ~ 25% patients with PE   ~ 1/3 have a recurrence within 10 years 5-8% US population have one of several genetic risk factors https://www.cdc.gov/ncbddd/dvt/data.html 10 Lymphatic Conditions Lymphatic Obstruction lymphedema and lymphangitis 11 12 Symptoms of PVD (arterial, venous or lymphatic)  Pain…..Intermittent claudication or REST pain  Changes in temperature and color of skin  Edema  Ulceration  Emboli  Stroke  Dizziness 13 History – Peripheral Vascular System  Pain in arms or legs  Can arise from skin disorder, PVD, MSK Dis., Neuro Dis.  Restless leg syndrome  Referred: MI to arm pain….. Spinal stenosis to arm or leg…  Intermittent Claudication  10% patients have classical symptoms  DDX: neurogenic claudication  Cold, numbness, pallor in legs: hair loss over anterior tibia  Raynauds Phenomenon or disease  Swelling (edema) in calves, legs or feet  superficial or deep thrombophlebitis  Swelling (edema) with redness or tenderness  Cellulitis, erythema nodosum 14 Other Causes of Edema  Hypoalbuminemia - Edema in loose Connective Tissue  Congestive heart failure  Dependent edema; sacral edema if supine; may see increased JVD; enlarged heart; S3 gallop, pulmonary edema  Renal Disease  Nephrotic syndrome – severe leg edema; sometimes whole body edema (anasarca)  Liver Disease (cirrhosis) - Fluid retention; low albumin: ascitis; leg edema  Lymphedema - Localized; involves one or both legs (no pitting)  Orthostatic edema – dependent edema – no cardiac, renal, liver or obstructive lesions, (unknown) etiology. 15 The Health History  Fatigue or aching that limits walking … identify location!  Buttock, hip: aortoiliac  Erectile dysfunction: iliac-pudendal  Thigh: aortoiliac or deep femoral  Upper calf: superficial femoral  Lower calf: popliteal  Foot: tibial or peroneal  Poor healing, non-healing wounds  Abdominal pain after meals associated with “food fear”  Any 1st degree relative with an AAA 16 Health Promotion & Counseling  Screen for PAD:  History and physical exam  Vascular consult – ankle-brachial index  Screen for Abdominal Aortic Aneurysm (AAA)  Ultrasound (US) is 95% sensitive  DX: infrarenal aorta diameter > 3cm, increased risk of rupture with diameter > 5.5cm  Risks: age >65, tobacco, FH, male, CAD, PAD  Syphilis, Marfan’s Syndrome  Screen Men 65-75 with Hx “ever smoking” or >60 with + FH of AAA 17 A 37-year-old man presented to the emergency department with chest pain of 2 days' duration pain was heavy in character, intermittent, and made worse by deep inspiration and lying flat. No SOB Chest radiography widened mediastinum 9.5-cm ascending aortic aneurysm 18 Ankle-brachial index (ABI)  Detects 50% or greater stenosis of 50% major arteries  Measure Systolic BP in each arm in each arm and then by doppler ultrasound in dorsalis pedis and posterior tibial  Divide highest R & L ankle pressure by highest R & L arm pressure  Normal: 0.90-1.20  Mild to Moderate PAD: 0.41-0.80  Severe PAD: 0.00-0.40 (20-25% annual risk for death) ** 19 Measurement of the Ankle-Brachial Index (ABI) Patient with symptoms Usually have ABI 0.41-0.40 20 Hiatt W. N Engl J Med 2001;344:1608-1621 Ankle-brachial index (ABI)  NOT a test to determine if surgery is necessary  Calcified arteries may falsely elevate readings  Helps evaluate the degree of disease  Used to evaluate baseline and changes after treatment. Severity of PAD closely parallels risk for MI, CVA and death from vascular causes 21 Risk factors for PAD  Age >60  Family History  Tobacco use: present or past tobacco use  HTN  Atheroscerosis (CAD)  Diabetes  Hyperlipidemia  Other: homocysteinemia, obesity, sedentary Age <60 with DM, tobacco use, hyperlipidemia, HTN, homocysteinemia 22 Postulated mechanisms of accelerated vascular damage with elevated homocysteine levels (1) endothelial cell damage (2) smooth muscle cell proliferation (3) lipid peroxidation (4) up-regulation of prothrombotic factors (XII and V) (5) down-regulation of antithrombotic factors or endothelial-derived nitric oxide http://www.ejves.com/article/S1078-5884(09)00248-2/abstract?cc=y= 23 Key Components of Peripheral Arterial “Examination”  Measure BP in both arms  Inspect ankles and feet for color, temperature, skin integrity; note any ulcerations; check for hair loss, tophic skin changes, hypertrophic nails  Palpate temporal, brachial, radial, ulnar, aorta, femoral, popliteal, dorsalis pedis and posterior tibial arteries  Palpate carotid upstroke after auscultating for bruits  Auscultate aortic, renal, iliac, femoral for bruits 24 The Physical Exam (PVD) Inspection  Size, Symmetry and Swelling of extremities (UE,LE)  Color skin, nail beds, skin texture  skin pigment