CVS-K47

Penyakit pembuluh darah arteri, vena dan limfe

Dr, Zainal Safri, SpPD, SpJP / Dr. Amran Lubis

SpJP (K)

Departemen Kardiologi dan Kedokteran Vaskuler

Fakultas Kedokteran Universitas Sumatera Utara
Medan

CVS-K47:
Penyakit pemb. Darah Arteri, Vena dan Limfe
Penyakit pemb. Darah Arteri
Penyakit arteri perifer
Athero emboli
Burger disease
Aneurisma Aorta
Vaskulitis takayasu
Reynauds Disesase
Subclavian steal syndroma

Peripheral Arterial Disease

EPIDEMIOLOGY
In US, Europe and The Middle East; PAD based
on ABI abnormal : 4.6% - 19.1%
In a free living population, participation in a
lipid research clinic protocol : PAD < 3% of
those younger than 60 but >20% of those 75
years and older; 27% more prevalent in men
than women

CONTRIBUTION OF RISK
FACTORS
Risk of Peripheral Arterial Disease in
Persons with Modifiable Risk Factors
RISK FACTOR
RELATIVE RISK
Cigarette smoking 2, 4, 10, 19, 20
Diabetes Mellitus 4, 14, 16, 19, 21
Hypertension 14, 16, 19
Hypercholesterolemia (per 40
50 mg/dl in total cholesterol) 10,14
Fibrinogen (per 0.7 gm/liter
in fibrinogen) 22-26
C-reactive protein 27
Hyperhomocyseinemia 28-30

ESTIMATED
2.0 5.0
3.0 4.0
1.1 2.2
1.2 1.4
1.35
2.1
2.0 3.2

CLINICAL FEATURES

Physical Findings
A /absent pulse location of arterial
stenosis. Bruits accelerated blood flow
velocity and turbulence at sites of stenosis.
Muscle atrophy in the legs of pts w/
chronic
aortoiliac
disease
Severe limb
ischemia: the skin is cool, ptechiae,
persistent cyanosis or pallor, dependen rubor,
pedal edema, skin fissures, ulceration or
gangrene.
Chronic low grade ischemia hair loss
thickened and brittle toenails, smooth and shiny
skin and subcutaneus fat atrophy of the digital
pads.

CLINICAL FEATURES
Categorization of PAD
Fontaine Classification of Peripheral Arterial Disease

STAG
E
I
IIa
IIb
III
IV

SYMPTOMS
Asymptomatic
Pain free, claudication walking >200
meters
Pain free, claudication walking <200
meters
Rest and nocturnal pain
Nocturnal pain

Natural History of Atherosclerotic

Lower Extremity PAD
For each of these PAD clinical
syndromes
Asymptomatic PAD
20%-50%

Claudication
10%-35%

Atypical leg pain

40%-50%

5-year outcomes
Limb morbidity

Stable
claudication
70%-80%

Worsening
claudication
10%-20%

CV morbidity & mortality

Critical limb ischemia

1%-2%
Amputation
(see CLI data)

Nonfatal CV event
(MI or stroke) 20%

Mortality
15%-30%

CV causes
75%

Non-CV
causes
25%

with permission from Hirsch AT, et al. Circulation. 2006;113:e463CLI=critical limb ischemia; CV=cardiovascular; MI=myocardialReprinted
infarction
654.

