PERIPHERAL

ARTERIAL DISEASE
(PAD)
T.SUNIL KUMAR
 INTRODUCTION
• PAD IS A CLINICAL TERM THAT DENOTES
AN OCCLUSIVE DISEASE ARISING FROM
NARROWING OF THE ARTERIES DISTAL TO
THE ARCH OF THE AORTA.
• PERIPHERAL ARTERY DISEASE (ALSO
CALLED PERIPHERAL ARTERIAL DISEASE)
IS A COMMON CIRCULATORY PROBLEM IN
WHICH NARROWED ARTERIES REDUCES
BLOOD FLOW TO THE LIMBS.
ATHEROSCLEROSIS OBLITERANS
• RISK FACTORS – MAIN FACTORS LEADING
TO PROGRESSIVE NARROWING OF THE
MAJOR ARTERIES OF THE LEGS ARE
SMOKING, HYPERTENSION, DIABETES
MELLITUS AND HYPERLIPIDAEMIA.
 SYMPTOMS
1. INTERMITTENT CLAUDICATION – SEVERE
CRAMPING PAINS OR DISCOMFORT ON WALKING
WHICH DISAPPEARS AFTER SHORT REST AND
RECURS WHEN THE WALK IS RESUMED. THE
SYMPTOM IS DUE TO INABILITY OF NARROW
ARTERIES TO PROVIDE ADDITIONAL BLOOD
SUPPLY NECESSARY FOR THE EXERCISING
MUSCLES.
• THE POSITION OF PAIN OF CLAUDICATION
DEPENDS ON THE LEVEL OF ARTERIAL LESION –
(A) CALF CLAUDICATION – USUALLY DUE TO
OBSTRUCTION IN FEMORO-POPLITEAL SEGMENT.
(B) THIGH CLAUDICATION – USUALLY DUE TO
ILIAC OCCLUSION WITH ASSOCIATED BUTTOCK
CLAUDICATIONS.
(C) CLAUDICATION OF BUTTOCKS, THIGHS AND
CALVES WITH IMPOTENCY IN MALES – AORTIC
BIFURCATION LESION.
2. REST PAIN– IS LESS COMMON AND SUGGESTS MORE
ADVANCED DISEASE.
(a) PAIN DUE TO ACUTE ARTERIAL OCCLUSION – SEVERE
PAIN IN TISSUES DISTAL TO THE SITE OF
OBSTRUCTION AGGRAVATED BY LIMB MOVEMENT.
(b) (B) PAIN DUE TO ISCHAEMIC NEUROPATHY – SEVERE
BURNING OR LANCINATING TYPE OF PAIN OCCURRING
USUALLY IN PAROXYSMS AND WORSE AT NIGHT.
(c) (C) PAIN OF PREGANGRENE – BURNING, THROBBING
TYPE OF PAIN WHICH MAY MAKE THE PATIENT SIT UP
IN BED AND HOLD HIS LEGS. PAIN AGGRAVATED BY
HEAT.
3. OTHER SYMPTOMS– NUMBNESS AND
TINGLING AND FEELING OF COLDNESS IN
THE INVOLVED EXTREMITY. THE
OCCURRENCE OF SEPSIS IN MINOR
ABRASIONS OF THE FEET MAY BE THE FIRST
EVIDENCE OF INCIPIENT ISCHAEMIA IN THE
LIMB.
 EXAMINATION
(A) INSPECTION – OF FEET. IN PRESENCE OF REST
PAIN, FEET AND TOES WILL BE COLD WITH
PURPLE OR BLUISH DISCOLOURATION. IN MORE
ADVANCED CASES (PREGANGRENE) ATROPHIC
SKIN, POOR COLOUR AND SLUGGISH CAPILLARY
CIRCULATION.
(B) PALPATION – (I) ABSENCE OF PULSES BELOW
THE FEMORAL PULSE (FEMORAL ARTERY IS
MOST COMMONLY INVOLVED) IN AFFECTED LEG.
IF BUTTOCK OR THIGH CLAUDICATION IS
PRESENT, THE FEMORAL PULSE WILL BE WEAK
OR ABSENT INDICATING AORTOILIAC DISEASE.
