interactive case presentation happy foot
TRANSCRIPT
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Philippine Heart Association
Interactive Case Presentation
“ Happy Foot ”
Ruby Rose S. Cacatian, MD
St. Luke’s Medical Center
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General Data
S.G.
81 y/o, female
married, Chinese
from Quezon City
Chief Complaint:
non-healing wound, L
foot
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History of Present Illness
11 months
PTA
• Pain on the leg pain L>R upon walking <200 m• L leg pain radiates to to the 5th digit L foot
• (-) skin changes or visible lesions• (-) trauma
• advised an arterial duplex scan of lower extremeties showed occluded LE arteries
• Persistent leg pain
• consult with Rheumatologist: Arthritis • given steroid injection plantar aspect of L lateral
foot• open wound post injection site
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History of Present Illness
• persistent non-healing wound, lateral aspect of the 5th digit, L foot
• leg pain at rest relieved by dangling LE
• difficulty walking
• underwent debridement of the wound in local hospital
• no improvement in the wound, no relief of leg pain
• advised amputation
2 months PTA
1 month PTA
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History of Present Illness
• Deterioration of the non-healing
wound and development of
gangrene involving the 5th digit, L foot
• intolerable leg pain worst at night
Referred to vascular service
Few days
PTA
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Review of Systems
• General: (-) fever (+) weight loss
• Integumentary: no rashes (-) bleeding tendencies
• HEENT: (-)headache (-) dizziness (-) eye pain (-) blurring
of vision
• Cardiovascular: (-) exertional dyspnea, (-) easy
fatigability, (-) chest pain, (-) palpitations, (-) syncope
• Pulmonary: (-) pleurisy
• Gastrointestinal: (+) loss of appetite (-) nausea/vomiting
(-) change in bowel habits (-) abdominal discomfort
• Genitourinary: (-) dysuria (-) hematuria
• Neurologic: (-) dizziness (-) loss of consciousness (-)
paralysis
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Past Medical History
• Diabetic x 30 years
– Sitagliptin/Metformin 50/500 BID
– Glimepiride 2mg/tab OD
• Hypertensive x 30 years
– Telmisartan 40 mg tablet OD
– Diltiazem 60 mg tablet OD
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Past Medical History
• Dyslipidemic on Atorvastatin 20 mg tablet ½ OD
• Other meds:
– Cilostazol 100 mg/tab OD
– Clopidogrel 75 mg/tab OD
– Beraprost 20ug/tab TID
• (+) Colon CA-20 years ago S/P Colon Resection
• (+) PTB – treated 2007
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Personal and Social History:
• non-smoker
• non-alcoholic beverage drinker
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Physical Examination
General Survey: Conscious, coherent, wheel-chair borne
BP= 160/90 R arm, 150/90 L arm,
130/70 R leg, L leg BP cannot be appreciated
HR=60 bpm,reg RR=20, Temp=36.6 ⁰C,
Weight=41.3 kg, Height= 1.52 cm, BMI=18 kg/m2
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Physical Examination
• HEENT: pink palpebral conjunctivae,
anicteric sclerae, (-) TPC (-) enlarged
tonsils
• Neck: supple, (-) CLAD, no neck vein
engorgement, (+) Left Carotid Bruit
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Physical Examination
• Chest/Lungs: SCE, no retractions, clear
breathsounds , no wheezes, no crackles
• Heart: Adynamic precordium, Apex beat at
5th ICS left midclavicular line, (-) heave, (-)
thrills, normal rate, regular rhythm, no
murmurs
• Abdomen: flat, NABS, soft, nontender, no
organomegaly, (+) bruit, left lower quadrant
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Physical ExaminationNo discoloration
No swollen joints
Thigh and Calf atrophy L>R
Cold LLE > RLE
No hairs
No edema
2X3 cm Ulcer, plantar
aspect L foot, dry, pale
based, irregular border
gangrene, 5th digit, L foot
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Physical Examination
• Pulses: Regular rhythm
PULSES CAROTID BRACHIAL RADIAL FEMORAL POPLITEAL DPA PTA
RIGHT ++ ++ ++ + + 0 0
LEFT ++ Br ++ ++ + + 0 0
Neurologic Exam: oriented to 3 spheres, no cranial nerve deficitMotor: 5/5 both lower extremitiesSensory: intactReflexes: ++No babinski
