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Diseases of peripheral arteries and aorta

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(1)

Diseases of peripheral arteries

and aorta

(2)
(3)

Leg arteries: obliterations Causes:

90% - atherosclerosis (AS)

M. Buerger

vaskulitides

fibromuscular dysplasia

Cystic degeneration of adventitia

trauma, physical causes

Periphery artery disease – PAD

(4)

Epidemiology – prevalence, impact

12% of adults

20% of persons above 70

2-3x increased cardiovascular mortality (AS is a usually not limited to leg arteries only)

Worsened quality of life

(5)

cerebrovascular

coronary renal visceral

leg

(6)
(7)
(8)
(9)

Risk factors (RF)

 smoking

 Positive family history

 DM

 hypertension

 Dyslipidemia

 Age above 50

 Male gender

 Obesity

(10)

Clinical pictures

Acute  chronic occlusion

(11)

Acute occlusion = acute limb ischemia (ALI) Embolism, thrombosis, trauma

“6P”:

“pain”

“pulselessness”

“pallor”

“poikilothermia”

“paresthesias”

“paralysis”

sometimes a 7

th

P is added- ‘prostration’

– a general deterioration, sometimes even shock.

(12)

The extent depends on the location of the occlusion (peripheral or more proximal)

!Risk of limb loss and amputation!

Embolic occlusion - very rapid onset

- colour and temperature demarcation of ischemic zone

- needs urgent procedure

(radiointervention or vascular surgery)

(13)

ALI

→immediately: heparin bolus 5000-10000 units i.v.; analgetics; dressing Transport to specialized dpt (radiointervention or vascular surgery)

Angiography

Anticoagulation (continuous i.v. heparin) Urgent revascularization

- Endovascular (radiontervention) - i.a. thrombolysis, aspiration of thrombus or embolus

- Open surgery - Acute bypass surgery; surgical embolectomy If ischemia nonreversible →amputation

(14)
(15)

Chronic PAD

Classification – Fontaine I. – asymptomatic

II. claudication IIa > 200m

IIb < 200m < 50m

III. – rest pain

IIIa ancle pressure > 50mmHg

IIIb < 50mmHg

IV. Ischemic ulcers

(16)

Claudication

Pain in the muscle during walking, resolves after stopping, in 3-4 minutes

Worsening during fast walking or walking uphill

Localization of pain → localization of stenosis/occlusion (calf, thigh, gluteal)

Colateral circulation development

(17)

Rest pain

usually occurring or worsening at night, at rest

Relief - hanging legs down

(18)

Ischemic defects

usually located on the toes, heels and bone protrusions, well demarcated, have a pale base without granulation, often necrotic, and surrounding area is dark red and cool

(19)

Chronic critical limb ischemia (CLI) -definition Duration >2 weeks

Persistent pain

Ulcers or gangrene

Ancle pressure < 50 mm Hg

Toe pressure < 30 mm Hg

(20)

Lerisch´s syndrome

– isolated stenosis/occlusion of aortic bifurcation and proximal segments of both common iliac arteries

→ gluteal claudication, impotence

(21)

PAD - Dg History

- RF, symptoms

Physical examination

Color, temperature, pulsation Ratschow´s test

treadmill test

(22)
(23)
(24)

Plantar/dorsal flexion every 1 s, max 2 minutes Then sit, hang the legs down

Intervals:

5s red colour

10s veins in dorsum 15s diffuse red colour

Prolonged intervals are signs of PAD

Ratschow´s test

(25)

Treadmill test

claudication interval

(26)

Ankle pressure

(27)

ABI =

Ankle - Brachial Index (ABI)

Higher value of ATP, ADP pressures a. brachialis systolic pressure

Normal: ABI 0.90 - 1.40 (> 1,4 – mediokalcinosis

diabetes,

renal insufficiency

)

ABI < 0.90 => PAD

(28)

Toe-brachial index TBI

(29)

PAD - Dg

Ankle pressure (toe pressure) Imaging methods

USG

AG (angiography)

CT-AG

(MR-AG)

(30)

Angiography

- Multiple stenoses of iliac arteries

(31)

CT-AG

arterial segment occluded

(32)

Angiography - stenosis of femoral artery bilaterally

(33)

Therapy - conservative RF management

Smoking

hyperlipidemia

DM

hypertension

Obesity

(34)

Therapy – conservative

Pharmacotherapy (Rx) Antiplatelets

Acetylsalicylic acid (ASA) Clopidogrel

Vasodilatative therapy

Naftidrofuryl

Cilostazol

(35)

Reologic therapy

Pentoxifyllin (Trental, Agapurin)

Sulodexid (Vessel Due F)

Prostaglandins

i.v. in advanced ischemia (if intervention or surgery is not possible)

(36)

Rehabilitation

Supervised exercise Walking

(37)

Therapy - revascularization

Endovascular methods

Vascular surgery

(38)

PTA - ballon angioplasty

(percutaneous transluminal angioplasty)

(39)

stent

(40)
(41)
(42)
(43)
(44)

Therapy - experimental

In chronic CLI (risk of amputation) - stem cells

(45)

