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Arterial Disease part II

NANDA NURKUSUMASARI
Chronic Peripheral artery disease
Two types
1. Claudicatio intermittent : Pain on activity
2. Critical Chronic Limb Ischemia : Rest Pain

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Claudicatio Intermittent

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Claudicatio intermittent
 Symptoms : cramp or pain may be in leg, thigh, gluteal area ,
shoulder or arm
 Patophysiology : not only reduce flow , but also due to
disorder of metabolism in skeletal muscle
 Pain in activity and relieve after take a rest
 Etiology :
 PAD ( the most common)
 Coarctatio aorta , takayasu, Buerger

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Physical Examination
 Weak pulsation in arteri (upper or lower limb)
 ABI < 0.9 = arterial obstruction
 ABI > 1.3 = non compressible (arterial wall stiffness, most
common in elderly or diabetic patient) Continue with Toe
Brachial Index if TBI <0.9 = arterial obstruction

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Therapy
 Antiplatelet : Cilostazol 2 x100 mg
 Supervised limited exercise : increase dose to 6 month
(hoping that there will be collateral circulation)  If Failed
 Revascularization
 Modified the atherosclerotic risk factors

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Critical Chronic Limb Ischemia

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 Same with claudication intermittent; except
 Rest pain
 Tissue loss

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Therapy
 Revascularization : Stenting or Bypass Grafting
 Oral medication : Statin, anti platelet
 Modified the atherosclerosis risk factors

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Arterial Steal Syndrome

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General definiton
 Insufficiency of blood flow in distal artery due to Run-off
arterial blood flow to the other channel (A-A or A-V)

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Arterial Steal Syndrome

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Dialysis steal syndrome

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 Distal hypoperfusion ischemic syndrome (DHIS), commonly
referred to as hand ischemia or 'steal' after dialysis access
placement, occurs in 5-10% of cases when the brachial artery
is used, or 10 times that of wrist arteriovenous fistulas
(AVFs) using the radial artery.

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 These three causes of steal may occur alone or in concert.
The diagnosis of steal is based on an accurate history and
physical examination and confirmed with tests including an
arteriogram, duplex Doppler ultrasound (DDU) evaluation
with finger pressures and waveform analysis..

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 It is typically seen in elderly women with diabetes, and may
carry severe morbidity including tissue or limb loss if not
recognized and treated.
 Three distinct etiologies include (1) blood flow restriction to
the hand from arterial occlusive disease either proximal or
distal to the AV access anastomosis, (2) excess blood flow
through the AV fistula conduit (true steal), and (3) lack of
vascular (arterial) adaptation or collateral flow reserve (ie
atherosclerosis) to the increased flow demand from the AV
conduit.

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 Treatment of steal includes observation of developing
symptoms in mild cases. Balloon angioplasty is the
appropriate intervention for an arterial stenosis. At least
three distinct surgical corrective procedures exist to
counteract the pathophysiology of steal

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Subclavian steal syndrome
 With exercise, innate and metabolite-induced vasodilatation
leads to a drop in peripheral resistance in upper-limb vessels,
and the mismatch between arterial inflow and metabolic
demand may lead to claudication of the arm. Furthermore
increased retrograde flow through the ipsilateral vertebral
artery may “steal” blood away from the cerebral circulation.
This may be more likely if there is concomitant stenotic
disease of the other extracranial or intracranial vessels.
 Neurologic disorder is common (dizziness, vertigo, blurred
vision, diplopia, and near-syncope) upon exercise of the
ipsilateral arm

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Work Up
 Physical examination
 Chest X-ray
 ECG  related to coronary heart disease
 USG Doppler vascular
 CT – angiography
 Trans catheter – angiography
 Magnetic Resonance Angiography

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Therapy
 Stenting and bypass with/out conduit
 Modified the atherosclerotic risk factors

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Arterial embolism
 Acute Limb Ischemia
 Non Haemorrhagic Stroke

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Source of Emboli
 Cardiac , eg : LV thrombus from advanced Heart Failure, AF
 And Non Cardiac, eg Aortic dissection related thrombus,
Vascular Trauma related thrombus

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Acute Limb Ischemia

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 Acute limb ischemia occurs due to a sudden decrease in the
blood flow to a limb, resulting in a potential threat to the
viability of the extremity.
 Unfortunately, the threat is not only to the limb, but these
patients are also at high risk for death. Limb hypoperfusion
results in systemic acid-base and electrolyte abnormalities
that impair cardiopulmonary and renal function.
 Successful reperfusion may result in the release of highly
toxic free radicals, further compromising these critically ill
patients.

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Symptoms (Sudden onset)
 pain, pallor, paralysis, pulse deficit, paresthesia, and
poikilothermia
 In history taking should find any involvement of cardiac
disease or not

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Therapy
 PIAT (percutaneous intra arterial thrombolysis)
 Thrombectomy/embolectomy ( transcatheter or surgery)
 Amputation
 Additonal Therapy :anticoagulation, “atherosclerotic
medicine”

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Arterial Aneurism

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Aortic Aneurism
 Dilatation of the aortic pipe ( Aortic root –Abdominal aorta)

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Etiology
 Atherosclerosiswhich weakens arterial walls.
 Hypertension (high blood pressure).
 Local injury to the artery.
 Congenital abnormality. A number of conditions, such as
Marfan syndrome or bicuspid aortic valves are present at
birth and can cause weakness of the artery walls.
 Aging
 Syphilis used to be a common cause of thoracic aneurysms,
but it is no longer as common.

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Symptoms
 Mostly no symptoms until expansion to the other organ or
after a complication
 Tearing pain in the chest, abdomen, and/or middle of the
back between the shoulder blades.
 Thoracic aneurysms may cause shortness of breath,
hoarseness, cough (due to pressure on the lungs and airways),
and difficulty swallowing (pressure on the esophagus)
 Rupture of an aneurysm can cause loss of consciousness,
stroke, shock, or a heart attack

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Work - Up
 Physical examination
 CXR
 Echocardiography
 CT-Aorta
 MRI
 Trancatheter angiography

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Therapy
 Aorta replacement with conduit
 Or, EVAR / TEVAR

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