changes, ulcers, cyanosis, hair distribution  Venous pattern  Varicosities (standing) 25 Ischemic Gangrene The Physical Exam Auscultation  Bruits  Carotid : always auscultate first  Abdominal: aortic and renal, iliacs, ……. femoral 27 Auscultation for bruits 28 The Physical Exam Palpation  Assess skin temperature  Palpate pulses:  Carotid  Temporal, Radial, Brachial, Ulna  Femoral  R/O Coarctation Aorta  Popliteal  Dorsalis Pedis and Posterior Tibialis Grading of Pulses 0: absent 1: diminished 2: normal 3: increased 4: bounding 29 The Physical Exam  The Lymphatics  Palpate Epitrochlear, Axillary, Inguinal Nodes   Epitrochlear nodes: 3cm above medial epicondyle Inguinal Horizontal (skin lower Abdomen, ext genitalia, anal canal, lower vaginal and gluteal area) and Vertical (LE)  Observe for lymphangitis  Lymphedema: usually does Not pit 30 31 Special Techniques  Arterial supply lower extremities  Dependent rubor Buerger’s sign  Pallor on elevation  Capillary refill Lower Extremities (2 secs)  Arterial Supply Upper Extremity: Allen Test  Test for incompetent Saphenous Veins (venous mapping)  Test for Retrograde filling  Trandelenburg Maneuver 32 Allen's Test Peripheral Arterial Disease (PAD)  Partial or complete obstruction of one or more arteries in the lower extremities  Femoral and popliteal most common  May be asymptomatic  Symptomatic disease compromises daily function  Risk factor for cardiovascular & cerebrovascular events 34 Symptoms Peripheral Arterial Disease (PAD) Intermittent Claudication  Vascular vs neurogenic Rest Pain Non-Healing Ulcers Atrophic changes 35 Intermittent claudication muscle pain (ache or cramp), classically in the calf muscle, which occurs during exercise, such as walking, and is relieved by a short period of rest M/C cause is PAD in the superficial femoral artery. (High risk with cigarette smoking, HTN and DM) (It is distinct from neurogenic claudication, which is associated with lumbar spine stenosis). 36 What’s your diagnosis? Case 1  A 54yo man with DM and a 30 pack years tobacco use has calf pain after walking 2 blocks that resolves with rest Case 2  A 65yo man complains of back and leg pain that is aggravated by standing and walking and relieved when he walks bending forward 37 Signs of PAD  Cool Temperature  Decreased or Absent Pulses  Skin Color Changes  Pallor on elevation and Dusky Red on Dependency  Atrophy……thin, shiny skin  Dry, brittle, thick nails  Ulceration and gangrene  Thinning or Hair loss 38 A 69-year-old man presented with a 10-day history of discoloration of the left foot and pain in the left foot while at rest Buerger's symptom: foot became pale when elevated (Panel B) and became red again while hanging down 39 Acute Arterial Occlusion  Acute limb ischemia from thrombus, embolus or trauma  Signs and symptoms related to location, duration and collateral circulation  Consider Atrial fibrillation….causes distal embolization 40 Signs of Acute Arterial Occlusion – 6P’s  Pain  Pallor  Paresthesia  Paralysis  Pulselessness  Poikilothermia 41 Diagnostic Studies for Revascularization  Duplex Ultrasonography  CTAngiogram  MRAngiogram indicated in patients who are candidates for revascularization in order to determine the location and morphologic characteristics of the obstructive lesion (or lesions) 42 Treatment of Acute Arterial Occlusion  Immediate embolectomy  Best done in < 4-6 hours Surgical consult! STAT  Preoperative treatment with heparin  Keep limb below the horizontal plane  If thrombosis is suspected because of prior history of occlusive arterial disease then non operative approach with Heparin and warfarin (coumadin) may be considered 43 Angiogram for diagnosing PAD  Intra Arterial Contrast Study  Evaluates flow before and after stenosis  Only used if surgical intervention is being considered  Gold Standard for diagnosing PAD 44 Magnetic Resonance Angiography (MRA) Uses magnetic fields and radio waves to produce two-dimensional or three-dimensional images of the structures inside your body, such as your heart, brain or blood vessel 45 MRA – Carotid stenosis 46 Occlusive Disease of Aorta and Iliac Arteries Occlusive disease usually occurs just proximal to the bifurcation of the common iliac arteries 47 RENAL ARTERY STENOSIS(RAS)  RAS is more common in patients with PAD, HTN, & CAD  Lowering the BP in presence of severe renal stenosis may lead to ischemic renal atrophy 48 Percutaneous transluminal renal angioplasty (PTRA) is treatment of choice for RAS 49 Clinical Findings Aortoiliac Occlusive Disease  Intermittent Claudication of thigh or buttocks  Rest pain…>>suggests severe occlusion  Impotence (erectile dysfunction)  Femoral