Peripheral arterial

pathology
Epidemiology

 World prevalence = indeterminate

 In the USA ~ 8-12 million cases
 United States National Health and Nutrition
Examination Survey that includes 2381
pacienti  AOMI prevalence 4.3%
 Every year>100.000 patients undergo
some form of arterial revascularization
intervention.
 Topographic and evolutionary pattern
 The evolution of stenotic arteriopathies can
be: persistently stable, progressive to
critical ischemia, irreversible ischemia;
fatal, non-fatal cardiovascular events
 Stenotic arteriopathies: central, peripheral -
PAD
 Lower limb arteriopathy
 Acute ischemia
 Std I, Std IIA, Std IIB, Std III irreversible
 Chronic ischemia
 Leriche Fontaine classification
 Rutherford classification
 Leriche Fontaine classification
 Std. I -asymptomatic
 Std. IIA -IC greater than 200m
 Std. IIB -IC less than 200m
 Std. III -pain at rest
 Std. IV - trophic lesion: ulcer, necrosis,
gangrene
 Std III, Std IV = critical ischemia
 Rutherford classification
 Std 0 -asymptomatic
 Std I -claudicant
 Category 1 - light
 Category 2 -medium
 Category 3 - severe
 Std II - resting pain
 Category 4
 Std III
 Category 5 - arterial ulcer
 Category 6 - necrosis, gangrene
Critical ischemia

 Objective clinical confirmation of the

diagnosis
 Topographic and evolutionary pattern
 PAD lower limbs:
 Aorto-iliac occlusive disease type I, II, III
 Infrainguinal occlusive disease
 Infragenicular occlusive disease
 Upper limb PAD: acute, chronic, critical
ischemia, functional vasculopathies
 Coronary ischemia: angina, AMI
 Carotid, vertebro-basilar ischemia: CV
insufficiency, TIA, stroke
 Renal ischemia: Dry hypertension, CKD
 Mesenteric ischemia: angina, IEM
 Paraclinical investigations
-Biological examinations
 Standard: hemoleukogram with no. platelet count, ESR,
PCR, fibrinogenemia, glycemia +/- glycosylated
hemoglobin, glucose tolerance tests, urea, creatinine, blood
ionogram, lipidogram, coagulation tests, urine summary
examination

 special
cytolysis tests (GOT, GPT, LDH, CPK, troponin,
myoglinobinemia, myoglobinuria),
  pro BNP cardiac dysfunction tests,
  virological tests, bacteriological tests
 Clinical-paraclinical
examinations

Pulmonary x-ray, PFR

  EKG,
  Transthoracic, transesophageal,
  exercise test, pharmacological stress test
Effort test - claudication

 On the treadmill
On the cycle ergometer
BP is measured in the leg
before and after exertion -
it does not increase with
exertion as in the arm
 Paraclinical investigations

-Continuous Doppler examination: examination with

Doppler pencil (transducer) at the level of standard
areas
   -Vascular Doppler ultrasound in:
  B-mode,
Color Doppler,
Spectral Doppler;
  morphopathological information regarding ectasia
or stenotic lesions in longitudinal and cross sections;
hemodynamic information - systolic and telediastolic
velocities
   -Mandatory examination of bilateral arterial axis
limbs, bilateral carotid artery
Simple X-Ray
Duplex: combination of