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Salient Features
• 81/F
• Diabetic
• Hypertensive
• Dyslipidemic
• Non-healing wound L 5th
digit for 11 months
• Leg pain at rest
• Limitation of activity
• Carotid bruit, L
• Left lower quadrant bruit
• cold left LE > right LE
• gangrene, 5th digit, L foot
• ulcer, lateral aspect L foot
• Gr 1 pulse femoral artery
& popliteal artery
• Absent pulses DPA, PTA
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Question # 1
• Based on the salient features of our
patient, the most likely cause of L leg/foot
pain is:
A. Diabetic neuropathy
B. Venous claudication
C. Arthritis
D. Critical Limb Ischemia
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Differential Diagnosis Condition Location of
Pain/Discomfort
CharacteristicDiscomfort
Onset Relativeto exercise
Effect of Rest
Effect of Body Position
Other Characteristics
Diabetic Neuropathy
Symmetricalleg, foot
Burning, shootingworst at night
None Not relieved by rest
Not relieved by dependency
Cutaneous hypersensitivity, decrease reflexes,decrease vibration
Venousclaudication
Entire leg, butusually worse in thigh and groin
Tight,bursting pain
After walking
Subsidesslowly
Relief speeded byelevation
History of iliofemoraldeep vein thrombosis, signs of venous congestion, edema
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Differential Diagnosis
• Diabetic neuropathy
• Venous claudication
• Arthritis
• Critical Limb Ischemia
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Differential Diagnosis Condition Location of
Pain/Discomfort
CharacteristicDiscomfort
Onset Relativeto exercise
Effect of Rest
Effect of Body Position
Other Characteristics
Diabetic Neuropathy
Symmetricalleg, foot
Burning, shootingworst at night
None Not relieved by rest
Not relieved by dependency
Cutaneous hypersensitivity, decrease reflexes,decrease vibration
Venousclaudication
Entire leg, butusually worse in thigh and groin
Tight,bursting pain
After walking
Subsidesslowly
Relief speeded byelevation
History of iliofemoraldeep vein thrombosis, signs of venous congestion, edema
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Differential Diagnosis
• Diabetic neuropathy
• Venous claudication
• Arthritis
• Critical Limb Ischemia
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Differential DiagnosisCondition Location of
Pain/Discomfort
CharacteristicDiscomfort
Onset Relativeto exercise
Effect of Rest
Effect of Body Position
Other Characteristics
Arthritic, inflammatory processes
Foot, arch Aching pain After variable degree of exercise
Not quickly relieved(and may be present at rest)
May be relieved by not bearing weight
Variable, may relate to activity levelSwollen,tender joints
Critical Limb Ischemia
Distal part of foot or vicinity ofulcer or gangrenous toe
Intolerably severe
- Occurs at rest
Partially Relieved by dependent positionWorst when elevated
Cold exacerbates painPain worst at night
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Differential Diagnosis
• Diabetic neuropathy
• Venous claudication
• Arthritis
• Critical Limb Ischemia
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Differential DiagnosisCondition Location of
Pain/Discomfort
CharacteristicDiscomfort
Onset Relativeto exercise
Effect of Rest
Effect of Body Position
Other Characteristics
Arthritic, inflammatory processes
Foot, arch Aching pain After variable degree of exercise
Not quickly relieved(and may be present at rest)
May be relieved by not bearing weight
Variable, may relate to activity level
Critical Limb Ischemia
Distal part of foot or vicinity ofulcer or gangrenous toe
Intolerably severe, worst at night
- Occurs at rest
Partially Relieved by dependent position
Worst when elevated
Cold exacerbates pain
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Answer
D. Critical Limb Ischemia
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Impression
Critical Limb Ischemia
L foot Ulcer, lateral aspect, probably ischemic in
origin, secondary to severe PAOD
Diabetes Mellitus type 2
Hypertension
Dyslipidemia
Underweight
Colon Cancer s/p colon resection
PTB IV
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Question # 2
• Based on history and physical
examination, what is the level of arterial
occlusion?
