Discussing the risk factors causing Gangrene, and the development of Peripheral Vascular Disease. Role of non surgical Vascular Interventions and Hyperbaric Oxygen treatment in treating Peripheral Arterial disease.

1. Preventing Gangrene
and Saving Legs from
Amputation
DR SHOAIB F PADARIA
Interventional Cardiologist
Director, Department of Vascular
Sciences, Jaslok Hospital, Mumbai

2. Dry
Gangrene
Wet
Gangrene
Gas
Gangrene
GANGRENE

3. Most common cause of Gangrene is
decreased blood supply

4. Decreased blood supply to legs
Peripheral Arterial Disease

5. Risk factors for PAD
Murabito JM et al. Circulation 1997;96:44–49; Laurila A et al. Arterioscler Throm Vasc Biol 1997;17:2910–2913;
Malinow MR et al. Circulation 1989;79:1180–1188; Brigden ML. Postgrad Med 1997;101:249–262.
 Gender (male)
 Age
 Smoking
 Hypertension
 Diabetes
 Hyperlipidaemia
 Fibrinogen
 Homocysteinaemia
PAD
Ischaemic
stroke
Myocardial
infarction
Atherosclerosis Atherothrombosis

6. Peripheral Arterial Diseases in
Diabetics has a Poor Prognosis
PAOD is 20 times more common in diabetics than non diabeticsLower limb amputation is 15 times more common in diabetics
Ten year incidence of lower limb amputation is 5.4% in type I
diabetes and 7.3% in type II
10% of diabetics will eventually get an ulcer ,
45% of ulcers are ischemic with associated neuropathy, infection,
biomechanical abnormalities and Charcot deformity

7. Presentation of Peripheral arterial disease
Symptomatic
10%
Asymptomatic
90%

8. How dangerous is Peripheral Arterial Disease ?
Depends on the severity of Symptoms
Criqui MH et al. N Engl J Med 1992;326:381–
386.
Time (years)
0 2 4 6 8 10 12
0.00
0.25
0.50
0.75
1.00
Survival
Severe symptomatic
Symptomatic
Asymptomatic
Normal
10 year
Survival
Rates

9. PAD is a Dangerous Disease
5-year mortality rates
1American Cancer Society. Cancer Facts and Figures – 1997.
2Kampozinski RF, Bernhard VM. In: Vascular Surgery (Rutherford RB, ed). Philadelphia, PA: WB Saunders: 1989;chap
53.
15 18
28
38
86
0
10
20
30
40
50
60
70
80
90
100
Breast cancer1 Hodgkin's
disease1
PAD2 Colon and
rectal cancer1
Lung cancer1
Patients(%)

10. Main Symptom of Peripheral artery
disease
Claudication
Claudication is pain, tired or weak feeling that
occurs in the legs, usually during activity like
walking, and goes away a short time after rest
Complete relief of symptoms should occur
within 5 to 10 minutes.
It should not be necessary for the patient to sit
to obtain relief

11. Symptoms of
Claudication associated
with Peripheral Arterial
Disease usually
manifest in the muscle
groups below the
arterial level of
narrowing or blockage

12. Arterial
Claudication
Venous
Claudication
Neurogenic
Claudication
Types of Claudication

13. How to differentiate between different types of claudication

14. Progression of Peripheral Arterial Disease
Critical Limb Ischemia leading to
Gangrene and Amputation
Initial Symptoms are usually Claudication Pain
Later Pain occurs even at rest
Skin changes, loss of hair, loss of nails, ulcer

15. Diagnoses of
Peripheral Arterial
Occlusive Disease

16. Clinical Examination
Feel the Pulses in the feet
Dorsalis Pedis Posterior Tibial

17. Measurement
of Ankle –
Brachial Index

18. Arterial Doppler Ultrasound Examination

19. CT and MR Angiography

20. Gold Standard
Digital Subtraction Angiography

21. Treatment Options
Risk Factor
Modification
Exercise
Therapy
Pharmacologic
Therapy
Re-
Vascularisation

22. Risk Factor Modification

23. In most patients,
regular exercise
helps to increase
the distance they
can walk before
they develop
claudication
pain.
This is because
of gradual
development of
new blood
vessels –
Collateral
circulation