(1) Doppler ( 2)echogra phy

-Angio-CT, Angio-MRI

   -Arteriography- invasive procedure,

anterograde or retrograde catheterization
by Seldinger technique

   -Endovascular techniques -
endovascular ultrasound, angioscopy.
Control after angioplasty
MR angiography
 Therapy of arterial diseases
 Prophylactic, curative treatment
 Elective, emergency treatment
 Conservative treatment
 Correction of risk factors: smoking cessation, hypertension
correction, diabetes, dyslipidemia, hyperuricemia, BMI
correction
 Medical physical exercise: walking training, evaluation by
exercise tests for the progressive increase of HF
 Pharmacological: vasodilators and hemorrheologic
(pentoxifylline, cilostazol, Ca channel blockers) analgesics
and antispasmodics, antiplatelets (aspirin, clopidogrel),
anticoagulants (unfractionated heparin, HGMM, ACO),
synthetic prostacyclin analogues (iloprost, alpostradil)
 Therapy of arterial diseases
 Invasive treatment
 Endovascular: PTA, stent, laser endoarterial
therapy, radiofrequency atherectomy, graft stent
 Surgical: arteriography, arterial anastomosis,
thromboembolectomy, thrombendarterectomy,
enlargement angioplasty, interposition, bypass,
sympathectomy, amputation, decompression
operations
 Hybrid: sequentiality according to the
morphopathological and topographic pattern of the
lesions
 Therapy of arterial diseases
 Endovascular treatment vs. surgical is practiced
depending on the class of evidence and level of
recommendation, mandatory compliance with the
TASC guide which provides 4 types of injuries: cls. A
- lesions treatable by endovascular techniques, cls.
D - lesions treatable by surgical techniques.
 Endovascular treatment has
 - a lower risk of morbidity and mortality,
 - a lower long-term patent compared to the surgical
one.
 It is preferred for revascularization of the patient with
major surgical risks.
 Therapy of arterial diseases
 Complications of immediate, early, late vascular
surgery; local and systemic.
 Local complications - thrombosis, thromboembolism,
hemorrhage, pseudoaneurysm, aneurysm, lymphoid,
lymphocyte, wound infection-suppuration with or without
graft infection, reperfusion edema, arterial theft, arterio-
enteral fistulas (aorto-duodenal), arterial fistulas -cava),
prosthetic-enteral fistulas, arterial dissection
 Systemic complications - ischemic or hemorrhagic stroke,
ARSD, IMA, ICA, CID coagulation disorders, IEM, IRA,
medullary ischemia - paraparesis
 Complications of endovascular procedures: arterial
wall rupture, dissection, FAV, thrombosis,
thromboembolism, allergic reaction, IRA
 Therapy of arterial diseases
 Interposition or arterial bypass is performed with grafts:
 Biological (autograft or homograft):
 arteries (radial artery, internal mammary artery),
 venous (VSI - most commonly used, reversed or in-situ with
devalvulation, VSE, VFS
 Synthetic: woven, cast.
 Dacron - woven, velvety. May require precoagulation or may be
impregnated with albumin, collagen; impregnation with Ag ions
 PTFE - does not require pre-coagulation, less thrombogenic, more
resistant to infections, does not form pseudoanthrisms or aneurysms
 By-pass: donor artery stenosis below 20%; receptor
artery capable of ensuring quality circulation to the
level of the foot. Primary success: Postoperative IGB
greater than or equal to 0.8.
 Therapy of arterial diseases
 Types of by-pass
 Anatomical
 Aorto - bi iliacs
 Aorto – bi femoral
 ilio-femoral
 femur-popliteal: proximal, distal
 femur-tibial, femur-peroneal
 Extraanatomice
 axilo-femoral
 axilo-bifemoral
 femuro-femoral
 ilio-femoral crossover
 ilio-femoral transobturator
The role of surgical
sympathectomy
 Increased blood flow
 Increased collateral flow
 Increases the nutritional value of blood
flow
 Alteration of painful impulse transmission
 TRANSLUMINAL PERCUTANE
ANGIOPLASTY
 Definition: Remodeling / recalibration of stenotic /
thrombotic vascular lumen by techniques of dilation
of stenoses and recanalization of thrombosis

 Indications: -atheromatous arterial pathology,

dysplasia, generating stenoses and thrombosis,
some venous obstructions

                                                    
 -arteries: coronary, carotid, brachiocephalic,
renal, aorta, iliac, femoral, popliteal;

