PERIPHERAL ARTERY

DISEASE
(PAD)

WS PAPDI KALBAR 2018

Dr. Dany Lesmana, SpPD
 Laki-laki, tn HG 58 th, nyeri tungkai kanan bawah bila
berjalan 3 bulan, keluhan timbul dengan jalan kurang dari
100 meter. DM, CHF, IHD, riwayat merokok.

PAD??
 Wanita, ny. SB 64 th,
kesemutan kedua kaki 2
tahun. DM, IHD, riwayat
ACS, riwayat kaki
bengkak dengan
perubahan warna kulit
kaki, respon dengan
diosmin 1000mg selama 3
bulan
PAD??
 Garis besar pembahasan

1. Pengertian PAD
2. Kenapa PAD?
3. Diagnosis
4. Tatalaksana
 Garis besar pembahasan

1. Pengertian PAD ESC, 2017 :

 LEAD

 PAD
 PAD

is a group of disorders
characterized by
narrowing or occlusion of
the arteries resulting in
gradual reduction of blood
supply to the limbs.
Diabet. Med. 27, 4–14 (2010)
 The Evolution of Atherosclerosis

Foam Fatty Intermediate Fibrous Complicated

Cells Streak Lesion Atheroma Plaque Lesion/Rupture
Atherosclerosis - extensive inflammatory &
fibroproliferative response - dysfunctional
endothelium - increase in adhesiveness and
procoagulant properties of platelets.
 Risk factors for PAD

 Gender (male)
PAD
 Age > 40 years
 Smoking
 Hypertension
 Diabetes Atherosclerosis Atherothrombosis
 Hyperlipidaemia
 Hyperfibrinogenemia
 Homocysteinaemia Ischaemic Myocardial
stroke infarction
• Family history of PAD
• Known atherosclerotic disease in
another vascular bed (AHA,2016)
Murabito JM et al. Circulation 1997;96:44–49; Laurila A et al. Arterioscler Throm Vasc Biol 1997;17:2910–2913;
Malinow MR et al. Circulation 1989;79:1180–1188; Brigden ML. Postgrad Med 1997;101:249–262.
 Garis besar pembahasan
2. Kenapa, why PAD?
 Symptoms of PAD mistaken for something else.
 PAD often goes undiagnosed by ??
 People with PAD have a higher risk of coronary artery
disease, heart attack or stroke.
 ( NOT only ) LOCAL , both LOCAL + SYSTEMIC
 Left untreated, PAD can lead to QoL impairment,
gangrene and amputation, septicaemia, death
Tambahan : applicable in daily practice
CURIGA, WASPADA, PENASARAN
PAD – a marker for MI and IS

 Atherothrombosis = thrombus formation on top of existing

atherosclerosis
 Occurs in multiple arterial beds

Cerebrovascular disease
(ischaemic stroke, transient ischaemic attack)
Coronary artery disease
(stable/unstable angina, myocardial infarction)

PAD (intermittent claudication, critical leg ischaemia,

amputation, gangrene, necrosis)
 INTERMITTENT CLAUDICATION IS
INDICATIVE OF SYSTEMIC
ATHEROSCLEROSIS

 60% of people with PAD have CAD or

cerebrovascular disease or both
 40% of those with coronary or
cerebrovascular disease will also have PAD

Am J Cardiol 2001;87(suppl):3D-13D
Am J Cardiol 2001;88(suppl):43J-47J
Diabetic patients with PAD:

Are at high risk of increased

morbidity and mortality from
CVD.
Marker for:
1. Myocardial infarction
2. Ischaemic stroke
W
 PAD mortality – 10-year survival
rates of subjects in the San Diego
Artery Study
1.00

Normal
0.75
Survival

0.50 Asymptomatic
Symptomatic

0.25 Severe symptomatic

0.00
0 2 4 6 8 10 12
Time (years)
Criqui MH et al. N Engl J Med 1992;326:381–386.
 Garis besar pembahasan
3. Diagnosis
 Anamnesa
 Pemeriksaan fisik (inspeksi,
palpasi, auskultasi)
 Pemeriksaan penunjang
 the 6 P’s

Khas PAD Intermittent claudication

 WHAT CAUSES INTERMITTENT
CLAUDICATION?
1. Atherosclerosis in peripheral arteries of legs
During exercise, oxygen demand increases

Muscles operate anaerobically

Produce lactic acid and other metabolites

Leg pain
2. Lactic acid and other metabolites washed
away on rest
Am J Cardiol 2001; 87 (suppl): 3D-13D
 Major Symptoms of PAD
Patients with PAD have a reduced functional capacity that limits their ability to
perform daily activities.

