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VASCULAR DISEASE
RISK FACTORS
Modifiable Risk Factors Odds Ratio
Cigarette smoking 2.0 - 2.7
PATHOPHYSIOLOGY
Single or multiple
Intermittent Exercise
occlusive lesions
Impaired
Claudication
vasodilatation (NO) Activation of
Accentuated local sensory
vasoconstriction receptors by
(thromboxane, accumulation of
serotonin, lactate or other
angiotensin II, metabolites
endothelin, NE)
Abnormal rheology
(fibrinogen)
PERIPHERAL ARTERIAL DISEASE
PATHOPHYSIOLOGY
Circulatory supply
1. A shift to anaerobic
metabolism
2. I n c r e a s e d l a c t a t e
release
3. A c c u m u l a t i o n o f
acylcarnitine during
exercise
PERIPHERAL ARTERIAL DISEASE
CLINICAL PRESENTATION
SYMPTOMS
Intermittent claudication
Rest pain
PERIPHERAL ARTERIAL DISEASE
SYMPTOMS
Intermittent claudication
1. A pain, ache, sense of fatigue or other
discomfort
2. A f fe c t e d m u s c l e g r o u p w i t h e xe r c i s e
particularly walking and resolve with rest
SYMPTOMS
Rest pain
Palpation Auscultation
CLASSIFICATION
3 Severe claudication
IIb Claudication walking < 200 m
4 Ischemic rest pain
III Rest and nocturnal pain II
5 Minor tissue loss
IV Necrosis and gangrene III 6 Major tissue loss
PERIPHERAL ARTERIAL DISEASE
Ankle-Brachial Index
Using Doppler
systolic BP on ankle
ABI = 0.9
systolic BP on brachial
90-95% sensitive and 98-100% spesific
for angiographic verivied PAD
Contrast Angiography
PERIPHERAL ARTERIAL DISEASE
Contrast Angiography
Prognosis
Abnormal ABI
2-4 folds for:
Myocardial infarction
Angina
Congestive heart failure
Cerebrovascular ischemia
PERIPHERAL ARTERIAL DISEASE
Treatment
Exercise Rehabilitation
PERIPHERAL ARTERIAL DISEASE
1. Smoking cessation
3. Treatment of diabetes to
achieve HbA1C of less than 7%
Pharmacology Therapy
PAD
Claudication: Critical Leg Ischemia
Asses severity,
history, questionaires,
treadmill testing
Claudication therapy:
Supervised exercise Symptom deteriorate
Cilostazol
Revascularization:
Angioplasty
Bypass surgery
ACUTE LIMB ISCHEMIA
Clinical Categories
Category Description
Sensory Muscle
Arterial Venous
Loss Weakness
I:
Not immediately threatened None None Audible Audible
Viable
IIa : Minimal
Salvageable if promptly (often)
Marginally (toes) or None Audible
treated audible
threatened none
IIb : More than
Salvageable with immediate Mild- (usually)
Immediately toes, rest Audible
revascularization moderate inaudible
threatened pain
Major tissue loss or Profound,
III : Profound,
permanent nerve damage paralysis Inaudible Inaudible
Irreversible anesthesic
inevitable (rigor)
ACUTE LIMB ISCHEMIA
Arterial Thromboembolism
by initial clinical examination
Heparin
unless contraindicated
Treatment
Analgesic
Positioning the feet are lower than chest
The room should be kept warm
Heparin is admnistered intravenously as soon as the
diagnosis is made (PTT by 1,5-2,5 times control)
Catheter-directed intraarterial thrombolytic therapy
for category I or II if there is no contraindication
VEIN
VARICOSE VEINS
Prevalence 20-60%
Men 10-15% & women 20-25%
One of the most surgical-needing disease
VARICOSE VEINS
PAST ERA
Surgery
VARICOSE VEINS
NEW ERA
Endovenous
Surgery
Intervention
VARICOSE VEINS
VARICOSE VEINS
NORMAL
VARICOSE VEINS
Etiology
Arteriovenous shunt
VARICOSE VEINS
Risk Factors
Female
Defecation
Style
Elderly
Prolonged
Obesity
Upstanding
Low
Genetic
fiber diet
Pregnancy
VARICOSE VEINS
Pregnancy
Manifestations
Men Women
Swelling 23%
VARICOSE VEINS
Manifestations
Lipodermato
Superficial
Bleeding schlerosis
thrombophlebitis
ulceration
VARICOSE VEINS
Diagnosing..
Trendelenburg Test
Valsalva Maneuver
Perthes Test
VARICOSE VEINS
Trendelenburg Test
Valsalva Maneuver
Perthes Test
Management
Conservative
Modifying Venous
Risk Factor Compression
1. A v o i d p r o l o n g e d Use special venous
upstanding bandage / stocking
2. Manage obstipation
3. Manage obesity
4. M a n a g e i n t r a
abdominal pressure
5. Increase leg exercise
VARICOSE VEINS
Surgery
Recurrence (19-35%)
Nerve injury (4-25%)
Hematoma (<30%)
Infection (2-15%)
DVT (<2%)
Lung embolism (0.2-0.5%)
Endovascular Intervention
Less Traumatic
Cosmetic aspect
Low Cost
Outpatient Setting
VARICOSE VEINS
Endovascular Intervention
Indications: Contra
1. Prominent varicose veins Indications:
2. Pain 1. Deep veins obstruction
3. Heaviness leg
2. Severe PAD
4. Restless leg
3. Immobilized patient
5. Superficial thrombophlebitis
4. Poor general condition
6. External bleeding
5. Pregnant & nursing woman
7. Hyperpigmentation
8. Lipodermatoschlerosis
9. Skin athropy
Endovascular Intervention
Foam Schlerotherapy
Advantages:
Less agent
Does not mix with blood
Ultrasound echogenicity
Not inferior compared to
surgery
Radiofrequency Ablation
Device: VNUS
radiofrequency catheter
Introduced at 1998
Accepted by FDA at
1999
Suitable for diameter of
2-12mm
Introduced at 1990
Accepted by FDA at 2002
Suitable for any diameter
and CEAP classification
class II
Mechanism of action: Delivers thermal energy from the laser fiber into
the vein lumen and produce irreversible injury leading to complete vein
shrinkage
VARICOSE VEINS
Recurrence
Recurrence Rate
Etiology: 3 months 13.7%
?
VARICOSE VEINS
Edema
Pain
Warmth
Redness / discoloration
Usually in one calf
DEEP VEIN THROMBOSIS
Diagnosis
Calf swelling 1
Swollen leg 1
Clinical Features
Pathophysiology
Pathophysiology of right ventricular dysfunction. LV = left ventricular; PA = pulmonary artery; RV = right ventricular
Diagnosis