Page 5 - Carotid and peripheral vascular interventions textbook
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                 population (11). This disorder mainly impacts active   and 4) to monitor the result of percutaneous and surgical
                 young athletes with no prior cardiovascular risk factors’   revascularization therapy. The ankle-brachial index
                 history. Patients usually present complain of intermittent   (ABI) is both a reproducible and inexpensive way of
                 calf and foot pain which happens following exercise and   evaluating lower extremity hemodynamics. The ABI is
                 disappears at rest. If left untreated, the PAES may cause   the ratio of the highest systolic pressure within each leg,
                 distal arterial thromboembolism, popliteal artery thrombosis    taken at the posterior tibial and dorsalis pedis arteries
                 (PAT), popliteal artery stenosis (PAS), as well as limb   with a Doppler probe with the higher of the left or right
                 amputation. Screening for high-risk patients who need   arm brachial artery pressure. ABI ratio less than 0.9 are
                 prompt surgical intervention is important to prevent these   indicative of diagnosis of PAD and values below 0.5
                 complications.                                  indicate severe PAD. When ABI has conf rmed PAD,
                                                                 it is required to delineate the diseased lesion and assess
                 CLINICAL PRESENTATION                           revascularization therapy options. Several methods have

                                                                 been applied to def ne the location of the affected arteries.
                     Intermittent claudication is the most common    Each method has its strengths and limitations.
                 manifestation of isolated femoropopliteal arterial disease.
                 It is def ned as pain, cramping, discomfort or fatigue  Segmental limb pressure and
                 within the calf muscles which is continually caused by  pulse volume recordings
                 exercise, but rest relieves it within 10 minutes. If the PFA      The location and extension of PAD may additionally
                 circulation is normal, there is possibility that patients may   be def ned by using segmental limb pressure measurements,
                 be asymptomatic or if symptomatic, the claudication is   recorded by a doppler instrument using plethysmographic
                 usually relieved with exercise training and intervention is   cuffs covering the brachial arteries and different points
                 unnecessary. CLI (i.e., ischemic rest pain or non-healing   on the lower limb, which need to include the upper thigh,
                 ulceration) is uncommon, and when it occurs, patients   the lower thigh, the upper calf just below the knee, and
                 always  have  multi-level  arterial  occlusive  disease     the ankle. A pressure gradient of more than 20 mm Hg
                 involving infrapopliteal tibial arteries. Revascularization     between the lower thigh and the upper calf suggests distal
                 of the femoropopliteal arteries to increase proximal     SFA or popliteal artery disease. As noted, patients with
                 in-f ow might be enough to alleviate ischemic pain and   well-formed collateral f ows might not show a signif cant
                 to promote wound healing.                       pressure gradient. Besides segmental limb pressure, pulse
                     Peripheral vascular examination should include   volume recordings (PVRs) can evaluate changes within
                 palpation for all lower extremity pulses as well as     each limb’s volume, in various leg segments, within
                 auscultation for vascular bruit, especially at the femoral   every cardiac cycle. Using segmental limb pressures and
                 arteries. Absent or diminished pulses of popliteal artery   PVRs measurements together, the accuracy rate is 95%
                 suggests femoropopliteal occlusive disease. In case of tibial   in detecting and localizing occlusive disease compared   333
                 vessel involvement, other physical f ndings at the foot   with angiography (12).
                 should be examined such as shiny skin, hair loss, muscle
                 atrophy, and non-healing wound or ulcers. Dependent  Arterial duplex ultrasonography

                 rubor with elevation pallor can appear in advanced disease      Duplex ultrasonography (DUS) is a precise method
                 which is caused by impaired autoregulation within dermal   of determining the location and degree of stenosis of
                 arterioles and capillaries.                     femoropopliteal disease. The DUS combines doppler
                                                                 velocities and doppler waveform analysis. Doppler
                 DIAGNOSTIC TESTS                                waveforms may change from a typical triphasic pattern
                                                                 to a biphasic and, f nally, monophasic presentation in
                     Noninvasive vascular studies are used in many     signif cant PAD patients (Fig. 12-3). DUS is increasingly
                 purposes, including 1) to conf rm PAD diagnosis in    used to assess the hemodynamic effects of localized
                 patients with equivocal history or physical f ndings, 2) to   stenoses and peripheral arterial anatomy with high
                 grade the severity and to determine the level of stenosis   sensitivity and specif city. However, the accuracy of the
                 or occlusions, 3) to follow the progression of disease,    study is highly operator dependent.
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