 - veins: - superior vena cava, brachiocephalic

trachea, inferior vena cava, a-v shunt for dialysis,
venous APT procedure is frequently followed by vein
endoprosthesis
TEA with angioplasty
Venous patch
angioplasty
Aortofemural graft
Stenting iliac artery
AAA: Endovascular treatment
EXCLUDER
Endoprosthesis
CRITICAL ISCHEMIA
PELVIC LIMBS
THERAPEUTIC
MANAGEMENT
 Evaluation of cardiovascular risk factors in
all patients suspected of pelvic limbs critical
ischemia.
 Correction of cardiovascular risk factors..
 Antiplatelet therapy in all patients with pelvic
limbs critical ischemia.
 Antiplatelet of choice - Clopidogrel.
 Variant - COMPASS study - aspirin 75mg +
Rivaroxaban 2.5mg 1x2 / day - reduces
cardiovascular events in these patients.
THERAPEUTIC
MANAGEMENT
 No vitamin K antagonist is used in the
atherosclerotic patient with CLTI.
 Use of moderate or high doses
(depending on lipidogram and
transaminases) of statin to reduce
cardiovascular mortality in patients with
CLTI.
 Control of therapeutic hypertension, TAS
<140mmHg, TAD <190mmHg.
THERAPEUTIC
MANAGEMENT
 Diabetes control - HbA1c therapeutic target
<7% (53mmol / l).
 Use of Metformin as a first-line
hypoglycemic agent in the diabetic patient
with CLTI; discontinuation of Metformin 24
hours before and 48 hours after contrast
(CT, arteriography).
 Quiting smoking: psychotherapy,
pharmacological treatment.
THERAPEUTIC
MANAGEMENT
 Prescription of paracetamol-type
analgesics in combination with opioids in
patients with resting pain or trophic
lesions.
 Palliative treatment or amputation: in
patients with limited life expectancy, poor
functional status (bed rest), inability to
save the limb after a multidisciplinary
therapeutic decision and informed
consent.
THERAPEUTIC
MANAGEMENT
 Estimation of periprocedural risk and
assessment of life expectancy in all patients
with CLTI.
 Anticipated minor periprocedural risk before
surgery is defined as mortality below 5%,
life expectancy at 2 years over 50%.
 It defines high anticipated surgical risk,
mortality over 5% and life expectancy at 2
years below 50%.
THERAPEUTIC
MANAGEMENT
 Avoid AFC stenting and AFP origin;
 Endovascular revascularization is
indicated when it is technically feasible for
high-risk patients and CLTI.
 Surgical revascularization is indicated
after failure of the endovascular
procedure and failure to resolve CLTI
symptoms.
THERAPEUTIC
MANAGEMENT
 Lumbar sympathectomy is not indicated in
patients with CLTI when revascularization is
not possible.
 Prostanoid therapy is not indicated in
patients with CLTI in whom
revascularization is only possible
selectively.
 Optimal surgical treatment of the wound is
continued until complete healing or
amputation.
THERAPEUTIC
MANAGEMENT
 Forefoot amputation is performed - trans-
metatarsal amputation in the patient with CLTI
who requires more than 2 amputations in the
finger radius, especially when the toes are
involved.
 Secondary amputation is considered in patients
with CLTI in case of revascularization failure
presenting with excruciating pain, incurable
lesion or uncontrolled sepsis, after
multidisciplinary counseling and informed
consent.
THERAPEUTIC
MANAGEMENT
 Revascularization is indicated to improve post-
amputation healing and to choose a level as
distal as possible for amputation in order to
rehabilitate the patient and continue his
mobilization.
 Thigh amputation is indicated in all patients with
CLTI and inability to rehabilitate (patient
immobilized in bed, flexion contracture,
unrecovered sequelae hemiplegia, advanced
cancer) after multidisciplinary counseling.
THERAPEUTIC
MANAGEMENT
 The CLTI patient who has undergone limb
amputation is clinically and paraclinically
monitored for cardiovascular risk and
contralateral limb loss; in these patients the
treatment of the correction of the risk factor
is continued, with antiplatelet and statin.
 In patients revascularized by infrahinal
bypass with a prosthesis to maintain the
patent, 24 months of dual treatment with
aspirin and clopidogrel (DAPT) is indicated.
THERAPEUTIC
MANAGEMENT
 DAPT is indicated for at least one month in the patient with
sublingual endovascular revascularization and at least 6
months in case of recurrent procedure.
 The patient is monitored with bypass at least 2 years -
clinical examination, ankle-arm index, periodic vascular
Doppler ultrasound.
 The decrease in the ankle-arm index by more than 15% and
the recurrence of symptoms suspect the failure of
revascularization.
 Vascular Doppler ultrasound - graft with PSV greater than
350cm / s and PSV ratio over 3.5 or PSV below 45cm / s -
inefficient hemodynamic vascular assembly, requires
hemodynamic correction intervention.
AMPUTATIONS
 Minor amputations: amputations in the toes,
transmetatarsal forefoot, Lisfranc and
Chopart transtarsian
 Primary amputations: without attempted
surgical or endovascular revascularization.
Indications: arterial disease without the
possibility of revascularization, associated
with ulcer gangrene infection, tissue damage
incompatible with gait, paralysis, flexion
contracture with severe morbidities and
limited life expectancy