Abnormal skin color Coldness

Skin (of extremities) turns to a Cold sensation in
pale or purple color. one or both legs/
Numbness sometimes appears hands
together.

Claudication
Rest pain
Occlusion of the lumen Pain in one or both legs
of 90% or more will on walking, primarily
likely produce pain even affecting the calves,
at rest . that does not go away
with continued walking
and is relieved by rest

Other symptoms
Erectile dysfunction
Peripheral Neuropathy
history alone to result in missing up to 90 percent of cases
 PAD Diagnosis: Physical Exam

 Trophic Signs
 Skin atrophy, thickened nails, hair loss, dependent
rubor
 Ulceration, gangrene

 Pulse exam
 May miss more than 50%
 Elevation and dependency test

Criqui M, et al. Circulation, 1985: 71; 516-521

 Palpation
Palpation of
of pulses
pulses

Dorsal
Dorsal pedis
pedis

Posterior
Posterior tibial
tibial artery
artery Popliteal
Popliteal artery
artery
Elevation and Dependency Test
Color Return(s) Venous Filling(s)
Normal 10 10-15

Adequate 15-25 15-30

Collaterals
Severe Ischemia >35 >40

Halperin, Throm Res. 2002; 106: V303-311

 Pemeriksaan penunjang:
Vascular Tests – Diagnosis of PAD
 Non-invasive techniques
 ABI (Ankle/Brachial Index)
 Exercise Test
 Leg “angina”
 Segmental Pressures
 Segmental Volume
Plethysmography
 Duplex Ultrasonography
 Invasive techniques
 Peripheral Angiograms
 CT Angiograms
 MR Angiograms
(non)IMAGING:
 Arteriography
 Duplex Ultrasound
 CT/Magnetic Resonance
Angiography
 ABPI (Ankle Brachial Pressure Index)
Interpretation of ABPI
> 1.30 Non compressible
0.91-1.30 Normal
0.41-0.90 Mild-to-moderate PAD
0.00-0.40 Severe PAD
Doppler flowmeter

Left-arm
systolic pressure
Higher right-ankle Higher left-ankle
Right ABI = pressure Left ABI = pressure
Higher arm pressure Higher arm pressure

Right-ankle DP DP Left-ankle
systolic pressure PT PT systolic pressure

DT: Dorsalis Pedis, PT: Posterior Tibial Hiatt WR. N Engl J Med, 2001;344(21):1608-21
ABI-Toe Pressure and TcPO2
Non Invasive Evaluation
 Duplex Sonography
-gold standard for evaluation lower
limb (below knee)
-evaluation of stenosis, calified or
occlusion
 Doppler Vascular
-pulse wave form of blood vessel
-arterial calcification may impaired the
test
 Transcutaneus Oxygen (TcPO2)
-transcutaneus oxygen perfusion
Plethysmography
 More on
ABI (Ankle-Brachial Index)

• Screening
tool

Other control??
 Ankle-Brachial Index Values and
Clinical Classification

Clinical Presentation Ankle-Brachial Index

Normal > 0.90

Claudication0.50-0.90

Rest pain 0.21-0.49

Tissue loss < 0.20

Am J Cardiol 2001; 87 (suppl): 3D-13D

NEJM 2001; 344: 1608-162 1
w

Vasc Health Risk Manag. 2007 June; 3(3): 289–297 Nayak and Cavendish.

 PAD in diabetic patient

Difficult to determined the true-

prevalence, because :
- less symptomatic
- sensoric neuropathy in diabetic

Manifestation PAD in diabetic :

- Ischemic ulcer
- Unhealing ulcer
- Ganggren
- Amputation
- Critical limb ischemia

ADA.Diabetes Care 2012;35(suppl 1):S17.