A. Aorto-iliac
B. Popliteal Artery
C. Femoral artery
D. Tibial artery
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location of the symptom often relates to the site of the most proximal stenosis
Aorta and iliac arteries: buttocks, hip & thigh
Femoral or popliteal artery: calf
Tibial & peroneal artery: ankle or foot
Braunwald’s Heart diseases 9th ed., 2011
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Physical Examination
+1
+1
0
0
Bruit LLQ
PULSES
FemoralArteryfe
Popliteal
Artery
Anterior Tibial
Artery
Postrior Tibial
Artery
Peroneal Artery
Dorsalis Pedis Artery
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Answer
A. Aorto-iliac
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Question # 3
Which among the following statements on
critical limb ischemia is/are correct:
A. typically with chronic ischemic pain at rest
B. with ischemic skin lesions such as ulcers
or gangrene
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Question # 3
Which among the following statements on
critical limb ischemia is/are correct:
C. presence of symptoms for at least more
than 2 weeks
D. all of the above
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Critical Limb Ischemia(CLI)
• manifestation of peripheral artery disease (PAD)
• typical chronic ischemic pain at rest
• ischemic skin lesions, either ulcers or gangrene
• Attributable to objectively proven arterial occlusive
disease
• Should only be used to describe patients who have
chronic ischemic disease, which is defined as the
presence of symptoms for more than 2 weeks
Norgren and Hiatt et al. TASC II guidelines 2008
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Answer
• D. All of the above
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Acute Limb Ischemia vs
Critical Limb Ischemia
ACUTE LIMB ISCHEMIA
• sudden decrease in limb
perfusion that could
threaten limb viability
• 5 P’s
CRITICAL LIMB ISCHEMIA
• chronic ischemic pain at
rest or ischemic skin
lesions, either ulcers or
gangrene
• chronic ischemic disease;
symptoms of more than 2
weeks
Norgren and Hiatt et al. TASC II guidelines 2008
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Fate of the Claudicant Over 5 Years (ACC/AHA Guidelines)
Natural History of athersclerotic lower extremity PAD syndromes
PAD population (50 years and over)Initial clinical presentation
Asymptomatic PAD20-50%
Other leg pain30-40%
Typical claudication10-35%
Critical limb ischemia1-3%
1-year outcomes
Alive with two limbs45%
Amputation30%
Mortality25%
5-year outcomes
CV morbidity & mortalityLimb mortality
Stable claudication70-80%
Worsening claudication10-20%
Critical limb ischemia5-10%
Non-fatal cardiovascular
event (MI or stroke)20%
Non-CV causes
25%CV causes
75%Amputation
(see CLI data)
Fate of the claudication over 5 years (adapted from ACC / AHA guidelines5). PAD – peripheral arterial disease; CLI – critical limb ischemia; CV –cardiovascular; MI – myocardial infarction.
