Curriculum Vitae

Name : Prof. Dr. H. Djanggan Sargowo, dr., SpPD., SpJP(K),

FIHA, FACC, FESC, FCAPC, FASCC
Birth date/place : Sragen, 21 September 1947
Address : Wilis Indah E-10 Malang, Telp. 0341-552395
Education :
1. Doctor, graduated from Gadjah Mada University, Jogjakarta 1974
2. Cardiologist, graduated from University of Indonesia, 1983
3. Internist, graduated from Airlangga Univ, 1986
4. Doctoral, graduated from Airlangga Univ, 1996
5. Advanced Cardiology Course, Hong Kong Univ, 1984
6. Senior Visiting Program, State Heart Institute, Kuala Lumpur, 1996
7. Fellow of the American College of Cardiology (FACC), September 2006.
8. Fellow College Asia Pacific Society of Cardiology (FCAPC), December 2007
9. Fellow European Society of Cardiology (FESC), 2008
10. Fellow ASEAN College of Cardiology (FASCC) 2008
Possition :
11. Lecturers Brawijaya University ,Graduate Program , Post Graduate Program
12. Chairman of the Supervisory Board of Education Hospital
13. Director of the Academic Hospital of Brawijaya University

1
Overview of Peripheral Artery Disease

Prof. DR. dr. Djanggan Sargowo, SpPD, SpJP(K),

FIHA, FACC, FESC, FCAPC, FAsCC

Thursday, April 6th, 2017 2

 PERIPHERAL
ARTERY DISEASE
 Epidemiology
• Atherosclerosis of the abdominal aorta,
iliac, and lower-extremity arteries
• 12% of adult populations, equal in men
and women
– About 20% of adults >70 years have PAD
– Higher in smokers and diabetes

Olin JW, Sealove BA. Mayo Clin Proc 2010; 85:678-692

 Prevalence

Total ~ 10 million U.S. patients

Asymptomatic
5 million

Symptomatic
Symptomatic
untreated
treated
3.75 million
1.25 million

Pentecost, et al. “Guidelines for Peripheral Percutaneous Transluminal Angioplasty of the Abdominal Aorta and Lower Extremity 5
Vessels”; 1993
 Prevalence of PAD Increases With Age

Rotterdam Study (ABI <0.9)1 San Diego Study (PAD by noninvasive tests)2
60

50
Patients With PAD

40

30

20

10
(%)

0
55-59 60-64 65-69 70-74 75-79 80-84 85-89
Age (years)

ABI = ankle-brachial index

1. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192.

2. Criqui MH, et al. Circulation. 1985;71:510-515.
 Long-Term Survival in Patients
With PAD

100

Normal subjects
75
Survival

Asymptomatic PAD
50
Symptomatic PAD
(%)

Severe symptomatic PAD

25

0 2 4 6 8 10 12
Yea
r
Criqui MH et al. N Engl J Med. 1992;326:381-386. Copyright © 1992 Massachusetts Medical Society. All rights reserved.
 Mortality

• Life expectancy reduced 10 years in

patients with PVD
• Mortality rate
~ 25% at 5 years
~ 50% at 10 years
~ 75% at 15 years
• 75% of deaths caused by
cardiovascular events

NEJM, 1991; 325:577-8

8
Peripheral Arterial Disease and
Claudication

• Peripheral Arterial Disease (PAD)

A disorder caused by atherosclerosis that limits blood
flow to the limbs
• Claudication
A symptom of PAD characterized by pain, aching, or
fatigue in working skeletal muscles. Claudication
arises when there is insufficient blood flow to meet
the metabolic demands in leg muscles of ambulating
patients
ATHEROSCLEROTIC PLAQUE
Population At
Population Riskof
at risk ofPAD
PAD

Age

Diabetes

Smoking
 Clinical presentation

Classic claudication Atypical leg pain Asymptomatic

Pain, discomfort, Lower-extremity

aching, heaviness, discomfort that is
tiredness, tightness,
exertional but does
Without obvious
cramping, or burning symptoms
in the calf, thigh, hip not consistently
and buttocks occur at the same Usually
(1) Reproducible with distance walked associated with
similar level of walking May require a
(2) Disappear after
functional
longer time to
standing impairment on
(3) Occurs at the resolve, or to sit
down or change in formal testing
same distance once
walking has resumes body position