DIAGNOSTIC TEST
Segmental Pressure Measurement
A BP gradient >20 mmHg between successive cuffs
Arterial stenosis in the lower extremity, a 10 mmHg
gradient between sequential cuffs in the upper
extremity stenosis

Ankle / Brachial Index

ABI < 0.9 : abnormal sensitivity 95% peripheral
arterial stenosis (angiography)
Px w/ leg claudication ABI : 0.5 0.8, critical
limb ischemia ABI < 0.5

Ankle - Brachial Index

DIAGNOSTIC TEST

Pulse Volume Recording

Doppler Ultrasound
Duplex Ultrasound Imaging
Treadmill Exercise Testing
Magnetic Resonance
Angiography
Contrast Angiography

MANAGEMENT
Risk factor modification
Exercise therapy
Antiplatelet therapy
Medical therapy targeted at

symptoms
FDA approved drugs for IC
Pentoxifylline - 1984
Cilostazol 1999

Revascularisation

procedures

TREATMENT

Exercise
Session were at least 30 min in duration at
least 3x/week for 6 mo, the mode of exerxise.
Walking mechanism: regular exerxise the
development of collateral blood vessels.
Expression of angiogenic factors is by
exercise particularly in hypoxic tissue.
Improve endothelium-dependent vasodilation
of coronary arteries in pts w/ coronary
atherosclerosis & in the peripheral circulation
in pts w/ CHF

TREATMENT

Pharmacotherapy
Cilostazol
The
quinolone
derivative
inhibits
phosphodiesterase III cyclic AMP
degradation & its concentration in
platelet & blood vessels.
In experimental animals: cilostazol
inhibits platelet aggregation & causes
vasodilation in PAD

TREATMENT
Percutaneous Transluminal Angioplasty and
Stents
PTA and stent placement used in management
of pts w/ PAD esp. w/ disability claudication and
critical limb ischemia.
Peripheral Arterial Surgery
To improve quality of life in pts w/ disabling
claudication who are receiving maximal medical
th/ and to relieve rest pain and preserve limb
viability in pts w/ critical limb ischemia.

Buergers Disease: What

It Is
Buerger's disease (thromboangiitis obliterans)
is a rare disease characterized by a
combination of acute inflammation and
thrombosis of the arteries and veins in the
hands and feet. The obstruction of blood
vessels in the hands and feet reduces the
availability of blood to the tissues, causes
pain and eventually damages or destroys the
tissue. It often leads skin ulcerations and
gangrene of fingers and toes. Rarely, in
advanced stages of the disease, it may affect
vessels in other parts of the body.

Buergers Disease:
Appearance

Ulcers and Gangrene caused by Buergers

Disease

Buergers Disease: Who It

Affects
Buerger's disease affects approximately six
out of every 10,000 people. It almost always
affects men, ages 20 to 40, who smoke or
chew tobacco. Recently, however, more
women and men over the age of 50 have
been diagnosed with Buerger's disease. This
disorder is still very uncommon in children,
but it may occur in those with autoimmune
diseases. Buerger's disease is most common
in the Orient, Southeast Asia, India and the
Middle East, but is rare among AfricanAmericans.

Buergers Disease:
Symptoms
Enlarged,
red, Pain or tenderness

Numbness and tingling in the limbs

Skin ulcers or gangrene of the digits

Discoloration
Two or more limbs affected
Pain may increase with activity such as walking and

decrease with rest

Pulse may be decreased or absent in the affected
extremity
Symptoms may worsen with exposure to cold or with
emotional stress

Buergers Disease: The

Cause

Buerger's disease is greatly associated with

heavy to moderate tobacco use, both
cigarette and smokeless. The disease is an
autoimmune reaction triggered by tobacco.
To avoid the onset of Buerger's disease,
tobacco use should be avoided, particularly
by men

Buergers Disease:
Diagnosing
Buerger's disease is often masked by a wide variety of

other diseases that cause diminished blood flow to the

hands and feet, therefore, other disorders must be ruled
out with aggressive evaluation.
Blockage of blood vessels in the hands and feet caused
by Buerger's disease may be detected by one of the
following methods:

An angiogram or an arteriogram of the upper and lower

extremities
A Doppler ultrasound

Skin biopsies are rarely used because of concern that the

biopsy site near an area with poor blood circulation will
not heal.

