PERIPHERAL

ARTERIAL DISEASE ON
DIABETES
Melati Silvanni Nasution
Divisi Endokrinologi, Metabolik & Diabetes
Departemen Ilmu Penyakit Dalam
FK USU – RS HAM
What is Peripheral Arterial Disease?

• PAD encompasses a range of noncoronary arterial

syndromes
• Caused by the altered structure and function of
the arteries that supply the brain, visceral organ
and the limbs
 PAD occurs when blood vessels in the leg are
narrowed or blocked by fatty deposits,
platelets, fibrin and other substance
on arterial wall

Definisi PAD :
Penyakit pembuluh darah yang disebabkan oleh
proses sklerosis dan proses tromboemboli yang
merusak struktur dan fungsi pembuluh darah arteri di
tungkai bawah
It should not be confused with “arteriosclerosis” or
“atherosclerosis”

● Arteriosclerosis is a hardening (and loss of

elasticity) process of medium or large arteries

● Atherosclerosis is the most common form of

arteriosclerosis characterized by a thickening
of the intima with plaques that can contain lipid-
laden macrophages
 Pathogenesis
• … is a chronic inflammatory process that can be converted
into plaque rupture

Homeostatic and cellular function :

• Blood coagulation Endothelial dysfunction
• Leukocyte activity  the earliest lesion is
• Platelet reactivity fatty streak – plaque
• Capillary permeability
• Regulation of vascular smooth
progression
muscle tone
 Atherosclerosis Timeline

• Oxidized LDL
• Homocysteine
• Smoking
• Aging
• Hyperglycemia
• Hypertension
Major Vascular Manifestations of
Atherosclerosis Disease
 Patients at Increased Risk of PAD
• Age ≥ 65 yo
• Age 50-64 yo, with risk factors for atherosclerosis (e.g : diabetes
mellitus, history of smoking, hyperlipidemia, hypertension) or family
history of PAD
• Age < 50 yo, with diabetes mellitus and 1 additional risk factor for
atherosclerosis
• Individuals with known atherosclerosis disease in another vascular bed
(e.g : coronary, carotid, subclavia, renal, mesenteric, artery stenosis)
 Definition of PAD Key Terms
1. Claudication : Fatigue, discomfort, cramping or pain of vascular origin in
the muscles of the lower extremities that is consistently induced by
exercise and consistently relieved by rest (within 10 minutes)
2. Acute Limb Ischemia : Acute (<2 weeks) severe hypoperfusion of the
limb characterized by these features : pain, pallor, pulselessness,
poikiloyhermia (cold), paresthesias and paralysis
3. Critical Limb Ischemia : A condition characterized by chronic (≥ 2
weeks) ischemic rest pain, nonhealing wound/ulcers, or gangrene in 1 or
both legs attributable to objectively proven arterial occlusive disease
Acute Limb Ischemia VS
Chronic Limb Ischemia
Acute Limb Ischemia VS
Chronic Limb Ischemia
Clinical Presentation of PAD
Major Symptoms of PAD
Risk Factors of Intermitten Claudication
Pathophysiology of peripheral arterial disease in diabetes
mellitus, Yang, Journal of Diabetes, 2017
 PAD Diagnosis : History
• Use the history alone to detect peripheral arterial disease will
result in missing up to 90% of cases
• Asymptomatic patients with abnormal ABI have >50% increased
risk of cardiovascular complications
• Patients at increased risk of PAD should undergo a
comprehensive medical history and a review of symptoms to
assess for exertional leg symptoms, including claudication or
other walking impairment, ischemic rest pain and non healing
wounds
PAD Diagnosis : Physical Examination
PAD Diagnosis : Physical Examination
Vascular Tests Diagnosis of PAD
Ankle Brachial Pressure Index (ABPI)
Toe Brachial Pressure Index (TBPI)
 Vascular Flow Doppler
Non-invasive method of evaluating the blood vessels using sound
waves, similar to ultrasonography and echocardiography

• Can obtain both anatomic and hemodynamic information

• Anatomical detail (vessel wall, intraluminal obstructive lesions,
perivascular compressive structures)
Angiogram Procedure (Gold Standard)
2016 AHA/ACC Guideline on the
Management of Patients With
Lower Extremity Peripheral Artery
Disease

• Age 50-69 yo and smoking or

diabetes
• Age ≥ 70 yo
• Leg pain with exertion
• Abnormal results on vascular
exam of leg
• Coronary, carotid or renal
arterial disease
Recommendations
for Structured
Exercise Therapy
Recommendations for
Antiplatelets Therapy
 Recommendations for Statin

Recommendations for Antihypertensive

Recommendations for Anticoagulation

Recommendations for Glycemic Control

Recommendations for Cilostazol, Pentoxifylline, and
ChelationTherapy
Recommendations for Revascularization for CLI
Recommendations for Wound Healing
Therapies for CLI
Recommendations for Clinical Presentation of ALI

Recommendations for ALI Medical Therapy

 Recommendations for
Revascularization for ALI
 Two Major Goals in Treating Patients with PAD

Limb Outcomes CV Morbidity and Mortality

• Improved ability to walk • Decrease in morbidity from non-fatal MI and

- Increase in walking distance stroke
- Improvement in QoL • Decrease in cardiovascular mortality from fatal
• Prevention of progression to CLI and MI and stroke
amputation
THANK
YOU…