Olin JW, Sealove BA. Mayo Clin Proc 2010; 85:678-692

 CLINICAL CLASSIFICATION OF PAD
FONTAINE CLASSIFICATION RUTHERFORD CLASSIFICATION
Stage Symptoms Grade Category Symptoms
I Asymptomatic 0 0 Asymptomatic
II II A Claudication at a I 1 Mild claudication
distance > 200 metres
I 2 Moderate claudication
II B Claudication at a I 3 Severe claudication
distance < 200 metres

III Ischaemic rest pain II 4 Ischaemic rest pain

IV Ulceration and/or III 5 Minor tissue loss not exceeding
gangrene of the limb ulcer of of the digits of the foot

III 6 Major tissue loss; severe

ischemic ulcers or frank gangrene

White CJ et al., Circulation, 2007. 13

 General diagnostic approach
• Family hx of CVD •Blood pressure of both arms
• Symptoms suggesting angina •Inspections: colour,
• Walking impairment
• temperature, ulcerations, skin
Any pain at rest
• integrity
Poorly healing wounds
• •Palpations: pulses at
HT or renal failure
• Post-prandial abdominal pain extremities, abdominal
associated with weight loss •Ausculation: abdominal regions

Physical
History
exam

Others Laboratory

• Ultrasound (ABI, DUS) • To detect major risk

• Angiography
• CTA, MRA factors of CVD

ESC Guidelines. Eur Heart J 2011; 32:2851-2906

CRITICAL LIMB ISCHEMIA
Diagnosis Critical Limb Ischemia
• History
• Physical Examination
 Bed-side non-
invasive tests
• Investigations
 Assess lesion
 Laboratory
 Imaging
 Plans for
intervention
 ACUTE LIMB ISCHEMIA
 Defined as a sudden decrease in limb
perfusion that threatens the viability of the
limb

 Less than 14 days’ duration

 Symptoms develop over a period of hours

to days

 Variable ischaemic clinical manifestations

 Potential risk of limb loss

Shishehbor Mehdi H, 2014 17

 FACTS
• Incidence is estimated to be 1.5 cases per 10,000
persons a year
• Despite urgent revascularization, amputation
occurs in 10 to 15% of patients during
hospitalization
• Approximately 15 to 20% of patients die within 1
year after presentation
• Revascularization within 12 hrs: Mortality
19%,
Amputation 7%
• Delay > 12 hrs : Mortality 31%, Amputation
Norgren L, et.al. TASC II. 2007
 ETIOLOGIES OF ACUTE LIMB ISCHEMIA

 Thrombosis ( 50% of cases )

Atherosclerosis (native or bypass)
Aneurysm
Trauma
Vasculitis
Hypercoagulable states
 Embolism ( 30% of cases )
 Uncommon causes : Arterial
dissection

Naidoo et al, 2013 19

 ETIOLOGIES OF ACUTE LIMB ISCHEMIA

Acute
Acute arterial Acute arterial traumatic
embolism thrombosis
ischaemia

Of a relatively Of a previously
health arterial diseased arterial
tree tree
 PATHOPHYSIOLOGY

Acute Embolic Ischaemia

An embolus It usually arrest at
suddenly occludes a arterial bifurcation
relatively healthy (aortic, iliac, femoral
arterial tree popliteal)

An embolus can originate from:

• The heart (MS with atrial fibrillation,
MI with mural thrombus)
• Dilated diseased arteries (aortic
aneurism)
 POSSIBLE SOURCE OF AN EMBOLUS

Spontaneous (80%)
Cardiac source
Arrhythmias, MI, prosthetic valve, endocarditis
Non-Cardiac source
Proximal aneurysm, paradoxical emboli

Iatrogenic (20%)
Angiographic manipulation
Surgical manipulation
22
 Example of
acute arterial
embolus

“Saddle”
Embolus of
right iliac
artery
COMMON SITES FOR EMBOLUS LODGEMENT IN THE
ARTERIAL TREE

24
 CLINICAL DIFFERENTIATION BETWEEN
EMBOLISM AND THROMBOSIS
Differences Embolism Thrombosis
Cardiac source Obvious Not obvious
History of No Yes
Claudicatio
Contralateral Normal Abnormal
pulse
Angiogram Minimal Diffuse
atherosclerotic Atherosclerotic
Collateral Few Well developed
 CLINICAL FEATURES