Mortality10-15%
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Critical limb ischemia1-3%
1-year outcomes
Alive with two limbs45%
Amputation30%
Mortality25%
Fate of the claudication over 5 years (adapted from ACC / AHA guidelines
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Question # 4
Ulcers due to arterial occlusive disease typically have:
A. irregular borders, severely painful & usually involve the tips of the toes or develop at sites of pressure
B. irregular borders, mildly painful, pink base with granulation tissue & localizes near the medial malleolus
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Question # 4
Ulcers due to arterial occlusive disease typically have:
C. multiple in number & located in the lower third of leg & severely painful
D. it is often deep, frequently infected & located in the sole of the foot & usually not painful
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Differential Diagnosis of
Foot and Leg Ulcers
Origin Cause Location Pain Appearance Role of revascularization
Arterial Severe PAD, Buerger’s disease
Toes, foot, ankle, pressure sites
Severe Various shape, irregular borders, pale base, dry
Impor-tant
Venous Venous Insufficiency
Malleolar, esp medial
Mild Irregular, pink base, moist
None
Norgren and Hiatt et al. TASC II guidelines 2008
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Differential Diagnosis of
Foot and Leg UlcersOrigin Cause Location Pain Appearance Role of
revascularization
Neuro-pathic
Neuropathy from diabetes, vitamin deficiency, etc
Foot/plantar surface (weight bearing), associated deformity
None Surrounding callus, oftendeep, infected
None
Neuro-ischemic
Diabetic neuropathy + ischemia
Locations common to both ischemic and neuroischemic as arterial
Reduced due to neuropathy
As arterial As arterial
Norgren and Hiatt et al. TASC II guidelines 2008
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Answer
A. irregular borders and usually involve the
tips of the toes or the heel of the foot or
develop at sites of pressure and severely
painful
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Arterial Ulcer
Neuropathic Ulcer
Venous Ulcer
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Dependent Rubor
Pallor on Leg
Elevation
Ischemic Ulcer
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Question # 5
• According to Fontaine classification of peripheral arterial disease, presence of ulcer/ gangrene is classified as:
A. III
B. II A
C. II B
D. IV
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Rutherford, et.al. JVS, 1997
Fontaine’s Stages Rutherford
GRADE CATEGORY CLINICAL DESCRIPTION
I 0 Asymptomatic
1 Mild claudication
2 Moderate
3 Severe
II 4 Ischemic rest pain
5 Minor tissue lost: non-healing, ulcer, focal gangrene
III 6 Major tissue loss extending above transmetatarsal level,
functional loss, foot not salvageable
STAGE SYMPTOMS
I Asymptomatic
IIA Claudication > 200 m
IIB Claudication < 200 m
III Rest / nocturnal pain
IV Necrosis, gangrene
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Answer
D. IV
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Question # 6
Which among the following statement is correct:
A. Resting ABI is a class 2 recommendation in
establishing the diagnosis of lower extremity PAD
B. ABI should be measured in both legs in all
new patients with PAD of any severity to confirm
the diagnosis of lower extremity PAD & establish
a baseline
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ACC/AHA Guidelines on
lower extremity PAD
Class 1C recommendation
The resting ABI should be used to establish
the lower extremity PAD diagnosis in
patients with suspected lower extremity PAD
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Class 1B recommendation
The ABI should be measured in both legs in
all new patients with PAD of any severity to
confirm the diagnosis of lower extremity PAD
and establish a baseline
ACC/AHA Guidelines on
lower extremity PAD
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Ankle Brachial Index
• Most cost-effective tool for lower extremity
PAD detection*
• < 0.90: abnormal
90% to 95% sensitive & 98% to 100%
specific: angiographically verified peripheral
arterial stenosis**
• leg claudication: ABI 0.5 to 0.8**
• critical limb ischemia: ABI of <0.5**
**Braunwald Heart Diseases 9th ed, 2011
*ACC/AHA 2005 Guidelines on PAD
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M
E
A
S
U
R
E
M
E
N
T
O
F
A
B
I
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Segmental
Pressures
and ABI
results
Upper thigh
Above Knee
Below Knee
Interpretation: severe
PAD, both LE
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Segmental Pressure
• Class 1B recommendation
• useful to establish lower extremity PAD
diagnosis when anatomic localization of
lower extremity PAD is required to create a
therapeutic plan
ACC/AHA 2005 Guidelines on PAD
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Segmental
Pressures
and ABI
results
Upper thigh
Above Knee
Below Knee
Interpretation: severe
PAD, both LE
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Toe-Brachial Index
• Class 1B recommendation
• used to establish the lower extremity PAD
diagnosis in patients in whom lower
extremity PAD is clinically suspected but in
whom the ABI test is not reliable due to
noncompressible vessels
ACC/AHA 2005 Guidelines on PAD
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Toe
Brachial
Index
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Question # 7
• What is the gold standard diagnostic tool
for the diagnosis of PAD?
