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Lower Extremity Vascular Disease

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Collateral circulation allows for blood flow to all areas of ... Rest pain initially begins in the forefoot (metatarsalgia) and toes and progresses proximally. ... – PowerPoint PPT presentation

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Title: Lower Extremity Vascular Disease


1
Lower Extremity Vascular Disease
  • Vic V. Vernenkar, D.O.
  • St. Barnabas Hospital
  • Dept. of Surgery

2
Anatomy
3
Anatomy
4
Pathophysiology
  • Most predominant cause is atherosclerotic disease
  • Other causes include antiphospholipid syndrome,
    popliteal aneurysms, adventitial cystic disease,
    popliteal artery entrapment, and trauma.

5
Pathophysiology
  • Collateral circulation allows for blood flow to
    all areas of the lower extremity in the face of
    localized occlusive disease
  • Muscle arterial resistance can be decreased to
    allow a large increase in blood flow. This is
    physiologic during exercise and compensatory
    during ischemia
  • As occlusive disease progresses, it usually
    involves multiple sites in the lower extremity
    vasculature

6
Pathophysiology
  • The first symptoms are noted by the patient
    during exercise because the leg is no longer able
    to increase blood delivery in the normal fashion
  • Claudication, is reproducible lower extremity
    muscle pain on walking that is relieved by rest
  • Most commonly, it involves the calf.

7
Pathophysiology
  • As ischemia progresses, pain is encountered at
    rest.
  • With critical ischemia, the patient experiences
    rest pain and wounds are unable to heal, so that
    the patient is predisposed to infection,
    gangrene, and limb loss

8
Pathophysiology
  • Rest pain initially begins in the forefoot
    (metatarsalgia) and toes and progresses
    proximally.
  • Patients often notice a beneficial effect of
    gravity on their arterial blood flow.

9
Pathophysiology
  • Many let their legs hang over the side of the bed
    in a dependent fashion to increase the effect of
    gravity, which augments minimal perfusion and
    decreases pain.
  • Conversely, symptoms of rest pain are provoked
    and worsened when the extremity is elevated

10
Risk Factors
  • Diabetes
  • Smoking 1 preventable cause
  • HTN
  • Genetics
  • Obesity
  • Hyperlipidemia
  • Hypercholesterolemia

11
Patient Evaluation
  • History of pain (type, location position)
  • Non-healing ulcer, infection
  • Past medical history of diabetes, HTN, cardiac,
    hypercholesterolemia, hypercoagulable states
  • Social history (smoking, activity level)
  • Family history

12
Physical Exam
  • Full vascular examination
  • Appearance (color, hair, muscle, nails, skin)
  • Touch (temp, refill, tenderness, elevation)
  • Pulses
  • Stethoscope
  • Neck, Abdomen
  • Heart

13
Non-invasive Techniques
  • Ankle-Brachial Index
  • Useful in predicting the likelihood of wound
    healing
  • Amputations healed in all patients with an ABI
    above 70
  • Healing did not occur in 25 of those with an ABI
    below 70

14
Non-invasive Techniques
  • Simple and inexpensive
  • In diabetics is often unreliable because of
    abnormal wall calcification and
    noncompressibility
  • Additional information can be obtained by
    measuring pressures at various levels of the
    lower extremity
  • Gradients of more than 20 mm Hg are diagnostic of
    a hemodynamically significant lesion
  • Duplex Ultrasound
  • Exercise stress test can be performed

15
Invasive Techniques
  • Angiography is the gold standard for evaluating
    lower extremity ischemic disease
  • Done before OR for precision
  • From aorta to feet

16
Invasive Techniques
  • Hemodynamically significant lesions are
    identified by a reduction in the cross-sectional
    area of 75 or more or a 50 decrease in diameter
  • Dye load a problem for renal patients,
    anaphylaxis (lt3), local and distal complications
    (lt1-2)
  • Not done if no intervention planned!

17
Treatment
  • Claudication or limb threatening?
  • When limb-threatening, intervention is necessary
  • Claudication lifestyle limiting?
  • Co-existing problems, high or good risk patient?
  • Surgery or endovascular?

18
Conservative
  • Stop smoking
  • Walk
  • Preventative foot care in diabetics
  • Control of blood glucose level
  • Decrease cholesterol levels
  • Drug therapy

19
Drugs
  • Pentoxyphyllin (Trental), a hemorrheologic drug
  • Increases blood filtration and decreases platelet
    aggregation and plasma fibrinogen

20
Drugs
  • Decrease in viscosity
  • Increases blood flow in the lower extremity and
    increases muscle oxygen tension

21
Drugs
  • Cilostazol (Pletal), a phosphodiesterase
    inhibitor that suppresses platelet aggregation
    and acts as a direct vasodilator
  • Ticlopidine, an adenosine diphosphate inhibitor,
    also decreases blood viscosity

22
Endovascular Therapy
  • Discrete lesions of the superficial and deep
    femoral arteries have been successfully treated
    with percutaneous transluminal angioplasty
  • Balloon causes the atherosclerotic intima to
    rupture and stretches the media
  • Increased blood flow allows for continued patency

23
Endovascular Therapy
  • The atherosclerotic lesion can also re-form over
    time
  • Best results are observed in those with short
    focal lesions
  • Success rates are higher in larger vessels

24
Endovascular Therapy
  • Good runoff is important for patency
  • Distal disease increases the risk for restenosis
    and failure, and the consequences would be
    devastating if acute thrombosis were to occur
    during the procedure.

25
Endovascular Therapy
  • PTA has also been used successfully as an adjunct
    to surgery to improve inflow for a more distal
    bypass and outflow for a more proximal bypass
  • Stenosis in bypass grafts is also amenable to PTA
  • In the event of acute lower extremity ischemia,
    an immediate angiogram is optimal and
    fibrinolytic therapy may be warranted
  • Catheter is inserted into the clot and the
    fibrinolytic agent is infused into the clot
    during the ensuing hours along with heparin.

26
Surgical Therapy
27
Surgical Therapy
  • Optimize other medical problems
  • Debride and treat infections
  • Angiogram

28
Surgical Therapy
  • Endarterectomy, bypass, amputation
  • Bypass is indicated for the patient with critical
    ischemia and, in specific instances, the patient
    with claudication

29
Surgical Therapy
  • Both the physician and the patient must be
    certain that the disease is truly incapacitating
    and limits the activities of daily living
  • That conservative and medical management have
    been unsuccessful, and that the mortality risk
    and threat of limb loss as a complication of
    surgery are worth the possible relief of symptoms
  • Remember! claudication progresses to critical
    ischemia and limb loss in relatively few cases
  • All interventions in the peripheral circulation
    can be complicated by limb loss!

30
Surgical Therapy
  • Inflow and outflow vessels
  • Runoff
  • Vein (reversed or in-situ)
  • Graft

31
Complications
  • Perioperative mortality has been reported to be
    between 2 and 5
  • Perioperative myocardial infarction rates have
    been reported as 3
  • If silent and unnoticed myocardial infarctions
    are included, they may be as high as 10 to 15
  • Hemorrhage, hematoma, thrombosis, infection, and
    edema
  • Primary amputation (when?)

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