Haryo Aribowo

Sub Bag. Bedah Toraks Kardiovaskuler

SMF Bedah RS Sarjito
Yogyakarta
 Decrease of arterial limb perfusion causing
threat to limb viability

 Divide into acute and chronic

 Acute < 14 days
 Chronic > 14 days
 The prevalence of people aged over 55 years is 10%–
25% and increases with age

 70%–80% of affected individuals are asymptomatic

 In the USA: 12–20% age 65 and older

 A study 1999–2000 data found that PVD affects

approximately 5 million adults
Factors : wall – pump – blood

 Embolism

 Thrombosis

 Others : cancer, cardiac disease, coagulation

disorder, DM, CKD
 Older age (> 40 years)
 Male
 Smoking
 Diabetes mellitus
 Hyperlipidemia
 Hypertension

When risk factors coexist, the risk increases several-fold

Aorta & Iliac arteries: 30%

Femoral & Popliteal arteries: 80-90%

Tibial & Peroneal arteries: 40-50%

▪Acute

▪Chronic
 Acute Embolic Acute Thrombotic
Ischemia Ischemia

An embolus can originate from the heart (MS with atrial fibrillation, MI
with mural thrombus) or dilated diseased arteries (aortic aneurism) Atherosclerosis
causes
An embolus progressive
suddenly narrowing of the
occludes a arterial tree
relatively
healthy arterial
tree Stimulates
development of
It usually collaterals
arrest at
arterial Sluggish flow &
bifurcation rough surface
will favor acute
Aortic bifurcation
thrombosis
Iliac bifurcation
Femoral bifurcation
Popliteal trifurcation
To relieve exertional symptoms and improve
walking capacity

To improve quality of life

To reduce total mortality

Embolism :
 Sudden onset of symptoms
 Known embolic source
 Absence of previous claudication
 Normal pulse in the other limb
 Fixed mottling
5Ps & cyanosis

▪ Pain
▪ Pale
▪ Pulseless
▪ Paresthesia
▪ Paralysis
Femoral art.

Post tibialis

Popliteal art.

Dorsalis pedis
•Saturation %
•Heart rate
•Graph
 Doppler US
It is important to look for arterial Doppler
signals to assess the level of obstruction &
severity of ischemia
Value of angiography
Localizes the obstruction
Visualize the arterial tree & distal run-off
Can diagnose an embolus
 Clinical Findings Doppler Prognosis

Class Sensory Motor Arterial Venous

loss weakness signals Signals
I. Viable -ve -ve audible audible Not immediately
threatened

II.a Marginal Minimal No muscle Often not audible Salvageable if prompt

sensory loss weakness audible ttt (there is time for
threat angiography)
II.b Immediate Rest pain w Mild to Usually audible Salvageable with
threat sensory loss moderate not immediate ttt (no time
more than toes audible for angiography)

III.Irreversible Severe Paralysis w Inaudible Inaudible Not salvageable,

anesthesia muscle rigor permanent N. & muscle
damage , needs amputation
Multi discipline underlying disease
Timing : <6 hrs viable
6-12 hrs borderline
>12 hrs non viable

 Medications
 Minimal invasive
 Surgical
 Heparin
 Analgesia
 Haemorheolog
 Catheter directed trombolysis
Agents used: Streptokinase, Urokinase

 Embolectomy (fogarty catheter)

 Embolectomy open

 Amputation
 < 6 hrs : 100% limb salvage

 6 -12 hrs : 60-70% limb salvage

 >12 hrs : 100% amputation

 Progresive

 Asymptomatic

 Collateral
 I Asymptomatic
 II Intermittent Claudication
II a Claudication walking > 200m
II b Claudication walking < 200m
 III Rest/nocturnal pain
 IV Necrosis/gangrene
 Condition of skin and appendages
 Pulses (absence tends to overestimate PAD)
 Check for bruits
 Pallor during leg elevation
Time for color return after leg restored to
dependent position
 ABI
 ABI <0.9 is 99% sensitive and 99% specific for
angiographically diagnosed PAD
 Supine position
 Check systolic BP in upper extremities (using
Doppler) – use highest value
 Systolic BP in lower extremities using both PT
and DP – use highest value
 Divide ankle SBP by brachial SBP
Clinical Presentation Ankle-Brachial Index
Normal > 0.90
Claudication 0.50-0.90
Rest pain 0.21-0.49
Tissue loss < 0.20

Values >1.25 falsely elevated; commonly seen in

diabetics Am J Cardiol 2001; 87 (suppl): 3D-13D
NEJM 2001; 344: 1608-1621
 Femoral artery

stenosis
occlusion
atherosclerosis stenosis
To relieve exertional symptoms and improve
walking capacity

To improve quality of life

To reduce total mortality

Multi discipline
Timing ?

 Risk factor reduction

 Medications
 Minimal invasive
 Surgery
 Minimal invasive :

Percutaneus Transiluminal angioplasty

 A meta-analysis of 6 trials (n=1300)
demonstrated high initial success rates of
90%
 Long-term success rates vary from 51-70% at
five years depending on severity and local of
disease
 Best for stenosis (rather than occlusion),
short segment disease, larger vessels (ie:
iliac), no DM, normal renal function
 Bypass/shunting

 Sympatectomy

 Amputation
 Generally accepted as most effective
treatment for those with debilitating PAD,
but studies are inadequate to confirm this
view
 In appropriate context PTA or PTA with stent
appears to be equally effective (5 yr patency
rates of 64% vs 68%)
 In some contexts surgery appears superior
(infrainguinal lesions 5 yr patency 38% for
PTA and 80% with surgery)
Occlusion main artery
Collateral >>>

Vasoconstriction (-)
Blood flow >>>
Occlusion main artery
Collateral minimal
Symptom (+)

amputation
 Arterial occlusion divide into acute and
chronic
 Etiology : multi factorial
 Diagnostic : doppler USG or Angiography
 Treatment : multi discipline