A. CTA
B. MRA
C. Contrast Angiography
D. Duplex Scan
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Answer
C. Contrast angiography
– “gold standard” for defining both normal
vascular anatomy and vascular pathology
– most readily available and widely used
imaging technique
– dominant diagnostic tool used to stratify
patients prior to intervention
ACC/AHA 2005 Guidelines on PAD
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Duplex Scan
Class I A recommendation
• useful to diagnose anatomic location and
degree of stenosis of PAD
• routine surveillance after femoral-popliteal
or femoral-tibial- pedal bypass with a
venous conduit
ACC/AHA 2005 Guidelines on PAD
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Peripheral Arterial Duplex Scan
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TASC II Guidelines PAD
• If a patient qualifies for invasive
therapy, angiography will, ultimately,
be required in almost all elective
cases, preoperatively for surgical
reconstruction and before or during
catheter-based interventions
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FEMORAL ANGIOGRAM
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Question # 8
• According to TASC II guidelines, the
aorto-iliac lesion of this patient is classified
as:
A. Type A
B. Type B
C. Type C
D. Type D
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TASC Classification of Aorto-iliac Lesions
• Type A
• Type B
• Type C
• Type D
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Question
A. Type A
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MANAGEMENT OF CLI
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Goals of Treatment
• Relieve ischemic pain
• Heal (neuro) ischemic ulcers
• Prevent limb loss
• Improve patient function and quality of life
• Prolong survival
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Management of CLI
• Cardiovascular risk modification
• Early referral for Revascularization
• Supervised Exercise Rehabilitation
• Pharmacotherapy
• Foot Care
• Multidisciplinary Care
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Risk Modification
Grade A Recommendation
CLI patients should have
aggressive modification
of their cardiovascular
risk factors
TASC II Guidelines PAD,
2008
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Question # 9
What is the optimal treatment for CLI?
A. Revascularization
B. Medical treatment
C. Both
D. None of the above
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Answer
Grade B Recommendation
Revascularization is the optimal
treatment for patients with CLI
TASC II Guidelines PAD,
2008
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REVASCULARIZATION
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Recommendation
Patients with CLI should be referred to a
vascular specialist early in the course of
their disease to plan for revascularization
options
Grade C
TASC II Guidelines PAD,
2008
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Options in Limb Revascularization
Endovascular techniques:
1. Balloon angioplasty
2. Stents
3. Stent grafts
Surgical options:
1. Autogenous or synthetic bypass
2. Endarterectomy
3. Intraoperative hybrid procedures
TASC II Guidelines PAD, 2008
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Revascularization
The success of a revascularization procedure primarily
depends upon:
• Extent of the disease in the subjacent arterial tree
• Degree of systemic disease
• Type of procedure performed
TASC II Guidelines PAD, 2008
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Question: True or False
• Open surgery is preferred over
endovascular revascularization even they
have equivalent short- and long-term
symptomatic improvement.
A. True
B. False
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Recommendation
In a situation where endovascular
revascularization and open surgery are
associated with equivalent short- and long-
term symptomatic improvement,
endovascular techniques should be used
first
Grade B
TASC II Guidelines PAD, 2008
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Question # 10
• Based on the TASC II guidelines, the
recommended treatment in type C aorto-
iliac lesion is:
A. Surgery, in high risk patients
B. Endovascular
C. Surgery, in good risk patients
D. None of the above
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TASC Recommendation for treatment of
Aortoiliac Lesions
TASC A lesion: Endovascular therapy
TASC D lesion: Surgery
Grade C
TASC II Guidelines PAD, 2008
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TASC Recommendation for treatment of
Aortoiliac Lesions
TASC B lesions: Endovascular Treatment
TASC C lesions: Surgery for good-risk patients
The patient’s co-morbidities, fully informed patient
preference and the local operator’s long-term success
rates must be considered
Grade C
TASC II Guidelines PAD, 2008
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Answer
C. Surgery, in good risk patients
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Procedure done
Angioplasty and stenting by kissing
technique of bilateral common iliac artery
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Limb Salvage
• Preservation of some or all of the foot
• Should take place after a revascularization
• Waiting period: at least 3 days
• Two categories:
1. Amputation of some part of the foot
2. Debridement of the wounds, including
excision of bone
TASC II Guidelines PAD, 2008
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Management of Ulcer
• Restoration of perfusion
• Local ulcer care and
pressure relief
• Treatment of infection
TASC II Guidelines PAD, 2008
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Course in the ward
• Daily wound care
• Antibiotics
• Debridement and disarticulation of the 5th
digit of the left foot
Post-op:
moist, non foul-smelling
wound debridement site
with beginning granulations
• Relief of leg pain
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Clinical Surveillance post
Revascularization
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Recommendation
• Patients undergoing aortoiliac and
infrainguinal transluminal angioplasty for
lower extremity revascularization should
be entered into a surveillance program.
