นายแพทย์ชำนาญการพิเศษ Peripheral Arterial Disease :PAD นพ.ธีรพล เกาะเทียน นายแพทย์ชำนาญการพิเศษ ศัลยแพทย์โรคหัวใจ หลอดเลือด และทรวงอก โรงพยาบาลสรรพสิทธิประสงค์ อุบลราชธานี

Introduction PAD caused by atherosclerotic occlusion of arteries to legs Prevalence 12% and increases to 20% if persons older than 70 yr. Affects men and women equally pt. with PAD , even absence of Hx of MI or ischemic stroke have same relative risk of death from CVS cause as pt. with Hx of CAD or CVD

Introduction Rate of death of all causes equal in men and women and is elevated even in asymptomatic pt. Severity of PAD is closely associated with risk of MI , ischemic stroke , and death from vascular cause Lower ABI – greater risk of CVS events Critical leg ischemia – mortality of 25%

RISK FACTOR Smoking DM HT Hypercholesterolemia

Normal Artery and Artery With Plaque Buildup

PAD in THAILAND Male 4% Female 8% Risk Factor Age DM > 12 yrs HT

A Life Threatening Condition The REACH (Reduction of Atherothrombosis for Continued Health) Registry has expanded mortality associated with PAD At one year, 19% of the PAD population had experienced either an MI, a stroke or were hospitalised for an atherothrombotic event or had died from CV causes compared to 10% of the CAD population and 7% of CVD population.

PAD vs DM DM ทำให้เพิ่มความชุกของ PAD 2เท่า 50% จะถูกตัดเพิ่ม 50% ถูกตัดอีกข้าง ภายใน 2 ปี 50% ที่ถูกตัดขา เสียชีวิต ภายใน 5 ปี

Clinical Staging of LEAD

Screening for PAD ABI Selection of patient high risk DM Age 50 years.

Ankle-Brachial Index (ABI)

INTERPRETATION NORMAL 0.9 -1.30 MILD 0.7-0.89 MODERATE 0.4-0.69 SEVERE < 0.4 POORLY COMPRESSIBLE > 1.3

TREATMENT งดสูบบุหรี่ ออกกำลังกาย ควบคุม ความดัน (140/90 mmHg) LDH < 100 Medication Endovascular treatment Surgery

การประเมินผู้ป่วยที่มีอาการ Claudication ผู้ป่วยที่มีอาการแบบ classic claudication ตรวจร่างกายระบบหลอดเลือด ตรวจ resting ankle - brachial index (resting ABI) ABI ≤ 0.90 ABI > 0.90 - Exercise ABI - Toe-brachial index - Segmental pressure measurement - Duplex ultrasound exam. Confirmation of PAD diagnosis Abnormal results Normal results No PAD or consider arterial entrapment syndrome - Risk factors normalization - Pharmacological risk การรักษาภาวะ claudication

Intervention of PAD

Toe gangrene in a patient with diabetes

AORTO-ILIAC LESIONS Description Lesion type Type A Type B * Unilateral or bilateral single short (≤3cm) stenosis of EIA * Unilateral or bilateral stenosis of CIA * Single or multiple stenosis totaling 3-10cm. Involving the EIA occlusion not involving the origins of internal iliac of CFA * Unilateral CIA Occlusion * Short (≤3cm) stenosis of infrarenal aorta

AORTO-ILIAC LESIONS Description Lesion type Type C Type D * Heavily calcified unilateral EIA occlusion with or without involvement of origins of internal iliac and/or CFA * Unilateral EIA occlusion that involves the origins of internal iliac and/or CFA * Unilateral EIA stenosis extending tnto the CFA * Bilateral EIA stenosis 3-10cm long not extending into the CFA * Bilateral CIA occlusion * Bilateral occlusion of EIA * Iliac stenosis in patients with AAA requiring treatment and not amenable to endograft placement or other laesions requiring open aortic or iliac surgery * Unilateral occlusions of both CIA and EIA * Diffuse multiple stenosis involving the unilateral CIA, EIA and CFA * Diffuse disease involving the aorta and both iliac arteries requiring treatment * Infra-renal aorto-iliac occlusion

FEMORAL-POPLITEAL LESIONS Lesion type Type A Type B Description * Single occlusion ≤5cm in length * Single stenosis ≤10cm in length * Single popliteal stenosis * Heavily calcified occlusion ≤5cm inlength * Single or multiple lesions in the absence of continuous tibial vessels to improve inflow for a distal bypass * Single stenosis or occlusion ≤15cm not involving the infra geniculate popliteal artery * Multiple lesions (stenoses or occlusion),each ≤5cm

FEMORAL-POPLITEAL LESIONS Lesion type Type C Type D Description * Recurrent stenoses or occlusion that need treatment after two endovascular interventions * Multiple stenoses or occlusions totaling >15cm with or without heavy calcifications * Chronic total occlusion of popliteal artery and proximal trifurcation vessels * Chronic total occlusion of CFA of SFA (>20cm, involving the popliteal artery)

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