Peripheral Vascular

Disease
Aditya Adella Pratama
G1A220012

dr. Amran Sinaga, Sp. B

INTRODUCTION
• Global populations are undergoing a major epidemiological transition
in which the burden of atherosclerotic cardiovascular diseases is
shifting rapidly from high-income to low-income and middle-income
countries (LMICs)
• Research to date suggests that PVD might affect a greater proportion of
women than men in LMICs
• The clinical history and physical examination findings may suggest a
diagnosis of PAD, especially in patients with multiple risk factors or
classic claudication.
• People with PVD have cardiovascular risk as same as miocard infarc.
Definition

Peripheral vascular disease (PAD) is a chronic

progressive atherosclerotic disease leading to
partial or total peripheral vascular occlusion

PAD typically affects the abdominal aorta, iliac arteries, lower

limbs, and occasionally the upper extremities.
Risk Factor
• Tobacco use
• Diabetes mellitus
• Hypertension
• HIV
• High cholesterol
• Age more than 50 years
• Elevated homocysteine levels
• BMI greater than 30
• Family history of cardiovascular disease
Diagnosis
History
90% asimptomatic / atypical
• Intermitten Claudicatio :
• Exercise-induced cramping sensation with associated
fatigue, weakness, and or pressure
• Symptoms are exacerbated by leg elevation and relieved
by placing the limb in a dependent position
• Parastesia
• Critical Limb Ischemic :
• Pain at rest (>2 weeks)
• Nonhealing wounds or ulcers
• Gangrene in one or both legs
Diagnosis
Pemeriksaan Fisik :
• Shiny skin
• Absence of hair
• Distal pallor
• General inspection with attention to fingernail
tar indicative of cigarette smoking, scars from
previous vascular surgeries, and the presence
of amputations.
• Pulse exainationm
Evaluation
Ankle-Brachial Index (ABI)
• ABI measurment is a cost-effective noninvasive objective measure for
PAD diagnosis.
• The ABI is obtained by measuring the systolic ankle pressure ratio to
the systolic brachial pressure.

Interpretation

• <0,9 : abnormal, PAD

• 0.91 – 0.99 : Borderline
• 1.00 – 1.4 : Normal
• >1,4 : uncompressible
Evaluation
Ankle-Brachial Index (ABI)
Place a blood pressure cuff above the level of the ankle
• Place a Doppler ultrasonography probe on the dorsalis pedis or posterior tibialis
and then inflating the cuff until the signal from the probe ceases.
• The cuff is then slowly deflated, and the return of the Doppler probe signal marks
the systolic ankle pressure.
• The process is then repeated for the opposite leg. 
• The ankle pressure of each leg is then divided by the highest systolic pressure of
either brachial artery
Evaluation
Toe-Brachial Index (TBI)
• The TBI should be used to establish the lower extremity PAD diagnosis in patients
in whom the condition is suspected, and when the ABI test is not reliable due to
noncompressible vessels
• The ACCF/AHA 2005 guidelines defined a TBI <0.7 as diagnostic for PAD
• Based on study, 14%-27% PVD that had TBI measurement have normal ABI.
Evaluation
Laboratory examination
Complete blood count with platelet count
Fasting blood glucose or HbA1C
Fasting lipid profile
serum creatinine
• Urinalysis for glucosuria and proteinuria.
Evaluation
Ultrasonografi Duplex
• Arterial duplex ultrasonography allows direct visualization of the arteries of the
lower extremities.

Accepted clinical applications for the use Vessels are classified into 1 of
of duplex: 4 groups :

• The evaluation of symptomatic patients • Normal (Stenosis 1-19%)

with abnormal ABIs (<0.9) • Stenosis 20-49%
• The occlusion of occult inflow aorto-iliac • Stenosis 50-99%
disease in patients that require a lower • Full oclusion.
limb femoral-distal bypass graft
• Evaluation of hemodynamics in distal
arterial segments in patients who have an
ambiguous history and/or physical exam
Evaluation
Computed Tomography Angiography (CTA)
• CTA Provide excellent high-quality vascular imaging
Keuntungan :
• Non-invasive
• Shorter acquisition times and
thinner slices
• Higher spatial resolution
• Enable scanning of the whole
vascular tree in a limited period of
time with a smaller
• Less patient contraindications
Kekurangan
• Exposure to radiation, which can
accumulate with repeated studies and be
potentially carcinogenic,
• Necessity of giving iodinated contrast,
which can be problematic for those
patients with kidney disease.
• Some patients also have allergies to iodine
Evaluation
Magnetic resonance angiography (MRA)
Keunggulan :
• Intravenous contrast is not
standardly needed
• It does not utilize ionizing
radiation.
• Detect blood by its movement
compared with static
surrounding tissue.
• Non-invasive
Kekurangan :
• If a patient has a pacemaker
that is not compatible with
magnetic resonance imaging
(MRI), claustrophobic, or have
other metallic implants, MRI
might be contraindicated.
• Risk of nephrogenic systemic
fibrosis with the administration
of gadolinium
Evaluation
Conventional Angiography
• Conventional angiography is the gold standard for diagnosis in PAD
• This modality involves the intravascular injection of a contrast agent during
planar radiographic imaging.
• Allows only the opacified arterial system to be seen on the final image.
• DSA is able to provide superior contrast resolution with lower doses of
intravenous contrast, while also having the ability to magnify images and image
vessels in real-time
Diagnosis
Diagnosis
Management
Differential Diagnosis
Neurological
Nerve root compression
Spinal stenosis
Vascular
Peripheral neuropathy
• Nerve entrapment Chronic venous insufficiency
Thrombophlebitis
Musculoskeletal Deep venous thrombosis
Medial tibial stress syndrome Raynaud phenomenon
Osteoarthritis • Thromboangiitis obliterans
Muscle strain
• Baker cyst
Prognosis
• The overall prognosis of PVD must take into account patient
risk factors, cardiovascular health, and disease severity.
• In terms of limb health at 5 years, 80% of patients will have
stable claudication symptoms.
• Only 1-2% of patients will progress to critical limb ischemia
in 5 years.
• 20% to 30% of patients with PAD will die within 5 years,
with 75% of those deaths attributed to cardiovascular causes
Complication
Acute coronary syndrome
Stroke
Nonhealing ulcer
Gangrene
Amputation
Deep vein thrombosis
• Erectile dysfunction
CONCLUTION
• PVD specifically lower limb peripheral arterial disease,
can be defined as atheromatous narrowing or
occlusion of an artery or arteries in the lower limb
• PVD manifestation was intermitten claudikation adn
crotical lim ischemia
• For diagnosis consisted of hystory of risk factors,
physical examination and ABI measurement
• Newer imaging modalities for diagnosis have since
emerged, which consist of magnetic resonance
angiography and, more recently, computed
tomography angiography
THANK YOU FOR YOUR ATTENTION