AT TIMES PULSATIONS ARE PRESENT AT REST
(II) ABDOMEN – TO EXCLUDE ANEURYSM OF
ABDOMINAL AORTA.
(III) DISTAL TO OBSTRUCTION LIMBS ARE
COLD TO TOUCH.

(C) AUSCULTATION – OF ABDOMINAL AORTA,

ILIAC ARTERIES AND FEMORAL ARTERIES
DOWN TO THE POPLITEAL FOSSA MAY
REVEAL STENOSIS BY PRESENCE OF A
BRUIT.
 INVESTIGATIONS
1. ANKLE BRACHIAL PRESSURE INDEX – UNDER
NORMAL CONDITIONS, SYSTOLIC BP IN THE
LEGS IS SLIGHTLY GREATER THAN THAT IN THE
UPPER LIMB. THE ANKLE BRACHIAL PRESSURE
INDEX CALCULATED FROM THE RATIO OF ANKLE
TO BRACHIAL SYSTOLIC PRESSURE, IS A
SENSITIVE INDEX OF ARTERIAL INSUFFICIENCY.
THE HIGHEST PRESSURE MEASURED IN ANY
ANKLE ARTERY IS USED AS THE NUMERATORY
OF THE INDEX, A VALUE > 1.0 IS NORMAL, AND A
VALUE < 0.9 IS ABNORMAL.
MEASUREMENT WITH DOPPLER PROBE
• A HAND HELD PENCIL DOPPLER PROBE IS
PLACED OVER A PATIENT PEDAL ARTERY AND
THE FOOT RAISED AGAINST A POLE
CALIBRATED IN MM HG. THE POINT AT WHICH
THE PEDAL SIGNAL DISAPPEARS IS TAKEN AS
THE ANKLE PRESSURE.
2. EXERCISE TEST – IS PERFORMED BY
EXERCISING THE PATIENT FOR 5 MINUTES SAY
ON A TREAD MILL. THE ANKLE BRACHIAL
PRESSURE INDEX IS MEASURED BEFORE AND
AFTER EXERCISE. A PRESSURE DROP (DUE TO
PERIPHERAL VASODILATION) OF 25% OR MORE
INDICATES SIGNIFICANT ARTERIAL DISEASE.
3. ECG – FOR EVIDENCE OF ISCHAEMIA.
4. ANGIOGRAPHY – TO DEFINE EXTENT OF
DISEASE AND POSSIBILITY OF BYPASS
SURGERY OR ENDARTERECTOMY.
5. SPECIALIST DIAGNOSTIC AND
THERAPEUTIC DEVICES:
(A) PRESSURE WIRES WITH BUILT-IN
PRESSURE SENSOR AT TIP TO MEASURE
TRANSLESIONAL PERIPHERAL (AND RENAL
ARTERY) GRADIENTS TO DETERMINE
HEMODYNAMIC IMPORTANCE.
(B) INTRAVASCULAR ULTRASOUND FOR
LESION ASSESSMENT AND FOR
OPTIMIZATION AFTER ANGIOPLASTY OR
STENTING.
(C) SPECIFIC ATHERECTOMY DEVICES TO
DEBULK, SLICE AND REMOVE PLAQUE
THROUGH LONG SEGMENTS OF HEAVILY
CALCIFIED LESIONS.
(D) EXCIMER LASER TECHNOLOGY FOR
ENDOVASCULAR ABLATION FOR TOTAL
OCCLUSIONS.
• MANAGEMENT OF CHRONIC
PERIPHERAL ISCHAEMIC DISEASE.
A. MEDICAL TREATMENT – INDICATIONS:
(A) IF INTERMITTENT CLAUDICATION IS THE
ONLY SYMPTOM AND IT DOES NOT
INTERFERE WITH THE PATIENT’S
EMPLOYMENT.
(B) DIABETES MELLITUS IS NOT
ASSOCIATED.
(C) PRESENCE OF EXTENSIVE DISEASE
CONTRAINDICATES SURGICAL
1. MEASURES TO PREVENT PROGRESS OF
THE DISEASE
•• REST IF PRESENCE OF REST PAIN, WOUND
OR GANGRENE.