• Pain (symptom)
Signs of
acute • Pale
ischaemia
• Pulseless
• Parasthesia

6Ps • Paralysis
• Poikilothermia
 CLINICAL FEATURES

Pale Inspection (Color)

• Early: Pale
Fixed • Later: Cyanosed -> mottling
mottling & ->
cyanosis Fixed mottling & cyanosis

An area of
fixed cyanosis
surrounded by
reversible
mottling
Pallor
Empty veins:
Reversible compare the Rt.
(ischemic) & Lt.
Motting
(normal)
 CLINICAL FEATURES

Pulseless Palpation
• Palpate peripheral pulses:
Compare with the other side &
write it down on a sketch

• Temperature:
•The limb is cold with a level of
temperature change (compare
the two limbs)

• Slow capillary refilling of the

skin after finger pressure
 CLINICAL FEATURES

Parasthesia Palpation

Progress of Sensory Loss

• Loss of sensory Light touch

function Vibration sense
• Numbness will Proprioreception
progress to anesthesia
Deep pain
Pressure sense Late
 CLINICAL FEATURES

Paralysis Palpation
• Loss of motor function: Indicates advanced limb
threatening ischemia
• Late irreversible ischemia: Muscle turgidity
• Intrinsic foot muscles are affected first, followed
by
the leg muscles
• Detecting early muscle weakness is difficult because
toes movements are produced mainly by leg
muscles
 INVESTIGATIONS

Acute Limb Ischemia is a

CLINICAL DIAGNOSIS
If time allows, especially if atherosclerotic
thrombosis is suggested, preoperative
angiography is often wise

31
 Digital Subtraction
CT Angiography Angiography

Value of angiography
Localizes the obstruction
Visualize the arterial tree &
distal run-off
Can diagnose an embolus :
Sharp cutoff, reversed meniscus or
clot silhouette
 Buergers’s Disease

• Buerger’s disease / thromboangiitis obliterans (TOA) is

nonatherosclerotic, segmental inflammatory disease that
most commonly affects the small and medium-sized
arteries and veins in the upper and lower extremities.
• first described in 1879, when Felix von Winiwarter
(Austrian surgeon) reported a single case of what he
described as presenile spontaneous gangrene
• Buerger (1924) named the disorder “thromboangiitis
obliterans”, and only briefly mentioned its relationship
with smoking.

33
 Sign and Symptom

• Effort pain (rest pain in severe case)

• 2 or more extremity involved
• Skin colour abnormality in extremities
• Paresthesia
• Raynaud’s phenomenon
• Ischemic ulceration, gangrene, and no pulsation in idistal
arteries

34
 Sign and Symptom
Gambar
Thrombophlebitis
Ischemic
superficial
ulceration
Sign and Symptom
Gambar

Gangrene
 Etiology
Etologi (2)
• Autoimmune reactione induced by tobacco
• Genetic
• Hepatitis B Infection
• Frost bite
• Trauma
• Simpatomimetic drugs: Cocain, cannabis,
Amphetamine
 Diagnostic Criteria
Diagnos
Kriteria Olin Kriteria Shionoya
1. Age < 45 years 1. Smoking history;
2. Current or recent history of tobacco use
3. Presence of distal extremity ischemia 2. Onset before the age of
indicated by claudication, pain at rest, 50 years;
ischemic ulcers or gangrenes, and
documented by non-invasive vascular 3. Infrapopliteal arterial
testing;
occlusions;
4. Exclusion of autoimmune diseases,
hypercoagulable states and diabetes 4. Either arm involvement or
mellitus;
5. Exclusion of a proximal source of
phlebitis migrans;
embolization by echocardiography and 5. Absence of
arteriography;
6. Consistent arteriographic findings in the
atherosclerotic risk factors
clinically involved and noninvolved other than smoking.
limbs
 Allen Test
Allen Test