Buergers Disease:
Angiogram
Angiogram of the Hand

Normal

In Buergers Disease

Buergers Disease:
Treatment

The only method known to be an effective

treatment for Buerger's disease is

immediately quitting smoking. Patients who
continue to smoke after a diagnosis of
Buerger's disease will generally require
amputation of the fingers and toes.
Since there is no cure for Buerger's disease,

the goal of treatment is to control symptoms.

Buergers Disease: Symptom

Control
Gentle massage and warmth to increase

circulation
Avoid conditions that reduce circulation to
the extremities
Avoid sitting or standing in one position for
long periods
Do not walk barefoot to avoid injury
Do not wear tight or restrictive clothing
Report all injuries to physician for
appropriate treatment

Buergers Disease:
Prognosis
The symptoms of Buerger's disease
may disappear if tobacco use is
stopped. If the affected extremity is
to be saved, the patient must stop
smoking. If infection or gangrene
occurs, amputation of the affect
extremity may be necessary.

Some People Just CANT Quit!

(Even if it costs an arm & a
leg!)

A. THROMBOANGIITIS OBLITERANS
(Buergers Disease)
A segmental vasculitis
that affects the distal arteries, veins,
& nerves of the upper& lower
extremities

Sign & symptoms:

Pts can have claudication of the hands,
forearms, feet or calves
Also most presents with rest pain and
digital ulcerations

Diagnosis

No specific laboratory tests

Biopsy can diagnose TAO
If clinically indicated, a proximal source of

embolism should be excluded by computed

tomography (CT), magnetic resonance or
conventional arteriography
The patognomonic test is a biopsy showing
the classic pathological findings. (rarely
indicated)

Treatment
(The cornerstone) Stop smoking
Prostacyclin analogue iloprost (> effective

than aspirin)
Cyclophosphamide
An autogenous saphenous vein bypass graft
(can be considered) if a target vessel for
the distal anastomosis is available.

MRA of Lower
Extremities:
Iliac, femoral and
popliteal circulations
are widely patent.
Several short
segment moderate
stenoses in
posterior and
anterior tibial
arteries.
Warfel, JH. The Extremities, 5th edition
1985

Buergers Disease
(Thromboangiitis
Obliterans)

First described in 1879

In 1908, Leo Buerger described
pathologic findings in 11 amputated
limbs
Worldwide distribution
Prevalence: Middles East/Far East >
North America/Western Europe
12.6 per 100,000 in Olmstead County

Pathophysiology
Nonatherosclerotic segmental

inflammatory disease of small and

medium-sized arteries (skip lesions)
Distinguished from other vasculitis
Sparing of blood vessel wall
ESR, CRP normal
Autoantibodies negative

Diagnostic Criteria
Typically age less than 45 years and

male
Current or recent history of tobacco
use
Distal extremity ischemia in the
absence of proximal disease
Exclusion of autoimmune and
hypercoaguable diseases

Clinical Features
Usually presents as claudication, rest pain
Features

Atherosclerosis Buergers Ds

Age

> 40yo

20-45yo

Other risk factors

+++

no

Upper extremity
involvement

rare

Up to 90%

Proximal vessel
involvement

+++

rare

Pulse exam

decreased

preserved

Superficial
Thrombophlebitis

no

Up to 40%

Skin Exam

UptoDate.com
Accessed 9/6/05

Allen Test (+ in 65%)

Patient makes a fist
Examiners thumbs occlude
radial and ulnar arteries
Patient opens hand into
relaxed, partially flexed
position
Pressure on ulnar artery is
released while radial artery is
compressed
Normally, hand should turn
pink because of intact
interconnecting arteries

NEJM,2000;343(12):867.

Can be repeated releasing

pressure of radial artery

Treatment
Absolute abstinence of smoking
40% who continue to smoke will

require amputation, compared to 5%

who quit
Not amenable to surgery
Negative studies regarding
thrombolytic therapy

Objectives
Recognize Buergers disease
Describe diagnostic criteria and

clinical features of the disease

Describe the Allen Test
Know that complete smoking
cessation is the only treatment