•• NO SMOKING.
•• REDUCTION OF OBESITY.
•• CARE OF FEET – SKIN SHOULD BE
PROTECTED FROM TRAUMA, SHOES SHOULD
BE COMFORTABLE. AVOID TIGHT GARTERS.
TRIM NAILS CAREFULLY. AVOID SITTING
WITH LEGS CROSSED. NO OPERATIVE
REMOVAL OF CORNS. IF SKIN IS DRY, APPLY
OIL AT NIGHT AND DUSTING POWDER
(A) ANTIPLATELET THERAPY – ASPIRIN 75–
300 MG/DAY, IF ASPIRIN SENSITIVITY,
DIPYRIDAMOLE (200 MG BD) OR
CLOPIDOGREL (75 MG/DAY) OR PRASUGREL
(10 MG/DAY) OR TICAGRELOR 90 MG BD.
(B) CILOSTAZOL 100 MG BD ONE HR. BEFORE
OR TWO HRS. AFTER BREAKFAST AND
DINNER IF EXERCISE ALONE IS
INEFFECTIVE. IT SHOULD NOT BE USED IN
PATIENTS OF CONGESTIVE CARDIAC
FAILURE.
(C) PENTOXIFYLLINE, XANTHINE OXIDASE
INHIBITOR, DECREASES BLOOD VISCOSITY AND
ANTI-PROLIFERATIVE ACTION.
(D) CONTROL OF LIPAEMIA IN
ATHEROSCLEROSIS.
(E) ADEQUATE CONTROL OF DIABETES.
(F) CONTROL OF THROMBOSING TENDENCIES
WITH LONGTERM ANTICOAGULANTS
2. MEASURES TO INCREASE CIRCULATION
• (A) WALKING – THE PATIENT SHOULD BE
INSTRUCTED TO WALK SLOWLY UP TO THE
POINT OF CLAUDICATION SEVERAL TIMES
A DAY.
• (B) WARM ENVIRONMENT – HOT BAG TO
ABDOMEN MAY CAUSE VASODILATION IN
LOWER LIMBS. BLOOD FLOW CAN OFTEN
BE STIMULATED BY PLACING A
THERMOSTATICALLY CONTROLLED
HEATING UNIT OVER THE LOWER
EXTREMITIES; THE TEMPERATURE WITHIN
THE BOX SHOULD NOT EXCEED 90°F. THE
SOURCE OF HEAT IS USUALLY IN THE FORM
• (C) ACTIVE VASCULAR EXERCISE –
BUERGER’S EXERCISE – LEGS ARE
ELEVATED TO 60° AND KEPT IN THAT
POSITION FOR 2–3 MINUTES UNTIL
BLANCHING OCCURS. THEN DANGLE LEGS
FOR 5 MINUTES TILL MAXIMAL FLUSHING
IS SEEN. THEN KEEP LEGS IN HORIZONTAL
POSITION FOR 5 MINUTES.
CONTRAINDICATED IF INFECTION OR OPEN
WOUND.
• (D) PASSIVE VASCULAR EXERCISE – (I) “SUCTION
PRESSURE TREATMENT” – ALTERNATE HIGH
AND LOW PRESSURE IS PRODUCED IN A
HERMETICALLY SEALED BOOT (PAVEX BOOT).
(II) SAUNDER’S OSCILLATING BED FOR
EXTREMELY OLD AND DEBILITATED PATIENTS
IN PLACE OF POSTURAL EXERCISE. (III)
INTERMITTENT VENOUS OCCLUSION – WITH A
SPHYGMOMANOMETER, THE PRESSURE IS
RAISED TO ABOUT 60 MM HG. FOR 2 MINUTES
AND RELEASED FOR 4 MINUTES, THE PROCESS
BEING REPEATED FOR HALF AN HOUR.
• (E) OTHER MEASURES – TO ALTER FLOW
PROPERTIES OF BLOOD SUCH AS
HAEMODILUTION, DEFIBRINATION, PLASMA
EXCHANGE AND HAEMORHEOLOGICAL DRUGS.