Thrombangoitis obliterans – morbus Winiwarter - Buerger

= panangiitis (inflammation of vessel wall) of small and medium arteries Rare disease (2% of leg ischemia)

Affects the arteries segmentally, causes secondary thrombosis Reccurs and progresses

men>women, mostly smokers under the age of 40 Acral cyanosis

Pain, cold

Migratory phlebitis

Necroses, gangrenes of phalanges of fingers and toes

Screw-like colateral vessels Therapy:

Absolute exclusion of nicotin Prostaglandins

ASA

(sympatectomy)

(46)

Diseases of aorta

(47)

Aneurysm of abdominal aorta - AAA

Localized enlargement of a segment of AA Main RF – hypertension, smoking, AS, hyperlipidemia

The highest prevalence: age 50-70 Men:women=4-5:1

Clinically: usually asymptomatic, grows slowly

May cause deep, constant abdominal pain or back pain Complication – rupture

→abrupt severe abdominal pain or bac pain, shock - very high fatality

The risk of rupture ↑ with the diameter of AAA (10% year risk if diameter >5 cm)

(48)

Dg: USG

CT-AG, MR-AG Treatment

Management of RF, antiplatelet Rx, statins

Watchfull waiting - regular USG checks Repair needed if diameter > 5.5 cm

- Endovascular (stent-graft) - Surgical (resection + graft)

AAA

(49)

Localized enlargement of the upper aspect of the aorta, above the diaphragm Causes: AS, Takayasu arteritis, syphylis

rarely: inherited disorders – Marfan syndrome, Ehlers-Danlos sy Clinically - mostly asymptomatic, grows slowly

(if aneurysm of ascending aorta →aortic valve insufficiency)

may cause: tenderness or pain in the chest, back pain, hoarseness, cough, shortness of breath

Complications – dissection, rupture Dg: echocardiography

CT, MRI Treatment:

Treatment of the cause (if possible) Repair: surgical

endovascular in descending AA Aneurysm of thoracic aorta

(50)

Aortic dissection

Tear in aortic wall

- blood flows between the layers of the aortic wall, forcing the layers apart RF: hypertension, smoking, hyperlipidemia, trauma, aortitis,

cystic medial necrosis, Marfan sy, Ehlers-Danlos sy High fatality

Symptoms:

Nausea, abrupt severe chest pain, interscapular pain, back pain, dyspnea, Complication:

- Ischemia (blocked blood supply to organs): myocardial infarction, stroke, bowel necrosis, renal failure

- Pericardial tamponade - hemothorax

(51)

Dg: X ray, CT, MRI Classification:

Treatment:

ICU, bed rest, decreasing systolic pressure to 100-110 mm Hg Stanford type A - emergency surgical correction (graft)

B – conservative or endovascular repair (stent-graft)

(52)

Aortitis

Infectious inflammation – salmonella, staphylococcus

(atypical – Treponema pallidum, Mycobacterium TB) Fever + chest pain or abdominal pain (depending on location of inflammation) Complications – ulcer, aneurysm, rupture

Dg: history, lab, blood culture, USG, echo, CT of aorta, PET/CT Treatment: long term i.v. antibiotics

+ surgical or endovascular treatment (resection + graft, stent-graft) Noninfectious

usually associated with vasculitides immunosuppressive Rx

(53)

Diseases of other

peripheral arteries

(54)

Visceral artery ischemia Stenosis/occlusion of mesenteric arteries Men:women 3:1, mostly age > 50

Acute occlusion (embolic or atherothrombotic) – mesenteric infarction - urgent – fatality ˃80%

Chronic atherosclerotic occlusion – formation of collaterals Clinical picture:

Abdominal angina (postprandial abdominal pain), malabsorption syndrome, ischemic colitis

Acute mesenteric infarction – abrupt abdominal colic, nausea, vomiting - resolves in 2-12 hours

- finally progresses in paralytic ileus (meteorism, peritonitis, haemorrhagic diarrhea, shock

Dg: X-ray, abdominal USG, duplex sonography of artries (DUSG), CT-AG, angiography (AG)

Therapy: chronic form – antiplatelet Rx, management of RF of AS

acute mesenteric infarction – embolectomy or bypass in the first 6-12 hours, later – resection of the bowel segment

(55)

Renal artery (RA) stenosis

~2/3 caused by atherosclerosis

~1/3 caused byl fibromuscular dysplasia (mostly women, 20-40 years old)

→renovascular hypertension (activation of renin-angiotensin-aldosteron system) diastolic BP ≥110 mm Hg

night drop in BP is absent (24 hours monitoring) may be pharmacoresistant

-complications: hypertension crisis

ischemic nephropathy (if stenosis bilateral) - Murmur in paraumbilical region

- Abdominal ultrasound, DUSG of RA - AG, CT-AG, MR-AG

Therapy: nonsignificant stenosis - conservative, watchful waiting

significant stenosis - PTRA (percutaneous transluminal renal angioplasty)

(56)

Chronic upper limb ischemia 20 times less frequent than leg ischemia

Mainly AS in the first segment of subclavian artery Symptoms:

pain in the arms (hand) after exercise

subclavian steal syndrome

if subclavian artery is occluded in the proximal (prevertebral) part, blood flow in vertebral artery is reversed during the exercise of the affected upper limb, so the limb is supplied from the contralateral vertebral artery through the basilar artery and the ipsilateral vertebral artery. This is done at the expense of vertebrobasilar circulation. The result is so-called vertebrobasilar insufficiency with neurological symptoms - e.g. dizziness, fainting, visual disturbances, memory loss.