24. Pharmacologic Treatment
• Pentoxiphylline
• Cilostazole
Only Two
Drugs have US
FDA approval
for Intermittent
Claudication
• Aspirin
• Clopidogrel
• Rivoroxaban
Other drugs
which are
commonly used
include :
Some Other Drugs which can be
used
• Naftidrofuryl
• Levocarnitine
Changes in
tissue
Metobolism
• L-Arginine
Enhanced
Nitric Oxide
Production
• Statins
• Prostaglandins
• ACE Inhibitors
Vasodilatory
Effects

25. Ischemic
Rest Pain
Tissue Loss
Severe
Claudication
Indications for
Re –vascularization
in a Patient with
PAD

27. Angioplasty or Surgery for Peripheral Arterial Disease

28. Evolving Interventional Vascular Angioplasty Techniques have led to
The gradual decrease of classical vascular
surgery

30. Drug Coated Balloons and Stents
Decrease the Restenosis Rate
Use of Drugs like Sirolimus and Paclitaxel

31. When the Obstructive tissue is very large for Angioplasty
Debulking Technologies
Rotablator
Excimer Laser
Excisional Atherectomy
Orbital Atherectomy
Pathway Atherectomy

32. Case Studies
of Vascular
Intervention
How to treat
Arterial Blockages
in the Lower limbs
in time, to prevent
progression to
Gangrene and
Amputation

33. Disease of the Distal Abdominal Aorta.

34. Aortic Occlusive Disease
68 year old female : Diabetes, Hypertension, Impaired Renal function
Severe Rest Pain in Both lower limbs, with both femoral arteries very feeble
Initially diagnosed as “Slipped Disc” and treated for one month

35. Discrete Stenosis of Infra Renal Abdominal Aorta

36. Complex Aortic Bifurcation Stenosis

37. Iliac Artery Disease

38. Complex stenosis of Right Iliac Artery

39. Iliac Artery Stenosis and Occlusion
Right Iliac artery occluded. Left stenosed.

40. Left Iliac Artery Total occlusion

41. Right Iliac Artery Thrombosis

42. Superficial Femoral Artery Disease

43. Superficial Femoral Artery
Most common site of Peripheral arterial disease
Most common cause of Claudication Pain
Total occlusive disease of SFA is 3 times more common than stenosis
Usually calcification is seen in the diseased segment of SFA
SFA disease tends to be bilateral and “mirrored” in the other leg
Profunda artery collaterals are usually present, and rate of critical limb
ischemia is 2-3% per year

44. Discrete femoral artery stenosis

45. Chronic
Femoral artery
occlusion

46. Popliteal artery thrombosis

47. Popliteal Artery Thrombosis

48. Below Knee Angioplasty

49. Below Knee Disease
Most common in diabetic patients
Usually all three vessels, the Anterior
Tibial, Posterior Tibial and the
Peroneal artery are involved
Opening of even one of these
arteries is enough to salvage the leg
from amputation

50. Results of Treatment of Below knee Disease in Critical Limb Ischemia
71% clinical improvement at 19 months
• ( Cardiovasc Interv Rad 1992 ; 15 : 211 - 216 )
97% clinical improvement when restoration of straight line pulsatile flow to
foot ( Bakat et al )
Prevention of amputation :
: 88% Shwarten (Radiology 1988 ; 169 : 71 - 74 )
: 85% Buckhenham (Eur Jr Vasc Surg 1993 : 7: 21 - 25)

51. Below Knee – Anterior Tibial Angioplasty

52. Posterior Tibial Artery Stenting

53. No arterial flow below knee
Severe Rest Pain and Impending Gangrene – Advised Above Knee
Amputation

54. Peroneal artery occlusion at the level of the Ankle

55. What about those patients
suffering from PAD whose
disease is not suitable for
either angioplasty or surgery ?

56.  42 year old diabetic
 War injury to right leg resulting
in amputation
 Non healing of infected stump
for 3 months
 Advised amputation at hip
joint
INFECTED WOUND

57.  54 year old male smoker
 Has developed gangrene of
the toes
 Has been advised above
knee amputation
ARTERIAL WOUND