B. INTERVENTIONAL TREATMENT
• REVASCULARIZATION - PROCEDURES –
(A) PERCUTANEOUS RE-OPENING PROCEDURES–
(I) PERCUTANEOUS TRANSLUMINAL
ANGIOPLASTY – IS WIDELY USED FOR CRITICAL
STENOSIS OR OCCLUSION. (II) LOCAL
FIBRINOLYTIC THERAPY – AS ALTERNATIVE OR
ADDITIONAL PROCEDURE TO PTA,
PARTICULARLY IF SUGGESTION OF RECENT
THROMBOSIS AND IT CAN BE COMBINED WITH
THROMBECTOMY. STREPTOKINASE 6000
UNITS/HR DIRECTLY INTO THE OCCLUSION,
WITH REPEAT ARTERIOGRAPHY AFTER 6–12
HOURS. IF SIGNIFICANT IMPROVEMENT,
C. RECONSTRUCTIVE ARTERIAL SURGERY
(LIMB SALVAGE):
–– INDICATIONS – (A) PRESENCE OF SEVERE
CLAUDICATION INTERFERING WITH
EVERYDAY WORK. (B) CRITICAL LEG
ISCHAEMIA WITH REST PAIN OR IMPAIRED
SKIN AND TISSUE VIABILITY AND NON-
HEALING ULCERS.
–– PROCEDURE – BYPASSING OF OCCLUDED
SEGMENT – RECONSTRUCTIONS ABOVE
GROIN (AORTO-ILIAC SEGMENT) GIVE
BETTER RESULTS THAN THOSE BELOW THE
GROIN (FEMORO-POPLITEAL SEGMENT).
MORE DISTAL BYPASSES TO CALF ARTERIES
• VASCULOPATHY OF SPECIFIC
AETIOLOGY - NON-ATHEROSCLEROTIC
(VSE-NA) IN YOUNG PATIENT. PAD MAY BE
THE FIRST PRESENTATION OF CONNECTIVE
TISSUE DISEASE (CTD) OR
THROMBOPHILIC STATE, YOUNGER AGE OF
ONSET, FEVER, WT. LOSS, MULTIPLE LIMB
INVOLVEMENT, ANAEMIA, HIGH ESR,
PROTEINURIA AND RBCS IN URINE ALL
POINT TO CTD, UPPER LIMB INVOLVEMENT
BEING MORE COMMON.
 THROMBOANGIITIS
OBLITERANS
(BUERGER’S DISEASE)
INFLAMMATORY OCCLUSIVE DISORDER
INVOLVING SMALL AND MEDIUM-SIZED
ARTERIES AND VEINS IN DISTAL UPPER AND
LOWER EXTREMITIES, USUALLY IN MALES
IN AGE GROUP 25–40. HEAVY CIGARETTE
SMOKING IS A PREDISPOSING FACTOR.
INCREASED INCIDENCE OF HLAB5 AND A-9
ANTIGENS.
 CLINICAL FEATURES
1. MIGRATORY SUPERFICIAL
THROMBOPHLEBITIS – RED PAINFUL
AREAS ON DORSUM OF FOOT
PARTICULARLY IN REGION OF ANKLE OR
LOWER LEG AND OCCASIONALLY LOWER
ARM; OFTEN A VEIN 2 TO 4 INCHES IN
LENGTH IS INVOLVED. SLIGHT MALAISE
AND LITTLE RISE OF TEMPERATURE MAY
BE PRESENT. LASTS FOR 10 TO 12 DAYS
AND IS FOLLOWED BY A BROWNISH
PAIN – ONE OF THE EARLIEST SYMPTOMS,
VARIES IN INTENSITY FROM MILD TO
EXCRUCIATING PAIN AND OFTEN APPEARS
FOR THE FIRST TIME AFTER EXPOSURE TO
COLD.
(a) INTERMITTENT CLAUDICATION OCCURS
IN ALMOST ALL PATIENTS AND IS
CONFINED NOT ONLY TO CALVES BUT
ALSO OCCURS IN FEET. IT IS CRAMP-LIKE
AND OFTEN OCCURS AFTER
PROGRESSIVELY SHORTER INTERVALS
(B)REST PAIN MAY BE DUE TO IMPENDING
TROPHIC DISTURBANCES.
