PERIPHERAL VASCULAR DISEASES
Peripheral vascular diseases
Peripheral vascular disease (PVD) refers to diseases of the
blood vessels (arteries and veins) located outside the heart
and brain.
Characterized by a reduction in blood flow and hence
oxygen through the peripheral vessels.
When the need of the tissue for oxygen exceeds the supply,
areas of ischemia and necrosis will develop
Factors contributing to the development of
peripheral vascular disease:
Atherosclerotic changes
Thrombus formation
Embolization
Increased coagulability of blood
Hypertension
Inflammatory process/ infection
Risk factors
Age (elderly)
Sex (Male)
Cigarette smoking
Hypertension
Hyperlipidaemia
Hyperhomocysteinaemia
Obesity
Lack of physical activity
Emotional stress
Diabetes mellitus
Family history of atherosclerosis.
Sign and symptoms
Clinical presentation is invariable, symptoms ranging from no symptoms at all to
pain and discomfort.
Most common characteristics are: intermittent claudication and pain at rest in the
lower extremities.
Intermittent claudication is described as fatigue, discomfort, cramping, pain, or
numbness in the affected extremities.
Physical examination: non specific signs of decreased blood flow (cool skin
temperature, shiny skin, thickened toe nails, lack of hair on the calf, feet and/or
toes.)
GOALS OF TREATMENT
Reduction of confounding variables contributing to disease process, progress and eventual
outcome.
Increasing maximum walking distance.
Increasing duration of walk
Increasing amount of pain-free walking
Improving control of comorbid conditions (hypertension, hyperlipidaemia, diabetes)
Improving overall quality of life.
Reduction in cardiovascular complications and death.
Peripheral vascular diseases
Arteriosclerosis Obliterans
Raynaud’s phenomena
Aneurysm
Arterial embolism
Thrombophlebitis
Deep vein thrombosis
Chronic venous Insufficiency
Varicose Veins
ARTERIOSCLEROSIS OBLITERANS
Disorder in which there is an arteriosclerotic narrowing or
obstruction of the inner & middle layer of the artery.
Common cause of arterial obstructive disease in the extremities.
Commonly affect femoral artery, iliac arteries, popliteal arteries.
Management:
• Pharmacological: vasodilators.
• Surgical intervention in advanced disease
RAYNAUD’S PHENOMENON
Refers to intermittent episodes during which small arteries
or arterioles of left & right arm constricts causing changes
in skin color & temperature.
Management:
• Prevent exposure to cold.
• Quit smoking.
• Calcium channel blockers, vascular smooth muscle relaxants,
vasodilators- promote circulation & reduce pain.
• Sympathectomy.
ANEURYSM
Localized or diffuse enlargement of an
artery at some point along its course.
Can occur when the vessels becomes
weakened from trauma, congenital vascular
disease, infection or artherosclerosis.
ARTERIAL EMBOLISM
Blood clots floating in the circulating arterial blood.
Emboli will tend to lodge in femoral or popliteal arteries.
Management:
• Anticoagulants (heparin, warfarin sodium)- prolongs blood clotting
time.
• Fibrinolytics or thrombolytics (streptokinase, urikinase i.v.)
• Embolectomy
NON-PHARMACOLOGICAL THERAPY
Smoking cessation
• Behavioral modification therapy with or without antidepressants
(e.g. bupropion)
• Nicotine replacement therapies (e.g. gum or patch)
Exercise
• Walking
• Aerobic exercise under supervision of healthcare provider.
Revascularization therapy
• Percutaneous transluminal angioplasty
PHARMACOLOGICAL THERAPY
HYPERTENSION
• Major risk factor- can lead to acute MI, stroke, heart failure &
death.
• Treatment goals for BP in patients of PVD is 130/85 mm Hg.
• ACE inhibitors (like ramipril) found to reduce BP and
other cardiovascular events.
• No specific antihypertensive is recommended.
• Drug therapy for hypertension should be selected on basis of
comorbidities, drug costs and availability, drug allergy and
other limiting factors
HYPERLIPIDEMIA
• Recommended levels: LDL- <100mg/dl; non-
HDL-<130mg/dl.
• Therapeutic lifestyle changes- reduction in
consumption of saturated fat, weight reduction,
increased physical activity.
• Drug therapy include- statins (simvastatin),
bile acid sequestrants (cholestyramine),
and nicotinic acid.
DIABETES MELLITUS
• Patients are less likely to experience
symptoms due to peripheral neuropathy.
• First sign may be gangrenous foot ulcer.
• THERAPY- oral anti-diabetic agents
(metformin or glitazone), insulin regimens,
and other pharmacological and non-
pharmacological strategies.
ANTI-PLATELET DRUG THERAPY
• ASPIRIN:
• Acetyl salicylic acid- ASA (81-325 mg/day).
• Clopidogrel (75 mg/day); if ASA is not tolerated.
• MOA: Irreversibly inhibits prostaglandin cyclooxygenase
in platelets, prevents formation of thromboxane A2.
• Side effects: GI upset and/or bleeding.
• Contraindications: active bleeding; hemophilia;
thrombocytpenia
ASA + DIPYRIDAMOLE extended release
(Aggrenox)
• For high risk patients with serious vascular events.
• 400 mg (+ aspirin 50 mg).
• MOA: may act by inhibiting platelet aggregation
• Side effects: angina, dyspnea, hypotension,
headache, dizziness.
• Contraindications: active bleeding; coronary artery
disease.
CLOPIDOGREL (Plavix)
• 75 mg/day prevents vascular events in high risk
patients.
• MOA: inhibits binding of ADP analogues to its platelet
receptor, causing irreversible inhibition of platelets.
• Side effects: chest pain, purpura generalized pain,
rash.
• Contraindications: active pathologic bleeding (e.g.
peptic ulcer, intracranial hemorrhage)
TICLOPIDINE (Ticlid)
• 500mg/day of ticlopidine therapy reduces mortality
and intermittent claudication.
• MOA: inhibits binding of ADP analogues to its platelet
receptor, causing irreversible inhibition of platelets.
• Side effects- hematological side effects (leukopenia),
rash, neutropenia/ agranulocytosis,
thrombocytopenia & aplastic anemia.
• Contraindications: active bleeding, hemophilia,
thrombocytopenia.
INTERMITTENT CLAUDICATION
• CILOSTAZOL (Pletal)
• 100 mg twice daily
• MOA: phosphodiesterase inhibitor, supresses platelet
aggregation, direct artery vasodilator.
• Side effects: fever from infection, tachycardia.
• Contraindications: all congestive heart failure patients
(decreased survival)
• WARNING: not to use it in patients with PAD &
coexisting heart failure.
PENTOXIFYLLINE (Trental)
• Dose- 1.2 g
• MOA: alters RBC flexibility; decreases platelet
adhesion; reduces blood viscosity; decreases
fibrinogen concentration
• Side effects: dyspnea, nausea, vomiting, headache,
dizziness.
• Contraindications: recent retinal or cerebral
hemorrhage, active bleeding.
EVALUATION OF THERAPEUTIC
OUTCOMES
LABORATORY ASSESSMENTS:
• Glycemic control (hemoglobin A1C)
• Total cholesterol
• LDL
• HDL
• Non-HDL cholesterol
• Blood pressure
• Exercise treadmill walking test (ABI- ankel brachial
index)
QUESTIONS??