Ischaemic ulcer
 On toes and foot margins
 Pale granulation, sloughy
tissue or eschar
 Dry with irregular borders
 Painful
 Pulses weak or impalpable

Slides current until 2008

Gambar???
 Garis besar pembahasan

4. Tatalaksana
 Manajemen faktor resiko kardiovaskular
 Non farmakologi
 Farmakologi
 Intervensi : endovaskular, open surgery
Management of PAD – intervention
 Endovascular
 Revascularization (angioplasty)
 Stent placement

 Surgical
 Endarterectomy
 Peripheral bypass graft
 Amputation
 ESC
guideline?
Recommendations
in patients
with PAD
 Management of PAD
AHA guideline
 Risk factors control
 Lifestyle modification
 Smoking cessation

 Regular exercise training

 Diet

 Pharmacological treatment
 Antiplatelet therapy

 Vasodilators for symptomatic relief

 MODIFICATION OF RISK FACTORS

1. Diabetes control (FBG 80-120 mg/dl, PPG < 180

mg/dl, HbA1c < 7%)

2. Dyslipidemia management (LDL < 100 mg/dl,

TG < 150 mg/dl)

3. Hypertension control (BP < 130/85 mmHg)

Am J Cardiol 2001; 87 (suppl): 3D-13D

NEJM 2001; 344: 1608-21
Am J Med 2002; 112: 49-57
Tatalaksana non farmakologi
Tatalaksana non farmakologi
Tatalaksana non farmakologi
Tatalaksana non farmakologi
Tatalaksana farmakologi
CILOSTAZOL
 Cilostazol
Drug Class: Phosphodiesterase III inhibitor derivative
Approved: January 1999
Dosing: 100 mg bid

Pharmacologic Platelet aggregation inhibitor

Properties: Vasodilation
 HDL-cholesterol (10%)
 Triglycerides (15%)
Inhibits smooth muscle cell proliferation in
vitro
Cilostazol induces healing of extremity ischemic ulceration
and obviate limb amputation.
Case Study : Pletaal® in Diabetic Ulcer Patient

Necrotomy
+

Pletaal 100 mg bid

16 weeks

Hamid Yanuar. Pengamatan Klinik Pemberian Cilostazol (Pletaal ) pada Penderita Kaki Diabetes.

MEDIKA No. 4 Tahun ke XXIV, April 1998 : 270-273.

 Cilostazol induces healing of extremity ischemic ulceration
and obviate limb amputation.

I. II.

The ulcer had healed with visible evidence of reepitheliazation. The Ulcer had closed completely.
A. Ischemic right hallux ulceration. A. Ischemic left hallux ulceration when first examined.
B. Right hallux after 10 weeks of therapy with Pletaal. B. Left hallux after only 7 weeks of therapy with Pletaal.

III.

The ulcers finally healed.

A. Ischemic-appearing ulcerations on right first and fourth toes.
B. After receiving Pletaal for 24 weeks.

* Steven MD, Patrick SV. Successful pharmacologic treatment of lower extremity ulcerations in 5 patients with
chronic critical limb ischemia. J AM Board Fam Pract. 2002; 15: 55-62.
 Medications for Patients With PAD
Therapeutic Goal

To Reduce To Improve
Ischemic Claudication
Drug Events Symptoms

Clopidogrel
Yes No
aspirin

Cilostazol

Yes Yes
 Laki-laki, tn HG 58 th, nyeri tungkai kanan bawah bila
berjalan 3 bulan, keluhan timbul dengan jalan kurang dari
100 meter. DM, CHF, IHD, riwayat merokok.

PAD??
ABI kanan 0,54
ABI kiri 0,72
 Wanita, ny. SB 64 th,
kesemutan kedua kaki 2
tahun. DM, IHD, riwayat
ACS, riwayat kaki
bengkak dengan
perubahan warna kulit
kaki, respon dengan
diosmin 1000mg selama 3
bulan
ABI kanan 0,79 PAD??
ABI kiri 0,74
Laki-laki, 62 th, keluhan
kaki 2 tidak ada. HT,
IHD, PPOK, riwayat
rokok

ABI kanan 0,85

ABI kiri 0,9
 Garis besar pembahasan

1. Pengertian PAD
2. Kenapa PAD?
3. Diagnosis
4. Tatalaksana
terima kasih

Semoga
bermanfaat