PERIPHERAL ARTERIAL DISEASE PATHWAY Map of Medicine/ELIC - PowerPoint PPT Presentation

1 / 25
About This Presentation
Title:

PERIPHERAL ARTERIAL DISEASE PATHWAY Map of Medicine/ELIC

Description:

Ankle brachial pressureindex(ABPI) Blood pressure taken around calf/ankle using Dorsalis Pedis pulse ... 0.2 Ankle brachial pressure index ... – PowerPoint PPT presentation

Number of Views:357
Avg rating:3.0/5.0
Slides: 26
Provided by: hai82
Category:

less

Transcript and Presenter's Notes

Title: PERIPHERAL ARTERIAL DISEASE PATHWAY Map of Medicine/ELIC


1
PERIPHERAL ARTERIAL DISEASE PATHWAYMap of
Medicine/ELIC
  • Mr Paul Flora
  • Consultant Vascular and General surgeon
  • BLT
  • Dominic Roberts
  • GP Lower Clapton

2
PAD Shared care Pathway
  • Case 1
  • Salient points of shared care pathway
  • Mr Flora
  • Medications for PVD
  • Use of duplex scans
  • Case 2
  • ELIC vascular surgery advice service

3
Case 1
  • 63 yr old male retired bus driver.
  • 6/12 Hx of bilateral intermittent calf pains on
    walking 30m.
  • Pain relieved by rest. Reproduced on exertion.
  • BMI 28, BP 128/78, smoker

4
Examination
  • Foot pulses not palpable
  • No skin changes
  • No AAA
  • No Radio-femoral delay
  • No renal, femoral or carotid bruits
  • Management? / Further examination?
  • Referral?

5
Ankle brachial pressureindex(ABPI)
  • Blood pressure taken around calf/ankle using
    Dorsalis Pedis pulse
  • Dorsalis Pedis BP / Brachial BP ABPI
  • Clinical status
    ABPI
  • Symptom free
    1 or more
  • Intermittent claudication
    0.5 -0.95
  • Rest pain
    0.3 - 0.5
  • Gangrene and ulceration
    lt0.2

6
(No Transcript)
7
Ankle brachial pressure index (ABPI)
  • Identify patients that can remain in primary care
    management
  • 95 sensitivity / 99 specificity
  • Strong indicator of CVS disease

8
ABPI
  • Brachial systolic 128
  • Dorsalis pedis systolic 90
  • ABPI 90 / 128 0.7
  • RL
  • Management?

9
Shared care!
  • Diet and lifestyle
  • Smoking cessation
  • Exercise therapy
  • Control risk factors DM, BP lt140/90
  • Full assessment of CV risk profile
  • Medications
  • Review after 3 months

10
  • ABPI 0.6-0.9 shared care
  • ABPI gt 1.0 consider different diagnosis
  • List of differentials in guidance
  • ABPI lt 0.6 Refer to vascular surgeon

11
Exercise And Diet
  • Stop smoking and keep walking (Housley 1988)
  • Structured, supervised exercise programme
  • Improvement in walking distance mean 105, SD 56
    (Robeer 1998)
  • Improvement vs no exercise groups (Robeer 1998)

12
Medications
13
Antiplatelets
ADP Pathway
ADP
Clopidogrel Inhibits ADP platelet aggregation
pathway
C
PLATELET
ADP Receptor
Dipyridamole Inhibits phosphodiesterase induced
cAMP release
COX
Aspirin Inhibits thromboxaneA2 platelet
aggregation pathway
TXA2 Receptor
cAMP Pathway
TXA2
TXA2 Pathway
Phosphodiesterase
14
Statins
  • Cholesterol lowering actions
  • Endothelial protective effect
  • Plaque stabilization
  • Diabetes Mellitus
  • CAD, CVD, PAD

15
Medications
  • Low dose aspirin
  • (clopidogrel only if not tolerated)
  • Statin if total cholesterol lt3.5mmol/L
  • High risk of future CVS events

16
Cilostazol
  • Phosphodiesterase III inhibitor
  • NOx mediated cAMP pathways
  • Inhibition of platelet aggregation
  • Increased vasodilatation
  • Inhibitor of smooth-muscle cell proliferation

17
Cilostazol vs Pentoxifylline
Dawson et al. Am J Med 2000 109 523 - 30
18
Medications cont..
  • Cilostazol
  • GI and neuro side effects
  • CI in heart failure
  • Stop if no better after 3/12
  • Naftidrofuryl
  • Use if poor quality of life.
  • Cost

19
Algorithm for PAD management
Peripheral Arterial Disease
  • Risk factor modification
  • Smoking cessation
  • LDL cholesterol lt 100 mg/dL
  • LDL lt 70mg/dL if high risk
  • HbA1c lt 7.0
  • BP lt 140/90 mmHg
  • BP lt 130/80 mmHg if diabetic or renal disease
  • Antiplatelet therapy
  • No limitation to quality of life or reduced
    exercise capacity
  • Monitor patient for loss of function
  • Limitation that affects quality of life
  • History of significant exercise limitation
  • Or
  • Reduced treadmill performance
  • Or
  • Reduced function by questionnaire
  • Claudication medical therapy
  • Supervised exercise or pharmacotherapy

Suspected proximal lesion
  • Localise the lesion
  • Conventional angio
  • MRA or CTA
  • Ultrasound
  • Hemodynamic localisation

Improved symptoms
Symptoms not improved or deteriorated
Continue
  • Revascularization
  • Endovascular
  • Surgical

20
Use of duplex scans
  • In health duplex US of lower limbs
  • When to use?

21
Case 2
  • 71 yr old male presents with sudden onset of
    pain, paraesthesia and weakness rt lower leg
  • O/E
  • Rt lower leg - Pale, cold, no pulses palpable
  • Management?

22
Sudden acute limb ischaemia
  • Often caused by embolism
  • Urgent immediate referral
  • Limb threatening

23
Vascular surgeon advice service
  • Harpaul.flora_at_nhs.net

24
Current Vascular service network
Homerton 240,000
Whipps Cross 350,000
BLT 300,000
Newham 240,000
Staff Vascular Surgeons 6 Interventional
Radiologists 5 Vascular Technologists 4 Vascular
Nurse Specialists 3
AAA operative workload EVAR 94 (2000-07) Open
120 (2003-07)
25
Questions?
  • Thank You
Write a Comment
User Comments (0)
About PowerShow.com