Rob Kawa, OMS III

Predoctoral OPP Fellow

DidacticsOnline.com

Peripheral Vascular Disease

Peripheral vascular disease (PVD) can really be a vascular pathology of either the veins or arteries.

PVD is also known as peripheral artery disease (PAD) because it is generally thought of as a disease of the blood vessels in which narrowing and hardening of the arteries occur.

The most common areas affected are the legs and feet.

Peripheral Vacular Disease

Arteriosclerosis is “the hardening of the arteries” and is the process of fat build up on the walls of the arteries in the form of plaques.

The artery becomes narrow, the walls become stiff, and together this blocks the dilation of arteries when there is increased demand for blood and oxygen in working tissues.

As a result, your legs can not receive blood when walking or running and pain develops. Eventually , due to disease progression, there may not be enough blood available during rest.

Arteriosclerosis

Why are there so many terms that all sound the same? (arteriosclerosis, atherosclerosis, arteriolosclerosis)

Where did the plaque come from?

Lets Back Up A Minute!

Arteriosclerosis-A broad term describing thickening and loss of

elasticity of arterial walls. Three main types:

Medial calcification which is dystrophic calcification and of no clinical concern unless associated with atherosclerosis (Ex: calcification in uterine arteries)

AtherosclerosisArteriolosclerosis

Lets Talk About The Terms

Atherosclerosis- Endothelial cell damage of muscular and elastic arteries Causes of endothelial damage include smoking, hypertension, homocysteine, and

LDL. Cell response to endothelial injury

Macrophage and platelets adhere to damaged endothelium Released cytokines cause hyperplasia of medial smooth muscle cells. Smooth muscle cells migrate to the tunica intima Cholesterol enters muscle cells and macrophages (foam cells) Smooth muscle cells release cytokines that produce extracellular matrix

Development of fibrous cap (plaque) Components include smooth muscle, foam cells, inflammatory cells, and ECM Cap overlies a necrotic center Disrupted plaque may extrude underlying necrotic material leading to vessel thrombosis Fibrous plaque becomes dystrophically calcified and ulcerated

Serum C-reactive peptide (CRP) is increased in patients with disrupted inflammatory plaques. Plaques rupture, produce vessel thrombosis, and cause acute MI. CRP may be a stronger predictor of cardiovascular events than LDL

Lets Talk About The Terms

Atherosclerosis Popular sites for atherosclerosis in descending order

Abdominal aorta Coronary artery Popliteal artery Internal carotid artery

Complications of atherosclerosis Vessel weakness (aneurysm) Vessel thrombosis

Acute MI Stroke Small bowel infarction

Hypertension (renal artery may activate RAAS) Cerebral atrophy (block circle of willis or internal carotids) Peripheral vascular disease

Increased risk of gangrene Pain when walking (claudication)

Lets Talk About The Terms

ArteriolosclerosisHardening of arterioles

Hyaline arteriolosclerosis: Increased protein deposited in the vessel walls occludes the lumen. Associated conditions include diabetes mellitus and hypertension.

Hyperplastic arteriolosclerosis: Renal arteriole effect from an acute increase in blood

pressure (Ex: malignant hypertension)Smooth muslce cell hyperplasia and basement

membrane duplicationArterioles have an “onion skin” appearance

Lets Talk About The Terms

A common disorder that usually affects men over 50

Higher risk with history of:Abnormal cholesterolDiabetesHigh blood pressure

(hypertension)Heart disease

(coronary artery disease)Smoking Kidney disease involving hemodialysisStroke (cerebrovascular disease)

Peripheral Vascular Disease

Pain, achiness, burning, fatigue, discomfort of the calves, feet, or thighs. These symptoms usually appear with exercise and go away with rest (Claudication).

Numbness, pale skin, cool to the touchSevere disease:

ImpotenceUlcers that do not healWorsening pain with leg elevationLeg pain at night

Symptoms

Signs: What can the healthcare provider find on examination?Arterial bruits – a

whooshing sound heard with the stethoscope over an affected artery

Decreased blood pressure in the affected limb

Loss of hair on the legs or feet

Decreased or absent pulses in the limb

Calf muscles that shrink Hair loss over the toes and feetPainful non-bleeding ulcers (usually black)

that are slow to healPale skin or a blue appearance

(cyanosis)Shiny tight skinThick toenails

Signs in severe disease

Blood test – A blood test may show high cholesterol or diabetes

Angiography of the arteries in the legs (arteriography)

Blood pressure measurements in the arms and legs for comparison

Doppler ultrasonography Magnetic resonance angiography or CT

angiographyPlethysmography – Tests a change in volume

in the body, organs, or vessels.

Tests

Self-care:Balance exercise and rest: If you exercise to the

point of pain and follow with rest over time you can improve circulation as new, small (collateral) blood vessels form.

Stop smokingReduce your weightKeep your blood pressure under controlTake particular care with foot health, especially if

diabeticMonitor blood sugarIf your cholesterol is high eat a low cholesterol, low

fat diet.

Treatment

Medications:Aspirin or a medication called clopidogrel

(plavix) keep your blood from clotting in the arteries by affecting platelets.

Cilostazol is also an anti-platelet medication but works to dilate arteries in moderate to severe cases where surgery is not an option. The dilated arteries can improve blood flow to areas of claudication.

Cholesterol medicationsPain relievers

Treatment

Prostanoids for treating people with severe peripheral arterial disease of the legs

First published: January 20, 2010; This version published: 2010. Review content assessed as up-to-date: October 28, 2009.

The question is whether specific drugs such as prostanoids reduce mortality and progression of the disease, including amputations, more than placebo or other treatments. This review of 20 trials did not find any evidence that prostanoids provided long‐term benefit.

Prostanoids seem to have efficacy regarding rest‐pain relief and ulcer healing.

Treatment Research

TreatmentSurgery/Procedures

Angioplasty and stent placement – This procedure is similar to the technique used to open coronary arteries but is done in the affected leg.

TreatmentSurgery/

Procedures:Arterial bypass

surgery for vessels with significant blockage. Lower extremity vessels and the abdominal aorta are common sites.

TreatmentSurgery/Procedures:

Endarterectomy – The surgical removal of plaque in a blocked vessel

Limb Amputation – In severe cases where tissue becomes necrotic and gangrene is a concern.

TreatmentAn Osteopathic

Consideration:MFR and Fascial

Ligamentous Release

LASDiaphragmsLymphaticsFluid DynamicsMuscle Energy?

Websites: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001224/ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001223/ http://www.fashion-writings.com/peripheral-vascular-disease-test/ http://www.endovascularsurgery.com/patient-vascular.html http://www.acu-heal.com/vascular-progress.html http://www.vascularweb.org/vascularhealth/pages/peripheral-artery-disease-(-

pad-)-.aspx

http://jama.ama-assn.org/content/291/7/809.extract http://www.alexkolesar.com/diabetic-foot/peripheral-vascular-disease.html http://www.podiatricresidency.com/insight/insight9.html http://www.tobaccolabels.ca/gallery/hongkong/hongko~9 http://www.osteoworks.com.au/1-services/osteopathy-brisbane

Books: Goljan E. (2010) Rapid Review Pathology Third Edition

Philadelphia: Mosby Elsevier Wolfsthal S. (2008) NMS Medicine Sixth Edition

Baltimore: Lippincott Williams and Wilkins

References