(C)INVOLVEMENT OF NERVES CAUSES SHARP,
SHOOTING, LANCINATING PAINS IN THE WHOLE
EXTREMITY. OCCASIONALLY PAIN IS RELIEVED
BY KEEPING THE LEG DOWN. PATIENT SITS ON
EDGE OF BED HOLDING THE INVOLVED FOOT,
WHICH IS CROSSED OVER THE HEALTHY LEG, IN
HIS HAND.
3. RAYNAUD’S PHENOMENON (RP) –
RAYNAUD’S PHENOMENON REFERS TO
REVERSIBLE SPASM OF PERIPHERAL
ARTERIOLES IN RESPONSE TO COLD OR
STRESS. RP IS USUALLY SEEN IN DISTAL
DIGITS BUT MAY INVOLVE NOSE, EARS AND
TONGUE. IT IS CHARACTERISED BY
TRIPHASIC RESPONSE:
–– PHASE 1: PALLOR DUE TO
VASOCONSTRICTION OF PRECAPILLARY
MUSCULAR ARTERIOLES.
–– PHASE 2: CYANOSIS DUE TO VENOUS
POOLING AND DEOXYGENATION OF VENOUS
BLOOD.
• RAYNAUD’S PHENOMENON SHOULD BE
DISTINGUISHED FROM RAYNAUD’S
DISEASE WHICH IS OCCURRENCE OF
VASOSPASM PRIMARILY WITH NO
ASSOCIATION WITH ANOTHER ILLNESS
(PRIMARY RAYNAUD’S). RP IS SECONDARY
TO OTHER CONDITIONS, MOST COMMONLY
AN AUTOIMMUNE DISEASE (SECONDARY
RAYNAUD’S).
 CLINICAL STAGES
1. PREMONITORY STAGE – OFTEN UNNOTICED
BY THE PATIENT. CHARACTERISED BY
ATTACKS OF RECURRENT PHLEBITIS,
SWELLING OF FEET, LOSS OF HAIR ON THE
LEGS AND FORMATION OF TENDER
NODULES IN SKIN. THE STAGE MAY LAST
FROM 2 TO 7 YEARS.
2. STAGE OF CLAUDICATION – SEVERE,
CRAMPING PAINS ON WALKING WHICH
DISAPPEAR AFTER SHORT REST AND RECUR
WHEN THE WALK IS RESUMED.
3. STAGE OF REST PAIN – PAIN COMES IN
PAROXYSMS EVEN AT REST, IS INCREASED BY
ELEVATION AND RELIEVED TEMPORARILY BY
LOWERING OF THE EXTREMITY.
4. STAGE OF TROPHIC CHANGES AND GANGRENE
– PAIN CONSTANT AND EXCRUCIATING,
VESICLES ON GREAT TOE FOLLOWED BY
ULCERS OR FISSURES. GANGRENE DRY OR
INVESTIGATIONS
• ARTERIOGRAPHY – SMOOTH, TAPERING
DISTAL SEGMENTAL VESSELS AND FINE
NETWORK OF COLLATERAL VESSELS.
• EXCISION BIOPSY – OF INVOLVED VESSELS
CONFIRMS DIAGNOSIS.

MANAGEMENT
NO SPECIFIC TREATMENT. ABSTINENCE
FROM TOBACCO. ARTERIAL BY-PASS OF
LARGER VESSELS IN SELECTED CASES AND
ALSO DEBRIDEMENT DEPENDING ON
SYMPTOMS AND SEVERITY OF ISCHAEMIA.
 RAYNAUD’S SYNDROME AND
PHENOMENON

• IT IS CHARACTERIZED BY SEQUENTIAL
DEVELOPMENT OF WHITE, NUMB ‘DEAD
FINGERS’ (DIGITAL ISCHAEMIA), CYANOSIS,
RUBOR OF FINGERS (AND TOES) ON
EXPOSURE TO COLD, AND SUBSEQUENT
FLUSHING PHASE DUE TO REWARMING.
