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Causes
Atherosclerosis patients >40 years old
Thromobosis
Embolus
Vascultits
Fibromuscular dysplasia Figure 1. PAD Statistics
Entrapment (Masmarami pa ang asymptomatic kaysa sa may
Cystic adventitial disease mga symptoms)
Trauma
Sixth and seventh decades of life The most common symptom is intermittent claudication
Patients with atheros of the coronary and defined as a pain, ache, cramp, numbness or a sense of
cerebral vasculature fatigue in the muscles; it occurs during exercise and is
relieved by rest
Increased risk of developing PAD in : o The site of claudication is distal to the location of
Cigarette smokers the occlusive lesion
DM Sumasakit ang legs on prolonged
Hypercholesterolemia walking tapos nawawala kapag
HPN nagpapahinga
Hyperhomocysteinemia o For example, buttocks, hip and thigh discomfort
occur in patients with aortoiliac dse, whereas calf
Pathology: claudication develops in px with femoral popliteal
Segmental lesions causing stenosis or occlusion dse.
are usually localized to large and medium sized Buttocks pain is least to be
vessels noticed,minsan akala UTI
Foot pain and leg pain are the MOST
The pathology of the lesion includes: COMMON MANIFESTATION in the
elderly, sometimes mistaken as arthritis
1. Atheros plaque with calcium deposition
2. Thinning of the media DIAGNOSIS
3. Patchy destruction of muscle and elastic fibers
4. Fragmentation of the internal elastic lamina I. HISTORY
5. Thrombi composed of platelets and fibrin Individuals with Asymptomatic PAD
Identified in order to offer therapeutic interventions
The primary sites of involvement: known to diminish their increased risk of MI, stroke and
death
1. Femoral and popliteal arteries (80-90% of px) A history of walking impairment, claudication and ischemic
2. The more distal vessels, including the tibial and peroneal arteries rest pain
(40-50% of px)
3. The abdominal aorta and iliac arteries (30% of symptomatic px) II. ROS
Atheros lesions occur preferentially: Recommended as a required component of a standard ROS for:
1. Adults >/ 50 yrs who have atheros R/F
1. Arterial branch points 2. Adults >/ 70 yrs
2. Sites of increased turbulence
3. Altered shear stress, and internal injury Key Components of the Vascular Review of Systems and Family
4. Involvement of the distal vasculature is most History
common I elderly individuals and px with DM 1. Any exertional limitation of the lower extremity
muscle or any hx of walking impairment
Manifestations of PAD o Claudication of this limitation:
Fatigue
53% - asymptomatic PAD Aching
o We need to identify this (since silent assassin ito) Numbness
o If patient has CAD+PAD -> worse prognosis Pain
o Patient has PAD+ CVD -> worse prognosis too
TREATMENT
Patient with PAD should receive therapies to
o Reduce the risk of associated CV events such as
MI and death
o Improve limb symptoms
o Prevent progression to critical limb ischemia
o Preserve limb viability
Risk factor modification and antiplatelet therapy should
be initiated to improve CV outcomes
BP control (ACE-I, B-blockers)
Treatment of hypercholesterolemia (statins, recommends
tx to reduce LDL, cholesterol to <100mg/dl )
Platelet inhibitors
o Aspirin sse: bleeding ->so do not give to px with
PUD. If given in px with PUD, give PPI muna then
aspirin
o Clodipogrel- proven MORE effective than aspirin
o Insufficient evidence if dual therapy (aspirin +
clodipogrel) is effective
Figure 3. Arterial duplex scan imaging and arteriography o Warfarin is NOT given because it does not
In the second picture, kita dito yung part na may stenosis and after improve outcome in patients with PAD
the part with stenosis, turbulent na yung blood flow. o Voraxapar
New drug
Dec limb ischemia but increases risk of
bleeding -> so it is not given in px with
bleeding disorders
PROGNOSIS
ACUTE LIMB ISCHEMIA Amputation rate: 6-20%
6% if revascularized within 12 hours
Acute limb ischemia 12% if revascularized within 12-24 hours
Results from sudden cessation of blood flow to the 20% if revascularized after 24 hours
extremity. The severity of the ischemia and the viability of Mortality rate: 6-12%
the extremity depend on the location and the extent of
occlusion and the presence and subsequent development of HISTORY
collateral BV
2 principal causes of occlusion: History of claudication
o embolism thrombus in situ History of heart disease
from proximal sites of atherosclerosis Interventions for poor circulation
and aneurysm of the aorta and large Has other cardiovascular risk factors
