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PERIPHERAL ARTERIAL DISEASE

By: Justitia Yudiarti Basri


12/329194/KU/14966
Pembimbing : dr.Haryo Aribowo, Sp.B KBTKV
Identitas Pasien
• Nama : Ny.S
• Alamat : Gentingan, Sleman
• Usia : 82 tahun
• Pekerjaan : Ibu rumah tangga
• Pendidikan : SMA
• No.RM : 0170xxxx
Anamnesis
• KU : luka pada kaki kiri yang tidak sembuh sembuh
• RPS : 13 TSMRS os ditabrak sepeda motor kemudian os tidak bisa
berjalan hingga 3 bulan, setelah itu os mulai latihan berjalan dan
beraktifitas seperti biasa lagi. 3TSMRS os terjatuh dan kaki kiri nya
tertancap paku hingga luka. Luka awalnya kecil kemudian melebar
karena tidak kunjung sembuh. Os melakukan kontrol luka rutin di
RS. Panti Rapih kemudian setelah beberapa bulan dirawat luka os
disarankan untuk menemui dokter bedah vaskular di RS ringroad
selatan, di RS ringroad selatan os disarankan melakukan USG
pembuluh darah, setelah USG dilakukan hasilnya berupa
penyumbatan pembuluh darah di kaki. Os melakukan kontrol luka
kembali di RS.JIH dan setelah beberapa bulan dirawat os
direncanakan untuk melakukan roentgen pembuluh darah di RSS.
Kemudian os dirujuk ke RSS untuk dijadwalkan tindakan tersebut.
• Nyeri -, deman-, riwayat patah tulang -, obat yang dikonsumsi rutin
-, luka perih panas -, berdarah banyak -, kaki kemeng -, kesemutan
kadang kadang
• RPD: Hipertensi +, diabetes mellitus -, os
belum pernah mengalami luka yang sulit
sembuh sebelumnya. Riwayat bedrest lama +,
merokok -
• RPK: tidak dijumpai keluarga os yang
mengalami hal serupa, hipertensi +, diabetes
mellitus –, riwayat kanker -
Pemeriksaan Fisik
• KU : sedang CM
• TD : 160/80 mmhg
• HR : 84 kpm
• RR : 21 kpm
• Kepala leher : SI -, CA -, pupil isokor, pembesaran
KGB -
• Thorax : ictus cordis + sic 5 linea midclav sinist,
fremitus normal, simetris, paru sonor, wh -/-, rh -
/-
• Abdomen: scaphoid, BU + 12 kpm, NT -, timpani
• Ekstremitas atas: jaundice -, anemis -, hangat,
WPK <2 detik, pulsasi + kuat simetris
• Ekstremitas bawah: jaundice -, anemis -,warna
kulit menghitam, hangat, WPK <2 detik, kuku
rapuh menebal, pulsasi bagian kiri < bagian
kanan, nyeri -, fungsi motoris +, fungsi
sensoris +
Pemeriksaan penunjang
• Darah lengkap
• Arteriografi
Darah lengkap
• PPT : 11.9 BUN : 15.60
• INR : 0.84 Creat : 0.82
• PPTC : 11.9 GDS : 86
• APTT : 29.2 HBsAg : non reaktif
• APTTC : 27.5 Mono : 5.3
• BT :3 Eos : 3.9
• SGOT : 20 Baso : 0.7
• SGPT :9 LUC : 1.3
• Netro : 57.3 CHCM : 32.8
• Limfo : 31.6 MCHC : 31.3
• Mono : 5.3 MCH : 29.8
• MPV : 8.5 MCV : 95.1
• Trombo : 192 Hct : 34.7
• HDW : 2.17 Hb : 10.9
• RDW : 15.0 eritro : 3.65
• CH : 31.0 leuko : 4.08
Arteriografi
• Tampak kontras mengisi arteri femoralis
profunda dan arteri femoralis superfisial
berlanjut ke arteri poplitea, arteri tibialis
anterior, arteri tibialis posterior dan arteri
fibularis.
• Tampak dinding arteri tibialis anterior
sepertiga proksimal ireguler dan kontras
berhenti di sepertiga tengah secara tappering
Diagnosis
• Partial occlusion of anterior tibial artery
Pembahasan
The Basic Spectrum of Artery Diseases

Peripheral Arterial Disease


Carotid and Cerebrovascular
Abdominal Aortic Aneurysm Carotid lining and Stenotic
Mesenteric Ischaemia
Stenosis / Spasm cerebral art.
Renovascular diseases
Stenosis / Spasm Vertebrobasiler
Intermittent Claudication
AVM
Critical Limb Ischaemia
Diabetic Angiopathy and diabetic food Retinal vascular diseases

Inflammatory Vascular Disease


Environmental Vascular Disease
Raynaud’s Phenomenon
Buerger’s disease
Aortitis and vessel vasculitides Erythromelagia

Small vessel vasculitides Cold Injury


Infectivevasculitides Radiation Induced Vascular disease
Modality of Investigation