CLASSIFICATION: OF RAYNAUD’S
PHENOMENON

PRIMARY OR IDIOPATHIC (RAYNAUD’S

DISEASE)
• NO UNDERLYING CAUSE. OCCURS
USUALLY IN FEMALES BETWEEN 15 TO 20
YEARS OF AGE. FAMILY HISTORY
COMMON. NEVER PROGRESSES
TO ULCERATION.
 MANAGEMENT
(1) WARM CLOTHING AND AVOIDANCE OF
EXPOSURE TO COLD
(2) DRUGS – (A) ADRENERGIC BLOCKING
AGENTS. (B) RESERPINE REDUCES PAIN
AND PROMOTES ULCER HEALING.
(C) CALCIUM ANTAGONISTS NIFEDIPINE OR
DILTIAZEM.
(D) PRAZOSIN.
(3) SURGICAL SYMPATHECTOMY – IF FAILURE TO
RESPOND TO DRUGS, BUT EFFECT TRANSIENT
• PERSISTENT DIGITAL ISCHAEMIA –
ISCHAEMIA OF A DIGIT OR DIGITS MAY LAST
FOR DAYS OR WEEKS. PATIENTS ARE USUALLY
MIDDLE AGE OR ELDERLY, OFTEN
HYPERTENSIVE. THE CAUSE IS NOT OBVIOUS
BUT MAY BE DUE TO OCCLUSION OF THE
DIGITAL ARTERY BY ATHEROMA. AT TIMES
POLYCYTHAEMIA VERA OR
DYSPROTEINAEMIA IS THE CAUSE, OR, IN
YOUNG SUBJECTS, A CERVICAL RIB MAY BE
RESPONSIBLE. TREATMENT – SPONTANEOUS
RECOVERY IS USUAL BUT FOR SEVERE
ISCHAEMIA REFLEX HEATING, ANALGESICS
AND DEXTRAN INFUSION, AND ANTIBIOTICS
FOR INFECTION. AMPUTATION ALONG LINE OF
• COLD INJURY – FREEZING OF TISSUES IN
HANDS AND FEET LEADING TO FROST BITE
CAN OCCUR FOLLOWING PROLONGED
EXPOSURE TO COLD. THERE IS USUALLY
REDNESS, BLISTERING, INFECTION AND
SUPERFICIAL GANGRENE OF THE DIGITS
OF HANDS AND FEET. TREATMENT –
REFLEX HEATING, ANTIBIOTICS AND
ANALGESICS AND DEXTRAN INFUSION.
DEEP TISSUES ARE USUALLY PRESERVED
AND SKIN GANGRENE SEPARATES OUT
• ACROCYANOSIS – REDDISH OR BLUISH
DISCOLOURATION OF HANDS AND FEET ON
EXPOSURE TO COLD OCCURRING MOSTLY IN
YOUNG WOMEN. IT IS THOUGHT TO BE DUE
TO ARTERIOLAR SPASM WITH DILATATION OF
VENULES IN THE SKIN. IT MAY COEXIST WITH
RAYNAUD’S PHENOMENON.
• WHEN THE HAND OR FOOT IS WARM, THE
SKIN BECOMES BRIGHT PINK.
ACROCYANOSIS MAY ALSO BE SEEN IN
ELDERLY PATIENTS WITH CARDIAC
DISEASE AND IN NEUROLOGICAL
DISORDERS SUCH AS STROKE,
POLIOMYELITIS AND MULTIPLE
SCLEROSIS. TREATMENT – LIMBS MUST BE
KEPT WARM. SYMPATHECTOMY MAY BE
NECESSARY IN PATIENTS WITH SEVERE
COLDNESS AND CHILBLAINS
• LIVEDO RETICULARIS – OCCURS USUALLY IN
YOUNG WOMEN. THERE IS BLOTCHY
MOTTLING AND DISCOLOURATION OF FEET
AND LEGS. IT IS LIKELY TO BE DUE TO PATCHY
ARTERIOLAR VASOSPASM IN THE SKIN. A
SECONDARY FORM MAY OCCUR IN PATIENTS
WITH POLYARTERITIS NODOSA OR
POLYCYTHAEMIA VERA. IT IS AS A RULE
LOCALISED TO DIGITS OR FEET AND THE
CONDITION MAY PROGRESS TO GANGRENE.
THANK YOU