vessels
arterial emboli tend to lodge at DIAGNOSIS
bifurcations ** ABI is not of use anymore
most frequently lodge in the femoral
artery, followed by the iliac artery, aorta 1. Physical examination
and popliteal and tibioperoneal arteries
o thrombus
entered the systemic circulation via a
patent foramen ovale or other septal
defect
INCIDENCE
Scanty information available
Estimate at 140 per 100,00
Decreased ALI incidence secondary embolism
Increase incidence of thrombotic acute limb ischemia
ETIOLOGY
Etiology of Arterial Occlusion
Thrombotic vs Embolic
o Embolic Sources
Cardiac- 75 %
Atrial Fibrillation- 51%
Acute Mi- 24%
o Non-Cardiac- 10%
Atheromathous Debris 5%
Aneurysmal 5%
Post CV Surgery 7%
2. Electrocardiogram
3.Standard chemistry
Emboli impact at branching points in arterial tree
4.Complete blood count
Femoral Artery 45%
5.Prothrombin time
Aorta and Iliac Artery -26%
6.Partial thromboplastin time
Poplitial Artery 15%
7.Creatinine phosphokinase level
Tibial Artery -1%
Hypercoagulable state will need additional studies
Clinical differentiation between thrombosis and embolism
Anticardiolipin antibodies
Embolism
Homocysteine concentration
o Obvious cardiac source
Antibody to platelet factor IV
o No history of claudication
o Normal pulses in the contralateral limb
o Angiography: may have minimal atherosclerosis
with few collateral noted
TREATMENT
** identify first the level of acute ischemia because treatment is
based on the level of the dse
Pharmacologic thrombolysis
A Damaged Vein
If heredity, an injury, or a blood clot weakens a vein,
the wall near the valve begins to sag. The valve may no
longer close fully, allowing blood to move in both
directions when the muscle relaxes.
Most vein problems begin with damaged veins
Dapat kasi, your bicuspid valve, meron syang
preferential flow going up. When this valve weakens, it
leads to a bidirectional flow due to gravity.
Sclerotherapy
Is the most commonly performed treatment
option for patients with venous telangiectasia and
reticular veins often for cosmetic reasons alone
Injection of a sclerosing agent direct into the
vessel
Pwede injection at pwede laser, mawawala sya
pero it will recur because you do not address the
primary problem. The primary problem is the
pathology in your deep vein.
Treatment Majority of the treatment failure in sclerotherapy
Chronic Venous Disease is due to the failure to use compression stockings
General measures after the treatment
Leg elevation pag mabigat yung legs mo, itaas
mo sya para mabawasan ung pain or gawin mo Sclerotherapy complications:
yung exercise na ginagawa saeroplano, or para Pain or cramping
mas mabilis, ilakad mo sya para mabawasan ung Hyperpigmentation
symptom Telangiectatic matting
Control of body weight Blistering or necrosis
Exercise of calf muscles with periodic flexion of Superficial thrombophlebitis
ankles and transfer of weight Deep vein thrombosis
Avoid heat (mas matagal exposure sa heat, mas Urticaria
madadamage ung vein. Hot showers pwede.) Edema
Avoid standing for long periods
Cold showers to delay progression of disease Laser therapy
Lying flat on the healthy side in the presence of much better compared to doing your injectable
unilateral varicose veins sclerotherapy
Controlling vein problems Indications:
When you sleep, you need to elevate your legs Superficial, fine-caliver venous telangiectasia
with 2-3pillows Telangiectatic matting
Raise your feet above heart level Patient afraid of needles
Elevate your feet at work to prevent worsening of Poor responders to sclerotherapy
leg edema Adverse side effects from sclerotherapy
Anti-stasis exercises Application of laser and light source indirectly over the
Exercises to improve venous circulation vessels
Walk on your heels Pero not allpatients will respond to laser therapy, mas
Stand on tiptoe maliit, mas magrerespond, the larger the varicose veins, di
Rock from your toes to your heels tatalab ung laser hanggang telangiectasia lang sya saka
Point your toes together and then apart reticular veins saka it will also depend on the type of the
Cycling movement: move your legs with laser that you are using.
energetic movements (15-20 times). Older lasers (5yrs ago) will not work lesser treatment
Cross and uncross your legs in a scissors success compared to the ones that came out 2-3 years ago
movement(10-15 times) Endovascular laser therapy(EVLT)
Move each leg in a small circle up to 10 Newer modality
times You need to puncture your femoral vein, papasok
ung ___?sa femoral vein tapos papasok sa greater