Diseases of peripheral arteries
and aorta
Leg arteries: obliterations Causes:
• 90% - atherosclerosis (AS)
• M. Buerger
• vaskulitides
• fibromuscular dysplasia
• Cystic degeneration of adventitia
• trauma, physical causes
Periphery artery disease – PAD
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
cerebrovascular
coronary renal visceral
leg
Risk factors (RF)
smoking
Positive family history
DM
hypertension
Dyslipidemia
Age above 50
Male gender
Obesity
Clinical pictures
Acute chronic occlusion
Acute occlusion = acute limb ischemia (ALI) Embolism, thrombosis, trauma
“6P”:
“pain”
“pulselessness”
“pallor”
“poikilothermia”
“paresthesias”
“paralysis”
sometimes a 7
thP is added- ‘prostration’
– a general deterioration, sometimes even shock.
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)
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
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
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
Rest pain
usually occurring or worsening at night, at rest
Relief - hanging legs down
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
Chronic critical limb ischemia (CLI) -definition Duration >2 weeks
Persistent pain
Ulcers or gangrene
Ancle pressure < 50 mm Hg
Toe pressure < 30 mm Hg
Lerisch´s syndrome
– isolated stenosis/occlusion of aortic bifurcation and proximal segments of both common iliac arteries
→ gluteal claudication, impotence
PAD - Dg History
- RF, symptoms
Physical examination
Color, temperature, pulsation Ratschow´s test
treadmill test
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
Treadmill test
claudication interval
Ankle pressure
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
Toe-brachial index TBI
PAD - Dg
Ankle pressure (toe pressure) Imaging methods
• USG
• AG (angiography)
• CT-AG
• (MR-AG)
Angiography
- Multiple stenoses of iliac arteries
CT-AG
arterial segment occluded
Angiography - stenosis of femoral artery bilaterally
Therapy - conservative RF management
Smoking
hyperlipidemia
DM
hypertension
Obesity
Therapy – conservative
Pharmacotherapy (Rx) Antiplatelets
Acetylsalicylic acid (ASA) Clopidogrel
Vasodilatative therapy
• Naftidrofuryl
• Cilostazol
Reologic therapy
• Pentoxifyllin (Trental, Agapurin)
• Sulodexid (Vessel Due F)
Prostaglandins
i.v. in advanced ischemia (if intervention or surgery is not possible)
Rehabilitation
Supervised exercise Walking
Therapy - revascularization
• Endovascular methods
• Vascular surgery
PTA - ballon angioplasty
(percutaneous transluminal angioplasty)
stent
Therapy - experimental
In chronic CLI (risk of amputation) - stem cells
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)
Diseases of aorta
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)
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
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
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
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)
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
Diseases of other
peripheral arteries
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
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)
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)
Acute upper limb ischemia
Mostly of embolic origin Risk of amputation
→ urgent Dg (USG, CT-AG)
→ urgent revascularization (surgical embolectomy)
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)
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
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)
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
Vasculitides
Classification
GBM - glomerular basement membrane
ANCA - Antineutrophil cytoplasmic antibodies
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)
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
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)