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Lower Extremity Arterial Disease Dr Dharmaraj Rajesh Babu Consultant National University Heart Center

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Introduction Epidemiology Natural History Diagnosis Management

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Introduction

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Introduction

Chronic lower limb ischemia secondary to peripheral arterial disease is most common limb pathology seen by vascular specialist

Due to increasing age, increasing prevalence of DM and other risk factors the prevalence is on the rise

Patient present with asymptomatic disease, intermittent claudication, rest pain, or tissue loss

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Epidemiology

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Epidemiology

Best method of assessing the prevalence is to record the ABI and correlate it with risk factors

ABI less than 0.9 and higher than 1.4 is abnormal

ABI correlated well with the mortality risk associated with PAD, regardless of whether leg symptoms are present

Overall prevalence is 4.3%

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Epidemiology

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Prevalence based on risk factors

Hypertension increases risk by 2.5 fold

PAD prevalence is 20% to 30% higher in DM

Severity of arterial occlusive is proportional to number of cigarettes smoked

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Odds ration for risk factors for symptomatic PAD

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Natural History

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Natural history

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One year outcomes

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Diagnosis

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Diagnosis

Complete History and detailed physical examination

Classical Risk factors and less commonly associated risk factors should be identified and defined

Diagnostic tests

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Diagnostic Studies

Hematological investigations

Cardiac and cerebrovascular

Evaluation

Exclusion of other associated

pathology like aneurysm

Vascular laboratory and imaging studies

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Hematological Studies

Full blood count Fasting Blood Sugar Serum creatinine

Fasting Lipid profile

Hypercoagulable states Homocysteine

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Vascular Laboratory

ABI

Toe Pressure

tcPO2

Exercise ABPI

Ultrasound Duplex

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Imaging

CT Angiogram

MR Angiogram

Conventional Angiogram

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Treatment

Control Cardiovascular Risk factors

Specific therapies

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Control Cardiovascular Risk Factors

Smoking

Diabetes mellitus

Hypertension

Dyslipidemia

Platelets and Thrombosis

Homocysteinemia

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Smoking

Smoking cessation has been shown to reduce the risk of MI and death in patients with pad and delay the progression of lower extremity symptoms from claudication to CLI and Limb loss

Three fold increased risk of graft failure in smokers

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Smoking Cessation

Education

Emotional Support

Pharmacological aids

Education

Emotional Support

Pharmacological aids

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Smoking Cessation

Bupropion

Varenicline

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Diabetes Mellitus

1% increase in glycosylated hemoglobin is associated with 28% increase in risk of PAD

DM leads to alteration in nitric oxide availability and stimulation of proatherogenic activity in vascular smooth muscles

DM enhances platelet aggregation=n, increased blood viscosity and elevation of fibrinogen levels

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Diabetes Mellitus

American Diabetes association guidelines recommend hemoglobin A1c levels less than 7%

Goal should be maintain glucose control close to normal without significant hypoglycemia

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Hypertension

2 to 3fold increased risk of PAD

Target blood pressure of 140/90 mmHg in high risk groups

Target bloos pressure of 130/80 mm Hg in patients who also have Dm or renal insufficiency

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Dyslipidemia

Total Serum cholesterol levels greater than 5.18 mmol/l are associated with an increased risk of cardiac related events, especially in combination with a low HDL fraction

Statins have lipid lowering properties

Statins also works by stabilizing existing atherosclerotic plaques, decreasing oxidative stress and reducing vascular inflammation

Statin also protects against thrombosis by altering the lipid content of platelets, thereby decreasing platelet aggregability

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Platelets and thrombosis

Antiplatelet therapy reduces the risk of non fatal MI, ischemic stroke and vascular related death

Asiprin, Clopidrogrel and newer drugs are available

All patients with diagnosed PVD should be started on antiplatelets. No evidence of it in patients at-risk

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Claudication

Exercise Therapy

Pharmacologic treatment

Revascularization in disabling claudication

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Pharmacological treatment

Pentoxifyline

Cilostazol

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Critical lower limb ischemia

Need tertiary care

Control of risk factors

Revascularization and debridement

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Thank You