How to Perform a Modified Allen's Test.mp4

 Radiologic Findings
Pemeriksaan Radiologi
Echocardiografi (transthoracic, transesofageal)
• To find cardiac embolic
thrombus
 Radiologic Investigation
Pemeriksaan Radiologi (2)
Arteriography
Spesific:
1. small and medium-sized
2. Segmental occlution
3. Normal proximal arteries
(no atherosclerosis)
4. corkscrew collaterals
5. No embolus.
 Radiologic Investigation
Pemeriksaan Radiologi (3)
Computed tomographic (CT), magnetic resonance
(MRI), invasive contrast angiography
• To exclude proximal
embolus
• better contrast
resolution in small
arteries
 Radiologic Investigation
Pemeriksaan Radiologi (4)
Colour duplex ultrasound (CDU)

Spesific:
• Arterial occlusion in pedis
• arterial occlusion in
forearm, wrist and fingers
• Normal proximal arteris
• Serpiginous / corkscrew
collateral in occlusion area
• Intact blood vessel walls
in the area of ​occlusion,
often free of calcification
 Corkscrew collaterals
Tipe corkscrew collaterals
Type 1 Tipe 2
 Corkscrew collaterals
Tipe corkscrew collaterals (2)
Tipe 3 Tipe 4
 Raynaud’s Phenomenon

• The discoloration of fingers and/or toes

46
 Primary Raynauds

• Most common form of Raynauds skin disorder

• No underlying disease or associated medical
problem
• At Risk:
– Usually begins between 15 years old and 40 years old
– More common in women than men

47
 Primary Raynauds

• Etiology:
– Nerve control of the blood vessel diameter is
abnormal
– Nerve sensitivity to cold temperatures

48
 AORTIC
DISSECTION
 epidemiology

• Uncommon, yet life-threatening

emergency that requires immediate
management
• 5-30 cases per million people per year
• Symptoms mimic myocardial ischemia,
physical findings may be absent
• Often missed diagnosis

OH2017
Khan IA, Nair CK. Chest 2002; 122:311-328
Classification of acute dissection

OH2017

Vascular Medicine: A Companion to Braunwald’s Heart

Disease, 2ed
 Clinical presentation
History Physical Laboratory
exam

• CXR
• Biom
• Hypertensi s (D-
• Pain on dime
• Organs • Murmur of hsCR
involveme AR smoo
nt (CV, • JVP musc
neuro, GI, elevation myos
pulmo) • Pleural heav
effusion chain
prote
sELA

Vascular Medicine: A Companion to Braunwald’s Heart

Disease, 2ed
Presentation and complications

ESC Guidelines 2014. Eur Heart J 2014; 35:2873-2926

Details required from imaging in
acute aortic dissection

Proximal aortic dissection,

imaged by TEE

ESC Guidelines 2014. Eur Heart J 2014; 35:2873-2926

Vascular Medicine: A Companion to Braunwald’s Heart
Disease, 2ed
Management of acute aortic dissection

OH2017
Vascular Medicine: A Companion to Braunwald’s Heart
Disease, 2ed
 AORTIC
ANEURYSM
 epidemiology

• Maximal aortic dimension >3 cm, or a 50%

increase in size compared with the normal
segment proximal to the aneurysm
– Normal Ø is 3 cm at the origin, 2.5 cm in the descending thoracic aorta,
1.8-2 cm in the abdominal aorta

• Affect any part of the aorta

– Abdominal aortic aneurysms (AAA)
• Age, gender, cigarette smoking
– Thoracic and thoracoabdominal aortic aneurysms (TAA/TAAA)

• True aneurysms
– Fusiform – circumferential expansion; common
– Saccular – focal outpouching of a segment
Vascular Medicine: A Companion to Braunwald’s Heart
Disease, 2ed
12-month AAA rupture risk by diameter

AAA diameter (mm) Rupture risk (%)

30-39 0
40-49 1
50-59 1-11
60-69 10-22
>70 30-33

ESVS Guidelines. Eur J Vasc Endovasc Surg 2011; 41:S1-S58

 Clinical history
Clinical history
• Typically no symptoms
• Depends on size and location

TAA •
•
•
Ascending aorta: CHF symptoms
Aortic arch: Dyspnea, cough
Descending aorta: Chest pain, hoarseness,
dyspnea

• Asymptomatic

TAAA •
•
Discomfort in epigastrium, LUQ abdomen
Abdominal component may rupture into
retroperitoneum, IVC, or duodenum

