Peripheral Artery Disease /

Chronic Obliterating Arteriopathy of

PAD
the Lower Limbs
chronic symptoms / signs:
pain: intermittent claudication,
relieved when the limb is decline, permanent
pallor, cold
skin thin, shiny, without hair; brown spots
friable nails with transverse striations
disease of the
ischemia hypotrophic muscles
peripheral arteries
peripheral pulse: low amplitude / absent pulse
Ankle-Arm Index < 90% (0.9) (Normal)
necrosis (gangrene): dry / wet

the most frequent:

atherosclerosis acute symptoms / signs: 5P + S
palor
pulse less
pain
paresthesia
paralysis
thrombosis
shock
embolism

Investigations:
Doppler ultrasound
CTA (CT angiography)
arteriography
Inspection PAD

» shiny skin with brown spots

» loss of hair
» palor (sometimes)
» hypotrophic muscles
Inspection PAD
Gangrene PAD
demarcation line NO demarcation line

Wet gangrene

Dry gangrene
-necrosis is well defined
-neighboring viable tissue
is normal
-necrosis is imprecisely delimited
-adjacent tissue with signs of
inflammation, cyanosis
-dirty, smelly secretion
Palpation PAD
Palpation PAD
Ankle-Arm Index PAD

Systolic BP ankle
Systolic BP arm

Normal > 0.9

(the BP on ankle must be at least
90% from BP on arm)

If AAIndex is less than 0.9  ischemia

Acute ischemia PAD
 Inspection of an ulcer Ulcer

» white-blue-red (outer-central-inner)
--> healing ulcer » sloping edge => healing ulcer
» red, with inflamation » punched edge => trophic ulcer
» healty granulation tissue
--> tendency to extension ("spreading" ulcer) » undermined edge => tuberculous ulcer
(pink, with marginal epithelisation)
» white, hard, fibrous » everted edge => malignant ulcer
=> healing ulcer
--> chronic NON-healing ulcer
» UNhealty granulation tissue
(white / red, without epithelisation, it bleeds easily)
=> chronic NON-healing ulcer
margin edge

granulation tissue
» medial side of the lower third of the calf
--> varicose ulcer
» on the lateral sidesof the neck
--> tuberculous ulcer » reduced, delimited
» on the face => healing ulcer
location ulcer floor necrotic tissue
--> basal cell carcinoma » abundant, adherent, indefinite
» on bony prominences => healing ulcer
--> diabetic ulcer, bedsores
» dorsal part of the foot / fingers
--> ischaemic ulcer
discharge
size,
shape,
number » reduced, clear
surrounding skin
=> healing ulcer
» abundant, dirty
=> healing ulcer
» red, with inflamation
--> extension ("spreading" ulcer)
» dark / brown/ violet withe eczema
--> varicose ulcer
» hipopigmentation, palor
--> non-healing ulcer
» scars
--> Marjolin ulcer
Location of the ulcer Ulcer

» medial side of the lower

third of the calf » on the lateral sidesof the neck
--> varicose ulcer --> tuberculous ulcer
 Location of the ulcer Ulcer

» on the face --> basal cell carcinoma

» on bony prominences --> diabetic ulcer

bedsore

» dorsal part of the foot --> ischaemic ulcer

Margins of the ulcer Ulcer
Edge of the ulcer Ulcer

sloping => healing ulcer punched => trophic ulcer

undermined => tuberculous ul. everted => malignant ulcer

The floor of the ulcer
» healty ulcer
» healty granulation tissue:
pink, with marginal
epithelisation and islands of
epithelisation
» without necrotic tissue
» small amount of fluid
Ulcer
» unhealty ulcer
» unhealty granulation
tissue: whitish / redish,
without epithelisation, it
bleeds easily)
» adherent necrotic tissue
» dirty, abundant fluid
 Surrounding skin Ulcer

Inflamation  spreading ulcer Hyperpigmentation, eczema 

varicose ulcer

Hypopigmentation  unhealing Scar  Marjolin ulcer

ulcer = cutaneous malignancy that arises in
the setting of previously injured skin
 Palpation of an ulcer Ulcer

» healty granulation tissue » easy to remove

minimal bleeding on palpation => healing ulcer
granulation tissue necrotic tissue
» UNhealty granulation tissue » adherent
abdundant / difuse belleding => non-healing ulcer

floor

» consistency » consistency
› soft --> healing ulcer › soft --> healing ulcer
edge ulcer base
› firm --> nonhealing ulcer › firm --> nonhealing ulcer (fibrosis)
› hard --> malignant ulcer › hard --> malignant ulcer

surrounding skin mobility

» temperature » mobility
--> extension ("spreading" ulcer) › mobile --> healing ulcer
» consistency › fix / limited mobility --> tumoral invasion
› soft --> healing ulcer
› firm --> nonhealing ulcer
› hard --> tumoral invasion
Palpation of surounding skin and edge Ulcer

temperature
» consistency
› soft --> healing ulcer
› firm --> nonhealing ulcer
› hard --> tumoral invasion
Palpation of the floor and the base Ulcer

» consistency
› soft / firm / hard
» healty granulation tissue
minimal bleeding on palpation
» UNhealty granulation tissue
abdundant / difuse belleding
» necrotic tissue: easy to remove / adherent
Mobility assessment Ulcer

» mobility
› mobile => healing ulcer
› fix / limited mobility => tumoral invasion