58. Treatment of Problem Wounds
• Add Hyperbaric Oxygen treatment
when needed
Infected wounds –
Proper surgical
debridement, antibiotics,
skin grafting if
necessary.
• Add Hyperbaric Oxygen treatment
when needed
Arterial wounds –
Restore arterial blood
flow by angioplasty or
vascular surgery

59. Hyperbaric Oxygen
Treatment
HBOT

60. What is Hyperbaric Oxygen Therapy (HBOT)
HBOT is delivery of 100%
oxygen which is inhaled by
patients , while they are
inside a special hyperbaric
chamber which has a raised
pressure

61. Hyperbaric Oxygen Treatment
Approved By US FDA
Guidelines for treatment formulated by
the Undersea and Hyperbaric Medicine
Society.

62. Hyperbaric Oxygen Treatment
100% oxygen
About 1100 cubic feet of oxygen
treatment for a treatment time of
60 to90 minutes
About 5 to 7 patients can be
treated per chamber per day
Each patient may need
between 5 to 15 treatments
Outpatient Treatment

63. • By breathing 100%
oxygen at 1 atmospheric
pressure, hemoglobin gets
100% saturated.
• (Only 3% increase)
Effect on
Hemoglobin:
When you
normally breath
air at sea level –
1 atmosphere
( 760 mm Hg),
hemoglobin is
97% saturated

64. HBO mainly increases the dissolved oxygen
in plasma
Oxygen solubility in plasma is proportional to the
partial pressure of oxygen pO2.
Breathing air at 1 atm , gives 0.31 vol%
Breathing 100% oxygen at 1 atm, gives 2.1 vol%
Breathing 100% oxygen at 3 atm, gives 6.8 vol %
Breathing 100% oxygen at 3 atm, increases plasma
oxygen solubility 21 times

65. HBOT increases Oxygen diffusion into tissue
 At 1 ata on air, capillary pO2 of about 100 mm Hg diffuses about 64
microns from functioning capillary
 As pO2 increases, oxygen diffusion distance also increases
 At pO2 of about 2000 mm Hg, oxygen diffusion distance increases about 4
fold.
3 atm2 atm1 atm
Capillary Tissue

66. How does HBOT lead to Wound Healing ?
Establishment of a gradient of Oxygen level
between the healthy tissue and the wound,
stimulates release of various vaso-active factors
which promote the formation of newer capillaries.
Multiple exposures to HBOT treatment are
necessary to establish this formation. Especially
useful in severe peripheral vascular disease
Neovascularisation – New Blood Vessel Formation

67. How does HBOT lead to Wound Healing ?
• Increases Leukocyte phagocytosis
• Improves bacterial killing by neutrophil-generated
high energy oxygen radicals
• Effect on Clostridium Perfringens (gas gangrene)
• Alpha toxin ceases at pO2 >250 mm Hg
• Bactericidal when pO2>1500 mm Hg
1: Leukocyte
Oxidative Killing
2: Converts anaerobic wounds with low pH to aerobic
wounds with normal pH – so kills anaerobic bacteria
Anti Bacterial Effect

68. How does HBOT lead to Wound Healing ?
Anti Bacterial Effect
3: Some antibiotics do not
work well in acidic pH –
HBOT converts to tissue to
normal pH
• Tobramycin and HBOT best
eradicates Pseudomonas aeroginosa
from infected bone (Mader JT et al ,
1987)
4: Adjunctive
role of HBOT:

69. How does HBOT lead to Wound Healing
?
By decreasing the
Tissue Edema
This decreases the
compression the blood
vessels, leading to
increased arterial flow, and
better return of blood by
the veins
The decreased edema
also allows for better
oxygen diffusion up to
the area of tissue which
needs more of oxygen

70. Healing of Amputation stump with HBOT
Before
After

71. Conclusion
With use of currently
available technology, it is
possible to treat severely
diseased lower limb
arteries, including the
distal vessels of the foot
with angioplasty procedure
Early diagnosis and
treatment of PAOD
prevents progression
to critical limb
ischemia and gangrene
Prevention of
amputation and
maintaining mobility
in patients is the
greatest gift we can
give to our patients.

72. Thank
you
Vascular OPD at Jaslok Hospital
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