• Mostly asymptomatic

AAA •

•
Abdominal discomfort, back pain, awareness of
abdominal pulsations (sometimes)
Infrequent pain on lower extremities

OH2017
Vascular Medicine: A Companion to Braunwald’s Heart
Disease, 2ed
 Physical examination
Physical examination
• Inspection
– Pulsatile mass may be visible at or slightly
above umbilicus
– Ecchymosis
• Palpation
– Lower extremities
– Abdominal pulses
• Auscultation
– Abdominal, femoral bruit
Vascular Medicine: A Companion to Braunwald’s Heart
Disease, 2ed
 Diagnostic testing
Diagnostic testing

Ultrasound CTA

Contrast
MRA
angiography

Vascular Medicine: A Companion to Braunwald’s Heart

Disease, 2ed
Repair of aaa

Kent KC. N Engl J Med 2014;371:2101-2108

Diagnostic Approach of Peripheral Artery
Disease

Prof. DR. dr. Djanggan Sargowo, SpPD, SpJP(K),

FIHA, FACC, FESC, FCAPC, FAsCC

Friday, April 7th, 2017 63

 Epidemiology
• Atherosclerosis of the abdominal aorta,
iliac, and lower-extremity arteries
• 12% of adult populations, equal in men
and women
– About 20% of adults >70 years have PAD
– Higher in smokers and diabetes

Olin JW, Sealove BA. Mayo Clin Proc 2010; 85:678-692

 Prevalence of PAD Increases With Age

Rotterdam Study (ABI <0.9)1 San Diego Study (PAD by noninvasive tests)2
60

50
Patients With PAD

40

30

20

10
(%)

0
55-59 60-64 65-69 70-74 75-79 80-84 85-89
Age (years)

ABI = ankle-brachial index

1. Meijer WT, et al. Arterioscler Thromb Vasc Biol. 1998;18:185-192.

2. Criqui MH, et al. Circulation. 1985;71:510-515.
 Long-Term Survival in Patients
With PAD

100

Normal subjects
75
Survival

Asymptomatic PAD
50
Symptomatic PAD
(%)

Severe symptomatic PAD

25

0 2 4 6 8 10 12
Yea
r
Criqui MH et al. N Engl J Med. 1992;326:381-386. Copyright © 1992 Massachusetts Medical Society. All rights reserved.
ATHEROSCLEROTIC PLAQUE
General diagnostic approach

Physical
History
exam

Others Laboratory

ESC Guidelines. Eur Heart J 2011; 32:2851-2906

 History (1)
co-morbidities (Hypertension, dyslipidaemia,
diabetes mellitus, smoking status, family
history of CVD)
Any walking impairment, e.g. fatigue, aching,
cramping, or pain with localization to the
buttock, thigh, calf, or foot, particularly when
symptoms are quickly relieved at rest.
Any pain at rest localized to the lower leg or
foot and its association with the upright or
recumbent positions.

69
 History (2)

Any poorly healing wounds

Upper extremity exertional pain, particularly
if associated with dizziness or vertigo.
Any transient or permanent neurological
symptom.
Post-prandial abdominal pain and
diarhoea, particularly if related to eating
and associated with weight loss.
Erectile dysfunction.
70
71
 1. History
History(cont’)
(3)

Is it vascular limb pain?

Historical Vascular Neurogenic

Clue Etiology Etiology

Onset Predictable Variable

Only with
walking? Yes No

Relief with
stopping or Yes Variable
standing?

Absent pedal Variable Variable

pulses at rest

72
 Physical examination (1)
vv

Inspection

Palpation

Auscultation

vvvv

73
Jones SA. 2005. ECG notes inerpretation and management guide. Philadelphia. www.fadavis.com
 Physical
physical examination (1)
(2)

Observation of the legs Assessment of the temperature

of each leg

http://www.osceskills.com/e-learning/subjects/peripheral-vascular-examination/
 Physical
Physical examination
examination (2)
(3)
Physical examination (2)

Check capillary return by If abnormal – perform Buerger’s

compressing the nail bed and then test
releasing it Raising the patient’s feet to 45
Normal colour should return within degrees; if poor arterial supply,
2 seconds pallor rapidly develops

http://www.osceskills.com/e-learning/subjects/peripheral-vascular-examination/
 Physical examination (4)

Feel for the popliteal pulse Feel for the posterior tibial Feel for the dorsalis pedis
pulse pulse

OH2017

http://www.osceskills.com/e-learning/subjects/peripheral-vascular-examination/
 Ankle–brachial index
• sensitivity and specificity at 79% and 96%.