Duplex Vascular
Doppler Vascular
Phletysmography
Laser Doppler Fluximetry and Dynamic Videomicroscopy
MRA / MSCT A
Angiography

Modality of Intervention

Angiography
Aspiration tool
IVUS
Laser
Hyperbaric ???
Surgery
In The Lower Limb
Acut Limb Ischemia ( ALI )
Chronic Limb Ischemia :
- Intermittent Claudicatio ( I C )
- Critical Limb Ischemia (C L I )

Each other have specific focus DIAGNOSTIC and TREATMENT


Chronic Arterial Ischemia
Definition:
It is the decrease in arterial blood supply to
the tissues due to partial occlusion of arteries.
Stenosis or occlusion produces symptoms &
signs that are related to the organ supplies by
the artery. The severity of symptoms is related
to the size of the vessel occluded & alternative
routes (collaterals) available for blood flow.

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Causes:

• Atherosclerosis

• Burger’s disease

• Raynaud’s disease

• Others

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Atherosclerosis
Definition:
It is the process underlying the formation of
focal obstructions or plaques in large &
medium sized arteries. It is characterised by
the presence of focal intimal thickening, these
intimal elevations being made up of
accumulations of cholesterol rich & a
proliferation of connective tissue. An essential
component of atherogenesis is inflammation
involving monocytes / macrophages, T
lymphocytes & mast cells.
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Risk factors
• Smoking
• Hypertension
• Hyperlipidaemia (raised LDL) High risk factors
• High fat diets

• Diabetes mellitus
• Elevated blood uric acid (gout)
• Hypothyroidism
• Renal disease Other risk factors
• Familial history of premature atherosclerosis
• Male sex & age

• Sedentary life
• Obesity Factors having an uncertain role
• Anxiety

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Symptoms
• Intermittent claudication
• Rest pain
• Erectile dysfunction
• Sensorimotor impairment
• Tissue loss
Signs
• Muscular atrophy
• Decrease hair growth
• Thick toenails
• Tissue necrosis ulcers infection
• Absent pulses
• Bruits
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Lower limb ischemia
• Intermittent claudication:
• ABI: 0.5-0.9
• Cludication distance
• Calf is the most common

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Rest pain
• Worst at night,lying, relieved by putting the
leg in dependent site
• Coldness
• Numbness
• Parasthesia
• Color change
• Differentiated from night cramps

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Ulcers and gangrene
• Gangrene Between the toes
• Ulcers at the foot dorsum and leg shins

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investigation
• General
• Diabetes
• Lipid profile
• Anemia
• High viscosity
• Full blood count
• Plasma fibrinogen
• Blood and urine glocuse
• ECG

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Investigation (non-invasive.)
• Doppler ultrasound
• ABI( rest and exercise )
• Duplex imaging:
• Blood flow and turbulence
• Plethysmography
• treadmill

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Investigation( invasive)
• Arteriography
• To decide whether intervention is needed
• Seldinger technique
• Hazards:
• Thrombosis
• Dissection
• Heamatoma
• Neurological dysfunction
• Anaphylaxis
• Digital substraction angiography

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Management
• Explanation and advice
• Life style adjustment
• Smoking
• Exercise
• Diet
• Heal raise
• Analgesics and use of position

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• Sympathectomy
• Transluminal angioplasty: usually
percutaneous
• Iliac success more than the leg arteries
• bypass
• Atherectomy

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Intermittent Claudicatio
Clinical Diagnosis Suspected
Pain induced by activity and reduced by rest
Skin tropic lesion

Confirmation Diagnosis by Doppler


Ankle Brachial Index ( ABI ) < 0.95
Toe Raising test - a pressure drop of >20 mmHg
Hyperemia test - a pressure drop of 20 mmHg
Intermittent Claudicatio
ABI by Doppler
≥ 0,95 - normal
< 0,95 - abnormal ,other test is appropriate
< 0,8 - probable claudicatio
< 0,5 - multilevel disease, or long segment occl.
Diagnostic
ABI Accuracy sensitivity specificity
0,8 – 0,95 75% 70 % 85%
< O,8 99 % 98 % 97 %
Conservative treatment of IC
1.Reguler extremity exercise
2.Control of risk factor
3.Established drug with proven .
Grade Recommendation The 7th ACCP
Pentoxfylline 1B
Aspirin 1 A & 1C
Cilostazol 2A
Clopidogrel 1C
Ticlopidin 1C
Prostaglandin 2B
LCarnitin -
CRITICAL LIMB ISCHEMIA
Clinical Diagnosis Suspect
Dependence of Rest pain
Wound or Gangren

Confirmation Diagnosis
Ankle Pressure <50 mmHg by Doppler ( non DM )
Toe Pressure <40 mmHg by Photo Phletysmography ( DM )
Type of lesion by Arteriography
Conservative Treatment of CRITICAL LIMB ISCHEMIA

1. Pain Control with Narcotic or Sympatectomy


2. Wound care
3. Sulodexide
4. Hyperbaric Oxygen
5. Angiogenesis
6. By Pass