Dg – DUSG, CT-AG, MR-AG

Treatment:

Management of RF, quit smoking, antiplatelet Rx, statin, Revascularization – endovascular or surgical (bypass)

(57)

Acute upper limb ischemia

Mostly of embolic origin Risk of amputation

→ urgent Dg (USG, CT-AG)

→ urgent revascularization (surgical embolectomy)

(58)

Raynaud´s phenomenon

caused by inadequate reactivity of finger arterioles to cold or emotional stress

→vasoconstriction occurs in the fingers, less frequently on the toes or ears, nose, or knees

-in seizures

The seizure typically begins with a sharply demarcated area of whitening and cooling of the finger or fingers, followed by cyanosis and, in 15-20 minutes after the vasospasms recede, erythema appears (redness) due to hyperaemia - “tricolour” syndrome, sometimes there are only white fingers during the seizure.

Colour changes are accompanied by pain and paraesthesia.

- primary Raynaud phenomenon(women:men = 9:1, usually 20-40 years; no trophic changes)

- secondary (associated with another disease - e.g. connective tissue disorders,

vasculitides, medicine or drug effects, haematological disease, trauma, professional - vibrations)

may proceed to finger ulcerations

Dg – cold challenge test

- laboratory tests – to exclude secondary Raynaud´s phen. (e.g. immunologic tests to exclude vasculitides)

(59)

Raynaud´s phenomenon

Treatment:

Avoid the triggers (cold, vibrations, trauma, smoking) Rx: antiplatelet therapy

vasodilatative therapy

(calcium channel blockers, ACE inhibitors, prostaglandins, sildenafil) Endoscopic thoracic sympatectomy

(60)

Diseases of carotid arteries

AS, mainly AS of internal carotid arteries – stenosis/occlusion

→cause of ischemic stroke (atherothrombotic origin in 30% of strokes)

Plaques form most often in carotid bulbus and bifurcation

Plaque ulceration or rupture + thrombus formation →thrombotic occlusion or embolization

RF

Hypertension

Hyperlipidemia

Smoking

DM

Male gender

Physical finding: pulsation weak or absent murmur

Mostly asymptomatic Neurologic symptoms

(transient blindness, slurred speech, weakness in a part of face, arm or leg,

numbness and tingling in face, arm, or leg, confusion, memory loss, inability to speak)

(61)

Dg:

DUSG CT-AG MR-AG AG

Treatment

Conservative: (in most asymptomatic stenoses)

RF management

antiplatelet Rx Revascularization:

Surgical: carotid endarterectomy preferred

Endovascular: angioplasty, stenting if high operating risk

(62)

Vasculitides

Classification

GBM - glomerular basement membrane

ANCA - Antineutrophil cytoplasmic antibodies

(63)

Vasculitides

Symptoms

- Nonspecific – systemic inflammatory reaction

(flu-like – mild fever/fever, night sweat, muscle and joint pain, fatique, unintended weight loss)

- Organ specific/local – induced by local ischemia Dg – lab (inflammatory markers, anemia,

immunologic tests in some vasculitides) - imaging methods – USG, PET/CT, MR-AG - biopsy

Treatment – immunosuppressive Rx (steroids, azathioprin, cyclophosphamid, methotrexate, biologic therapy)

(64)

Large vessel vasculitides Aorta + major branches affected

Giant cell arteritis (temporal arteritis) most often temporal a. affected

- age>50

may occur together with polymyalgia rheumatica - Nonspecific symptoms

- Specific symptoms: headache, facial pain, difficulties with vision, sometimes permanent visual loss in one or both eyes.

Takayasu's arteritis (pulseless disease) Age ˂40, mostly women

- Nonspecific symptoms

- Specific symptoms – mostly caused by stenosis/occlusion of subclavian a.

(murmur, difference between blood pressure on the right and left, weakness or pain in upper extremity – upper limb claudication)

Immunosuppressive Rx, antihypertensive Rx, revascularization – endovascular

(65)

Other diseases of peripheral arteries

Aneurysms (= enlargement by > 50% of normal diameter)

Causes: connective tissue disorders, AS, fibromuscular dysplasia, infection, vasculitis, trauma

Complications – rupture, thrombosis + embolism to peripheral artery

→ peripheral ischemia

mostly leg arteries, rarely upper limb arteries Palpation, auscultation (murmur)

Dg: USG

Treatment – surgical

Arterio-venous (AV) fistulas (direct connection between artery and vein) Causes: inherited, penetrating trauma, iatrogenic (postpuncture),

created for hemodialysis Palpation, auscultation (murmur)

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