pulses absent/very weak and distal pulses- absent  Bruits may be heard over aorta or iliac arteries  Low ABI index  Skin changes…..dry, scaly, hair loss  Subcutaneous and gluteal muscle atrophy  Coolness and dependent rubor late finding 50 Leriche’s Syndrome  MALE PATIENT 1. Buttock or Thigh Claudication 2. Impotence / Erectile Dysfunction 3. Atrophy Gluteus Muscle Chronic aortoiliac occlusion……. Severe atheroscerosis at the aortic bifurcation 51 A 46-year-old woman presented with lifestyle-limiting claudication of the legs computed tomographic angiogram showed aortic occlusion just below the origin of the renal arteries (red arrowhead) 52 Raynaud’s Disease and Phenomenon  Disease (Primary / Idiopathic)  Episodic spasm small arteries and arterioles  No vascular occlusion  Female (5:1) between age 20-40  Mother usu. h/o RA  Phenomenon (Secondary) Three Color Changes  White ( Pallor)  Blue ( Cyanosis)  Secondary to other conditions  Collagen vascular disease  SLE, Scleroderma, RA, dermatomyositis  Red ( Rubor) 53 Raynaud’s Disease or Phenomenon  Location Pain  Distal portion one or more fingers  Numbness and tingling or burning common  Timing  Brief but recurrent  Aggravating Factors  Exposure to cold, Emotional upset  Remitting Factors  Warm environment  Associated Findings  Pallor distal fingers followed by cyanosis then redness 54 Raynaud’s Disease https://www.uptodate.com/contents/image?imageKey=RHEUM %2F66438&topicKey=RHEUM%2F7543&source=see_link 55 Occlusive Disease of Femoral and Popliteal Arteries  Superficial femoral-artery stenosis or occlusion is the most common lesion associated with claudication  Most common site at HUNTERS CANAL… mid 1/3 thigh …… femoral vessels pass through here  Popliteal also common  Clinical Findings  Intermittent claudication of the calf muscles  Atrophic changes  Dependant rubor and pallor on elevation  Femoral pulses palpable…… distal pulses weak or not palpable 56 Adductor Canal “Hunter’s canal”  Components  Femoral artery  Femoral vein  Saphenous nerve  Boundaries  Posteromedially:  Adductor longus & magnus  Medial:  Vastus medialis oblique  Superior(roof):  Sartorius 57 Treatment Peripheral Arterial Disease Control Risk Factors / life style modifications Pharmacological Interventions Surgical 58 Risk-factor modification Treatment PAD – Lifestyle changes SMOKING CESSATION  Exercise program ……promotes collateral circulation  BP control  Diet therapy  LDL < 100……… < 70 for high risk patients  HgAIC < 7.0 59 Pharmacologic Treatment Peripheral Arterial Disease  Cholesterol lowering medication  Anti-hypertensive medications  Diabetic medications  Antithrombolytic agents: ASA or clopidogrel 60 Treatment Peripheral Arterial Disease  SURGICAL REVASCULARIZATION  claudication that limits their lifestyle or ability to perform their job and that has proved to be unresponsive to exercise and pharmacologic therapy  REST PAIN  GANGRENE  INFECTION PTA is preferred when possible in patients who are 50 years of age or younger, because they have a higher risk of graft failure after surgical therapy than do older patients 61 Follow-up after Percutaneous Interventions  History  Examination  ABI measurement The value of a walking program and risk-factor modification should be reinforced during these visits. 62 Risk of Limb Loss  For patients with claudication the risk of limb loss about 7-10%  Most die from complications before the need for amputation  Therefore operation is not usually recommended for mild to moderate claudication 63 Occlusive disease of the lower leg and foot  Usually involves the tibial, peroneal and pedal vessels  Intermittent claudication of the foot is common  Treat with ASA, antiplatelet drugs, and control risk factors 64 Thromboangitis Obliterans (Buergers Disease)  Inflammatory and thrombotic occulsions of small arteries and also veins  Occurs in cigarette smokers (required to make the dx)  Symptoms:  Intermittent claudication especially in arch of foot  Rest pain in fingers or toes  +/- worse at night  Aggravated by exercise  Relieved by rest and permanent cessation of smoking 65 Signs Buerger’s Disease  Distal coldness, sweating, numbness and cyanosis  Gangrene at tips of toes (usually Great toe) or fingers  Migratory thrombobophlebitis Dry gangrene 66 Dry Gangrene of the fingertips due DM Wet Gangrene 67 Gas Gangrene of the foot  Bacterial infection  M/C in Diabetes, Atherosclerosis, PAD, trauma pts.  Gas forming organisms (Clostridium perfringens)  invade necrotic tissue  infection spreads rapidly  gases produced by bacteria Absolute SURGICAL EMERGENCY Feels like ‘bubble wrap’. If any doubt, STAT X-ray. 68 69 Any Questions? 70