Management of Peripheral vascular diseases/Thrombosis

Sunil Kumar Daha

Peripheral vascular diseases

Arterial(i) Chronic lower limb arterial disease - Intermittent claudication - Critical limb ischemia - Thromboangitis obliterans ( Buerger’s disease)(ii) Chronic upper limb arterial disease - Arm claudication (rare) - Atheroembolism - Subclavian steal(iii) Raynaud’s phenomenon/disease(iv) Acute limb ischemia(v) Aortic Aneurysms

Venous(i) Vericose veins(ii) Thrombophlebitis(iii) Deep Vein Thrombosis (DVT)

Arterial Peripheral vascular diseases

Best Medical Therapy (BMT) for Peripheral

Arterial Disease• Smoking cessation• Regular exercise (30 mins of walking, three times per

week) • Antiplatelet agents (aspirin 75 mg or clopidogrel 75

mg daily)• Reduction of cholesterol (diet and statin therapy)• Diagnosis and treatment of diabetes mellitus• Diagnosis and treatment of frequently associated

conditions (e.g. hypertension, anaemia, heart failure)

Chronic lower limb arterial disease

Clinical features• Pulse: diminished or absent• Bruits: denote turbulent flow but bear no relationship to the severity of

underlying disease• Reduced skin temperature• Pallor on elevation and rubor on dependency (Buerger’s sign)• Superficial veins that fill sluggishly and empty (gutter) upon minimal elevation• Muscle wasting• Skin and nails: dry, thin and brittle• Loss of hair

Intermittent claudication

• It is an ischemic pain affecting the muscles of leg upon walking.• Pain most commonly felt in calf muscle because superficial femoral

artery is mostly affected.• Pain in thigh or buttock if iliac arteries are involved.• Pain comes on after a reasonably constant claudication distant• Pain subsides on stopping walking• ABPI (Ankle and brachial pressure index) 0.5-0.9

Critical limb ischemia

• Rest (night) pain• Require opiate analgesia and/or• Tissue loss (ulceration or gangrene)• present for more than 2 weeks• In the presence of an ankle BP of less than 5o mm Hg• ABPI usually below 0.5• Rest pain only, with ankle BP more than 50 mmHg, is known as

subcritical limb ischemia (SLI).• Pain relieved by hanging limb out of bed.

Chronic Lower Limb Arterial Disease1. Non-pharmacological: BMT2. Pharmacological:• Cilostazol: 100 mg BD

MOA: Inhibit phosphodiesterase III Inceases cAMP Vasodilatation

• Naftidrofuryl: 100-200mg TDS MOA: Inhibit vascular and platelet 5-HT2 receptor

decreases lactic acidosis

3. Surgical:• Angioplasty

- Percutaneous Transluminal Angioplasty (first option)

• Arterial Stenting- For recurrent iliac diseases

• Bypass Surgery

• Amputation- If the vascular damage is unreconstructable

Thromboangitis obliterans (Buerger’s Disease)

• Results in severe vascular insufficiency and gangrene of the extremities• Characterised by focal acute and chronic inflammation of medium-sized

and small arteries especially the tibial and radial arteries.• Associated with thrombosis• Almost exclusively in heavy tobacco smokers• Usually develops in male before 35 of age (in youngs).• Wrist and ankle pulses are absent but brachial and popliteal pulses are

present• Disease also affects the veins giving rise to superficial thrombophlebitis.

• Patient must stop smoking remits itself• Sympathectomy and prostaglandin infusion• Limb amputation if the patient continue smoking

Thromboangitis obliterans (Buerger’s Disease)

Takayasu’s disease(pulseless disease)• Corticosteroids• Surgical bypass to improve perfusion

Raynaud’s phenomenon/disease

• Results from exaggerated vasoconstriction of arteries and arterioles in the extremities• particularly in fingers and toes• But also sometimes in nose, earlobes and lips• Induces paroxysmal pallor or cyanosis• Involved digit characteristically show red-white-blue pattern of color

changes from most proximal to most distal• Reflecting proximal vasodilation, central vasoconstriction and more distal

cyanosis respectively.• Can be primary or secondary

Primary Raynaud’s phenomenon:• Avoid exposure to cold• Long acting nifedipine 10 mg twice daily

Secondary Raynaud’s phenomenon:• Fingers must be protected from cold• Antibiotics in case of infection• Prostacyclin infusion• sympathectomy

Raynaud’s phenomenon/disease

Acute limb ischemia• Frequently caused by acute thrombotic occlusion of pre-existing

stenotic arterial segment, thromboembolism or trauma that may be iatrogenic.

Signs and symptoms (5P’s):PainPallorParaesthesiaParalysisPulselessness

• 3000-5000 U intravenous bolus of low molecular weight heparin provided that patient has no contraindications (e.g. acute aortic dissection or trauma) and target aPTT 2-3 seconds.• Antiplatelet agents• High dose statins• Intravenous fluids to avoid dehydration• Correction of anaemia• Oxygen saturation

Management

Aneurysmal Diseases

Abdominal Aortic Aneurysms (AAA)• Medical Therapy

Control HTN Stop Smoking Have lipid-lowering medications Regular ultrasound surveillance

• Surgical Therapy Open Surgical Repair Endovascular Aneurysm Repair (EVAR) Laparoscopic Surgical Repair Regular ultrasound surveillance

Indications of Surgery• ≥5.5 cm diameter• expanding >1 cm/year• symptomatic

Thoracic Aortic Aneurysms (TAA):• If the aneurysm is > 6 cm then operative repair or stenting.• EVAR for isolated descending thoracic aneurysms

Cardiovascular syphilis• Penicillin• Aneurysms and valvular diseases are treated by usual methods

Venous Peripheral vascular diseases

Vericose veins1. Conservative measures• Compression (e.g., bandages, support stockings, intermittent pneumatic compression devices)• Elevation of the affected leg• Lifestyle modifications• Weight loss

2. Endovenous or interventional therapy• Endovenous obliteration• External laser therapy• Sclerotherapy (injecting substance that collapse the veins permanently)

3. Surgery:• Ligation• Phlebectomy• Stripping

Thrombophlebitis• Low molecular weight heparin with NSAID or alone for 45 days

Deep vein thrombosis• Bed rest until anticoagulation and then later mobilized, with an elastic stocking

giving graduated pressure over the leg.

• Low-molecular-weight heparins (LMWH)

• Warfarin is started immediately and the heparin stopped when the INR is in the target range.

• Thrombolytic therapy is occasionally used for patients with a large iliofemoral thrombosis.

References:• Kumar and Clark’s Clinical Medicine, 8th edition(Page 784)• Davidson’s Principles and practice of Medicine, 22nd edition(Page 600)

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