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Dr paul grant the patient with claudication

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This presentation for final year medical students covers the clinical signs and symptoms, pathophysiology, investigations and management of individuals with peripheral vascular disease. We touch on risk factors and medical as well as surgical management.

Veröffentlicht in: Gesundheit & Medizin
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Dr paul grant the patient with claudication

  1. 1. ClaudicationClaudication Paul GrantPaul Grant Physician / DiabetologistPhysician / Diabetologist
  2. 2. ClaudicationClaudication Chronic Arterial DiseaseChronic Arterial Disease
  3. 3. PlanPlan •Informal LectureInformal Lecture •PathophysiologyPathophysiology •DefinitionsDefinitions •Patient AssessmentPatient Assessment –HistoryHistory –ExaminationExamination –InvestigationInvestigation •Differential DiagnosisDifferential Diagnosis •Management StrategiesManagement Strategies –Conservative / MedicalConservative / Medical –Invasive / SurgicalInvasive / Surgical •DiscussionDiscussion
  4. 4. Chronic Arterial DiseaseChronic Arterial Disease  Atherosclerosis- platelet deposition onAtherosclerosis- platelet deposition on intimal lesions-subintimal depositionintimal lesions-subintimal deposition of lipids and calcium.of lipids and calcium.  Produces lipid richProduces lipid rich PlaquePlaque  StenosisStenosis (narrowing)-reduced flow(narrowing)-reduced flow  Intermittent claudicationIntermittent claudication  Rest painRest pain  Tissue necrosisTissue necrosis
  5. 5. Classification of PADxClassification of PADx •Fontaine StagingFontaine Staging –Stage I AsymptomaticStage I Asymptomatic • ABPI >0.9ABPI >0.9 • Decreased Foot PulsesDecreased Foot Pulses –Stage II IntermittentStage II Intermittent claudicationclaudication –Stage III Daily Rest PainStage III Daily Rest Pain –Stage IV Tissue necrosisStage IV Tissue necrosis • ABPI < 0.3ABPI < 0.3
  6. 6. Atheromatous plaqueAtheromatous plaque ((lipids macrophages SmM cells)lipids macrophages SmM cells)
  7. 7. Plaque Rupture,Plaque Rupture, Ulceration,proteolytic enzymes &Ulceration,proteolytic enzymes & metalloproteinases-may lead to thrombosis or embolisationmetalloproteinases-may lead to thrombosis or embolisation
  8. 8. Thrombus FormationThrombus Formation - occlusion- occlusion
  9. 9. DefinitionsDefinitions • Intermittent claudication • Derived from latin claudicatio, to limp • Exertional muscle pain relieved by rest • Described as 'cramp' or 'tightness' • Usually occurs after predictable distance (claudication distance) • Peripheral pulses may be present • Critical limb ischaemia • Characterised by rest pain or tissue loss (ulcers or gangrene) • Foot pulses are invariably absent • Rest pain • Usually at night –Decreased cardiac output –Elevation of legs • Eased by hanging leg out of bed
  10. 10. ImportanceImportance • PVD is an independent risk factor for cardiovascular disease • Five year Mortality from atherosclerotic cause: 29% • IHD: 60% • CVA: 15% • Overall survival • Survival at ten years: 38% • Survival at fifteen years: 22% • At 5 years of follow-up – 10% claudicants and 50% of those with critical ischaemia have had an amputation. – 20% claudicants and 50% of CLI’s have died usually from ischaemic heart disease
  11. 11. HistoryHistory • SymptomsSymptoms • Claudication symptom characteristics – Muscle pain (Calf > thigh > buttocks) – Pain worse with exertion (distance, speed, incline) – Pain relieved rapidly with rest – Pain relieved by standing (no need to sit) – Never get symptoms standing still • Rest pain – Furthest tissue from heart – In bed at night – Sitting with legs up when severe • Tissue loss – Furthest tissue from heart – Ulcers or Gangrene
  12. 12. HistoryHistory • Risk FactorsRisk Factors • Smoking –risk persists >5 years after cessation –smoking 20 per day: 2.11 relative risk –smoking 11-20 per day: 1.75 relative risk • Diabetes Mellitus • Systolic Hypertension • Hypercholesterolemia • Family History
  13. 13. ExaminationExamination -- Inspect, palpate, auscultateInspect, palpate, auscultate (Look, feel, move)(Look, feel, move) • Dry, scaly, shiny atrophic skin • Skin hairless over lower extremity (e.g. shin) • Dystrophic, brittle toenails • Ulcers / Gangrene • Decreased skin temperature • Previous surgical scars • Pulses • Bruits • Distal extremity colour change with position (Buergers) – Skin pallor when leg elevated >1 minute – Colour returns within 15 seconds in mild cases – Delay >40 seconds suggests severe ischaemia – Skin rubor when leg dependent • ABPI (hand-held doppler)
  14. 14. DryDry GangreneGangrene
  15. 15. ExaminationExamination •Ankle PressuresAnkle Pressures •Measurements can be made at rest and after exerciseMeasurements can be made at rest and after exercise •Normally lower limb pressures slightly greater than upper limbNormally lower limb pressures slightly greater than upper limb •Ankle-brachial pressure indexAnkle-brachial pressure index • (ratio of best foot systolic to brachial systolic pressure)(ratio of best foot systolic to brachial systolic pressure) •ABPI inABPI in • Normal >1.0Normal >1.0 • Claudication 0.4 -0.7Claudication 0.4 -0.7 • Critical Ischaemia 0.1-0.4Critical Ischaemia 0.1-0.4 •In normal individuals pressures do notIn normal individuals pressures do not fall flowing exercisefall flowing exercise
