ANGIOLOGY – VASCULAR MEDICINE for medical students 6. year of study

PADs Raynaud´s sy CVD

VIERA STVRTINOVA, 2018 DISEASES of the ARTERIAL SYSTEM

 PADs, PAOD - peripheral arterial diseases  PAD of lower limbs, upper limbs carotid artery disease, renal artery disease, splanchnic (mesenteric) artery disease  Aortic and arterial aneurysms

 CAD – carotid artery disease  CAD – CORONARY ARTERY DISEASE

Peripheral arterial disease PAD of LL

 is a common circulatory problem in which narrowed arteries reduce blood flow to the lower limbs - Peripheral artery occlusive disease

CAUSES: Atherosclerosis Winiwarter – Buerger disease Vasculitis (upper limb involvement is more common than in AS) ATHEROSCLEROSIS RISK FACTORS

 · Smoking  Hyperlipidemia (dyslipidemia) – chol., TG  ·High  ·Obesity (a body mass index over 30)  ·Diabetes mellitus  ·Age over 70 years (5O yrs)  ·Family history for AS  Physical inactivity and psychical stress Fontaine classification addapted

I. Stage - asymptomatic • Without pain (feeling of coldness, parestezias) • Murmur over the arteries

II. Stage – intermittent claudication IIa – claudicatory distance more than 200m • IIb - claudicatory distance less than 200m • IIc - claudicatory distance less than 50m Fontaine classification addapted

III.stage – rest pain • IIIa – ankle pressure more than 50 mm Hg (or toe pressure more than 30 mm Hg) • IIIb - ankle pressure less than 50 mm Hg (or toe pressure less than 30 mm Hg) • From III b – CLI – with progression to IV.st. (IVb IV. Stage - ulceration or gangrene • IVa – necrosis (localized) • IVb – necrosis and gangrene ABI (ABPI) Ankle Brachial Index is the systolic blood pressure at the ankle, divided by the systolic blood pressure at the arm PAD - Interpreting the ABI

 Normal ABI ranges from 1.0 — 1.4 ◼ Pressure is normally higher in the ankle than the arm.  Values above 1.4 suggest a noncompressible calcified vessel. ◼ In diabetic or elderly patients, the limb vessels may be fibrotic or calcified. In this case, the vessel may be resistant to collapse by the blood pressure cuff, and a signal may be heard at high cuff pressures. The persistence of a signal at a high pressure in these individuals results in an arteficially elevated blood pressure value.  An value below 0.9 is considered diagnostic of PAD.  Values less than 0.5 suggests severe PAD. ◼ Individuals with such severe disease may not have sufficient blood flow to heal a fracture or surgical wound; they should be considered for . Intermittent claudication  a "painful, aching, cramping, uncomfortable, or tired feeling in the legs that occurs during walking and is relieved by rest".  Claudication is most common in the calves but it can also affect the feet, thighs, hips, or arms

PAD – basic diagnosis

- typical pain – IC, rest pain  – inspection – assessment of skin colour and integrity, - of the pulses, - of the bruits  Ankle – brachial pressure index (ABPI, ABI) measurement. PAD – imaging diagnosis

 Duplex doppler ultrasound to look at site and extent of atherosclerosis  Other imaging can be performed by , where a catheter is inserted into the common femoral artery and selectively guided to the artery in question.  CT – angiography, MR-angiography

PAD - treatment

 Dependent on the severity of the disease, the following steps can be taken:  Management of RF of AS - management of diabetes mellitus, hyperlipidemia, arter. hypertension.  Stop smoking, keep walking  Regular exercise for those with claudication helps open up alternative small vessels (collateral flow) and the limitation in walking often improves. PAD - Drugs

 Management of cholesterol - statins, fibrates  Medication with antiplatelet drugs - aspirin, clopidogrel, which reduce clot formation, can help with disease progression and address the other cardiovascular risks that the patient is likely to have.  Cilostazol (CILOZEK), naftidrofuryl (ENELBIN) or pentoxifylline (TRENTAL, AGAPURIN) treatment to relieve symptoms of claudication Surgical treatment vascular or endovascular surgeon