77
Ankle – Brachial
ABSI Index (ABI)
 Recommendations for ankle-brachial index
(ABI) to screening population at risk of PAD

1. Age less than 50 years with diabetes, and one additional

risk factor (e.g. smoking, dyslipidemia, hypertension, or
hyperhomocysteinemia)

2. Age 50 to 69 years and history of smoking or diabetes

3. Age 70 years and older

4. Leg symptoms with exertion (suggestive of claudication)

or ischemic rest pain

5. Abnormal lower extremity pulse examination

6. Known atherosclerotic coronary, carotid, or renal artery

disease

A Collaborative Product Co-Developed by : ACC, AHA, TASC II, 2007

HAND-HELD DOPPLER

• Limb perfusion pressure

<50 mmHg indicates an
ischemia
Creager MA, et al. Acute limb ischemia. New England Journal of Medicine. 2012
Noninvasive laboratory testing (1)

• Segmental pressure
measurement/Pulse volume
recording (PVR)
– Measured by placing
sphygmomanometric cuffs on the
proximal thigh, distal thigh, calf
and ankle
– Arterial stenosis or occlusion will
decrease perfusion pressure
– Arterial pressure gradient
between cuffs indicate presence
of a stenosis

Vascular Medicine: A Companion to Braunwald’s Heart

Disease, 2ed
Noninvasive laboratory testing (2)

• Toe-brachial indices (TBI)

– Measuring digital perfusion in small-vessel
arterial diseases
– The ratio of the systolic pressure in the toe to
the brachial artery systolic pressure
– A cuff is placed on a toe (great toe)
– Normal TBI 0.70

OH2017
Vascular Medicine: A Companion to Braunwald’s Heart
Disease, 2ed
Noninvasive laboratory testing (3)

• Treadmill testing
– Measurement of ABI, initial
claudication time, absolute
claudication time
– May increase ABI sensitivity
– Carter protocol
• Constant exercise – speed 1.5-2.0
mph, treadmill grade 0-12%
– Hiatt or Gardner protocol
• Graded exercise – increase speed
and/or treadmill grade
OH2017
Vascular Medicine: A Companion to Braunwald’s Heart
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 Other diagnostic imaging

• Duplex Ultrasonography (DUS)

– Accurate identification of the location and
severity of stenoses
– Postoperative surveillance of arterial bypass
grafts
• Magnetic Resonance Angiography
(MRA)
– Accurate imaging modality to diagnose PAD,
visualize peripheral arteries, and determine
the location of stenoses
• Computed Tomographic Angiogram
(CTA)
Vascular Medicine: A Companion to Braunwald’s Heart
Disease, 2ed
Duplex ultrasound (2)

85
Duplex ultrasound (3)

86
 Duplex ultrasound (4)
Duplex ultrasound (4)

ABI + DUS  povide all information confirms the

diagnosis  management decisions  follow-up
after angioplasty or to monitor bypass grafts.
Pitfalls of DUS  difficulties in assessing the
lumen in highly calcified arteries. Also in some
cases (e.g. obesity, gas interpositions), the iliac
arteries are more difficult to visualize.
The major disadvantage  it does not provide full
arterial imaging as a clear roadmap

Tandera M, et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases. 87
European Heart Journal (2011) 32, 2851–2906
TCOM

88
Risk stratification

ESC Guidelines. Eur Heart J 2011; 32:2851-2906

Algorithm of pad evaluation

OH2017
Vascular Medicine: A Companion to Braunwald’s Heart
Disease, 2ed
CHRONIC LIMB ISCHEMIA:
presentation

OH2017

ESC guidelines 2011

OH2017
ESC guidelines 2011
Recommendation for the
management of cli
ACUTE LIMB ISCHEMIA: CLINICAL
CATEGORIES

ESC guidelines 2011

ALI RECOMMENDATIONS

OH2017
ESC guidelines 2011
ESC guidelines 2011
Treatment recommendation in
general

ESC guidelines 2011

98