  16. 16. InvestigationsInvestigations •BloodBlood – Hb, FBCHb, FBC – U&EsU&Es – LipidsLipids •DuplexDuplex •Imaging-MRA magnetic resonance angiogramImaging-MRA magnetic resonance angiogram •CTCT •AngiographyAngiography
  17. 17. Bi-Lateral Iliac OcclusionsBi-Lateral Iliac Occlusions
  18. 18. Differential DiagnosisDifferential Diagnosis •NeurologicalNeurological • Spinal Canal Stenosis (spinal claudication)Spinal Canal Stenosis (spinal claudication) • Peripheral NeuropathyPeripheral Neuropathy • Restless Leg SyndromeRestless Leg Syndrome •MusculoskeletalMusculoskeletal • Baker's CystBaker's Cyst • Muscle / tendon StrainMuscle / tendon Strain • Ligament SprainLigament Sprain • ArthritisArthritis • Connective tissue diseaseConnective tissue disease • Night CrampsNight Cramps
  19. 19. Management - Medical / ConservativeManagement - Medical / Conservative •Cardiovascular risk factor reductionCardiovascular risk factor reduction • Stop smokingStop smoking - arrests disease progression- arrests disease progression • Lipid-lowering drugsLipid-lowering drugs • Anti-hypertensivesAnti-hypertensives • Good diabetes controlGood diabetes control • Anti-platelet medicationAnti-platelet medication •Supervised exercise programSupervised exercise program •Lose weightLose weight
  20. 20. Management - Invasive / SurgicalManagement - Invasive / Surgical •IndicationsIndications • Failed maximal medical therapyFailed maximal medical therapy • Severe symptoms significantly reducing life qualitySevere symptoms significantly reducing life quality • Limb threatening ischemiaLimb threatening ischemia • Rest painRest pain • Non-healing woundsNon-healing wounds • GangreneGangrene •Angioplasty (with or without stent placement)Angioplasty (with or without stent placement) •EndarterectomyEndarterectomy •Arterial BypassArterial Bypass •(Sympathectomy)(Sympathectomy) •AmputationAmputation
  21. 21. Management - InvasiveManagement - Invasive •Angioplasty / StentingAngioplasty / Stenting –In aorto-iliac segment has a 90%In aorto-iliac segment has a 90% 5 year patency5 year patency –In infra-inguinal vessels has aIn infra-inguinal vessels has a 70% 5 year patency70% 5 year patency –Best results for short segmentBest results for short segment stenoses < 2 cm longstenoses < 2 cm long –Complications occur in less thanComplications occur in less than 2% of patients2% of patients • Wound haematomaWound haematoma • Acute thrombosisAcute thrombosis • Distal embolisationDistal embolisation • Arterial wall ruptureArterial wall rupture
  22. 22. AngioplastyAngioplasty
  23. 23. StentStentinging
  24. 24. EndarterectomyEndarterectomy
  25. 25. Bypass surgery • To bypass a long damaged segment • anatomical – aorto bi femoral – femoro above/below knee popliteal – femoro distal (below the popliteal artery) – popliteal distal • extra anatomical – femoro femoral crossover – axillo bi femoral • vein (reversed or in situ) • graft (plastic PTFE)
  26. 26. Aorto- Femoral BypassAorto- Femoral Bypass
  27. 27. Femoropopliteal BypassFemoropopliteal Bypass • To bypass a long damaged segment • anatomical – aorto bi femoral – femoro above/below knee popliteal – femoro distal (below the popliteal artery) – popliteal distal • extra anatomical – femoro femoral crossover – axillo bi femoral • vein (reversed or in situ) • graft (plastic PTFE)
  28. 28. Vein versus graftVein versus graft • Vein – patent for longer – less likely to become infected – not suitable if varicose or already removed! • Graft – more likely to thrombose – increased risk of graft infection (years later)
  29. 29. Immediate post op complicationsImmediate post op complications - specific vascular complications- specific vascular complications • Bleeding – usually drains present to control bleed – if unstable / expanding haematoma → theatre – contact seniors • No Doppler signal / no pulses – sometimes never present post op – if were present but disappear → contact seniors • Compartment syndrome
  30. 30. Compartment syndromeCompartment syndrome • When ischaemic muscle gets reperfused – muscle oedema – pressure in the compartment goes up – causes microvascular compromise – muscle necrosis • intense pain - especially to passive movement • parasthaesia in the feet • pulselessness is a late sign • requires fasciotomy → contact seniors
  31. 31. AmputationsAmputations •Toe/Ray (Diabetes)Toe/Ray (Diabetes) •Below KneeBelow Knee •Above KneeAbove Knee
  32. 32. SummarySummary • Atherosclerosis is a systemic disease – peripheral disease – coronary disease – cerebral disease – renal disease • Claudication usually improves with non operational treatment • Control / manage CV risk factors

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