• Surveillance programs should be
performed in the immediate post-PTA
period and at intervals for at least 2 years.
ACC/AHA Guidelines on PAD, 2005
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Recommendation on Antiplatelet drugs as
adjuvant pharmacotheraphy after
revascularization
Antiplatelet therapy should be started
preoperatively and continued as adjuvant
pharmacotherapy after an endovascular or
surgical procedure
Unless subsequently contraindicated, this
should be continued indefinitely
TASC II Guidelines PAD, 2008
Grade A
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Exercise Rehabilitation
Supervised exercise should be made available as part of the initial treatment for all patients with peripheral arterial disease
The most effective programs employ treadmill of track walking that is of sufficient intensity to bring on claudication, followed by rest, over the course
of a 30-60 minute session
Exercise sessions are typically conducted three times a week for 3 months
TASC II Guidelines PAD, 2008
Grade A
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Potential Favorable Effects of Exercise Training
↑ Nitric oxide synthase
↑ Prostacyclin
↓ Free Radical
↑ Vascular Endothelial Growth Factor
↑ Muscle oxidative activity
↑ Muscle enzyme activity
↑ Muscle acylcarnitine homeostasis
↓ Blood viscosity ↑ RBC filterability
↓ RBC aggregation
Exercise Training
Improved endothelial function
Reduced Inflammation
Possible vascular angiogenesis
Improved muscle metabolism
Improved hemorrheology
N Eng J Med. 2002;347(24):1941-1951
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Pharmacotherapy• Vasodilator Drugs
– Cilostazol 100mg BID X 3-6 mos (Class I LOE: A)
• Hemorrheologic Agents
– Pentoxifyiline (Class III LOE: B)
• Parenteral Prostaglandins
– Beraprost & Iloprost (Class IIb LOE A)
• Antiplatelet
– Aspirin and Clopidogrel (Class I LOE A)
• Statins (Class I LOE B)
• Angiogenic Growth Factors (Class IIb LOE C)
ACC/AHA Guidelines on PAD, 2005
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Antiplateletactivity
Antithromboticactivity
Producesvasodilation
Mildly increasesheart rate
Increasesblood flow
IncreasesHDL-C
Decreasestriglycerides
In vitro inhibition of vascular smooth
muscle cellsCilostazol
Pharmacologic effects of CilostazolIncreased intracellular cAMP
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Recommendation
3- to 6-month course of Cilostazol (100
mg orally 2 times per day) should be first-line
pharmacotherapy for patients with lower
extremity PAD and intermittent claudication
Class I
Level of evidence A
ACC/AHA Guidelines on PAD, 2005
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Foot Care
• Feet should be kept clean
• Moisturizing lotion
• Well-fitted shoes
• Regular feet inspection
• Avoid Elastic support stockings
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Discharge Medications
• ASA 80 mg/tab 1 tab OD
• Cilostazol 100mg/tab 1 tab BID
• Atorvastatin 20mg/tab ½ tab OD
• Telmisartan 40mg/tab 1 ta OD
• Diltiazem 90mg/tab 1tab BID
• Sitagliptin/Metformin 50/500mg 1tab BID
• Glimeperide 2mg/tab ½ tab OD
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Follow-up
1 day post-op 1 month post-op
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Follow-up
2 months post-op 3 months post-op
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Follow-up
4 months post-op
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Summary
• CLI is a clinical diagnosis but should be
supported by objective tests
• Early identification of patients at risk for
CLI and early management should be
given
• Patient education and close follow-up after
revascularization are necessary
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THANK YOU