(PTA or percutaneous transluminal angioplasty) can be done on solitary lesions in large arteries, such as the femoral artery, but angioplasty may not have sustained benefits.  Plaque excision, in which the plaque is scraped off of the inside of the vessel wall.  Occasionally, bypass grafting is needed to circumvent a seriously stenosed area of the arterial vasculature. Generally, the saphenous is used, although artificial (Gore-Tex) material is often used for large tracts when the are of lesser quality. Raynaud's phenomenon Raynaud's phenomenon Causes of secondary Raynaud's syndrome • Diffuse diseases of connecting tissue – SLE, RA, dermatomyositis/polymyositis, Sharp's sy, Sjögren's sy • Vasculitis – TAO, PAN, Wegener's granulomatosis • Compression syndromes of the upper chest aperture, carpal tunnel syndrome • Micro-trauma and physical damage from vibration, chronic effects of coldfrostbite • Drugs beta blockers, clonidine, cytostatics (cisplatin, bleomycin, vinblastine), interferon • Intoxications vinyl chloride, ergotamine, heavy metals • Other - Neurological diseases (cervicobrachial syndrome, sclerosis multiplex), haematological diseases (polycythemia, cryoglobulinemia, myeloma) Chronic Venous Disease and Insufficiency CVD, CVI

⚫ CVD - Chronic venous disease include all clinical abnormalities resulting from disease of the lower limb veins with chronic progressive course ⚫ CVI – Chronic venous insufficiency – indicate a failure of an organ or function, CVI is characterized by wall lesions, reflux and dilatation of the vein Chronic venous disease-related symptoms Venous symptoms may include: tingling, • aching, pain, • sensation of burning, • muscle cramps, • sensation of swelling, of throbbing, • heaviness, • itching, • restless legs, • and leg tiredness, fatigue Venous symptoms vary with:

• Time: more intense at the end of the day :

• Position: more intense after prolonged standing or sitting position

• Temperature: more intense in summer or after warm baths

• Hormonal status: more intense before menstrual periods, during pregnancy, or during hormonal therapy CEAP classification of CVD

C – clinical E – etiological A – anatomical P - pathophysiological CEAP – C – clinical classification

⚫ C0 – no visible or palpable signs of venous disease ⚫ C1 – Telangiectasias or reticular veins ⚫ C2 – Varicose veins ⚫ C3 - Edema ⚫ C4a – Pigmentation and/or eczema ⚫ C4b – Lipodermatosclerosis and/or atrophie blanche ⚫ C5 – Healed venous ulcer ⚫ C6 - Active venous ulcer ⚫ –––––––––––––––––––––––––––––––––––––––––––––––- ⚫ S – symptomatic or A - asymptomatic ⚫ C0 ⚫ C1

⚫ Symptoms: ⚫ Heaviness, ache, leg-tiredness, cramps, itching, burning sensations C2 – varicose veins

Complication SVT VARICOPHLEBITIS C3 - OEDEMA C4 trophical skin changes C5 – healed venous ulcer C6 Venous ulcer CEAP – E – etiologic classification

⚫ Ec - Congenital (e.g.- Klippel Trenaunay sy) ⚫ Ep – Primary (degenerative condition of venous valve and venous wall with a genetic basis) ⚫ Es - Secondary (post-thrombotic) CEAP – A – anatomic classification

⚫ As – Superficial veins ⚫ Ap - Perforating veins ⚫ Ad - Deep veins CEAP – P – pathophysiologic classification

⚫ Pr - Reflux ⚫ Po – Obstruction ⚫ Pr,o – Reflux + Obstruction CVD TREATMENT

1. Compression stockings 2. Venoactive drugs – e.g.Detralex, Daflon 3. Radical treatment – and/or surgical procedures

KOMPRESÍVNA LIEČBA CVI KOMPRESÍVNA LIEČBA CVI