Penyakit Arteri Perifer Oklusif Sal

PENYAKIT ARTERI PERIFER

PENYAKIT ARTERI PERIFER

OKLUSIF

OKLUSIF

Dr. Dion Faisal

Dr. Dion Faisal

DEFINISI

DEFINISI

Penyakit Arteri Perifer Oklusif (PAPO)/

Penyakit Arteri Perifer Oklusif (PAPO)/

Peripheral

Occlusive

Arterial

Disease

Peripheral

Occlusive

Arterial

Disease

(POAD)/

(POAD)/

Peripheral Arterial Disease

Peripheral Arterial Disease

 (PAD)

 (PAD)

::

Sindroma klinis yang disebabkan oleh adanya

Sindroma klinis yang disebabkan oleh adanya

stenosis atau oklusi lumen aorta atau

stenosis atau oklusi lumen aorta atau

arteri-arteri ekstremitas bawah.

arteri ekstremitas bawah.

Harrison’s Principles of Internal Medicine, 18th Ed. Harrison’s Principles of Internal Medicine, 18th Ed.

DEFINISI

DEFINISI

Penyakit Arteri Perifer Oklusif (PAPO)/

Penyakit Arteri Perifer Oklusif (PAPO)/

Peripheral

Occlusive

Arterial

Disease

Peripheral

Occlusive

Arterial

Disease

(POAD)/

(POAD)/

Peripheral Arterial Disease

Peripheral Arterial Disease

 (PAD)

 (PAD)

::

Sindroma klinis yang disebabkan oleh adanya

Sindroma klinis yang disebabkan oleh adanya

stenosis atau oklusi lumen aorta atau

stenosis atau oklusi lumen aorta atau

arteri-arteri ekstremitas bawah.

arteri ekstremitas bawah.

Harrison’s Principles of Internal Medicine, 18th Ed. Harrison’s Principles of Internal Medicine, 18th Ed.

ETIOLOI

ETIOLOI

 

  _{ArterArteriisklersissklersis  !"#O$: kelainan %ada tunika  !"#O$: kelainan %ada tunika}

intima arteri yang kom%leks& terdiri dari intima arteri yang kom%leks& terdiri dari %enyumbatan setem%at oleh berbagai bahan %enyumbatan setem%at oleh berbagai bahan li%ida& karbohidrat& darah ' kom%onen darah& li%ida& karbohidrat& darah ' kom%onen darah&  (aringan

 (aringan ikat ikat ' ' de%osit de%osit kalsium kalsium diikdiikuti uti kkelainanelainan tunika media.

tunika media.  

  _{ArteritisArteritis: %roses keradangan !in)amasi$ dinding: %roses keradangan !in)amasi$ dinding}

arteria yang menyebabkan %enebalan dinding arteria yang menyebabkan %enebalan dinding dan memberi sumbatan arteria

dan memberi sumbatan arteria yang kronisyang kronis  

  _{T!r"#e"#li$T!r"#e"#li$ bagian ke*il daribagian ke*il dari blood clot blood clot} 

yang terle%as menyebabkan sumbatan %embuluh yang terle%as menyebabkan sumbatan %embuluh darah.

darah.Puruhito. Buku Ajar Prier Ilu Bedah !oraks, "ardiak, #Puruhito. Buku Ajar Prier Ilu Bedah !oraks, "ardiak, #

$

PATOFISIOLO%I PAPO

  _{Lesi se&"ental !%lak atherosklerotik  dgn}

de%osit ,a& %eni%isan tunika media& destruksi otot ' serat elastik& ragmentasi

internal elastic laina& dan thrombus yang terdiri dari %latelet ' brin$ arteri 'ia"eter se'an& !in&&a #esar  enye"itan lu"en  /askularisasi

distal lesi !iskemia$  0a'ensin  nyeri iske"ik 

  _{Lesi: %er*abangan arteri& turbulensi& shear}

stress& ' intimal in(ury.

  _{1sia tua ' D 333}   _Lokasi:

 _{Femoral & popliteal 80-90%}

 !ibial # peroneal (&)*&+

TANDA * %E+ALA PAPO

  _{%E+ALA !7845 sim%tomatik$}

 _{Intermittent claudication}   rasa neri-kra-kebas  %ada ekstremitas saat aktiitas ' berkurang dengan istirahat 

 _{Iske"ia ekstre"itas #a,a!}   nyeri !9$ saat tidak beraktiitas !rest pain/& nyeri !9$ saat %ada %osisi hori;ontal !misalnya saat tidur< ni0ht pain$& u(ung kaki kebas

 _{o2er 3 upper e4treities}

  _{PE-ERIKSAAN FISIK} 

 _{Pulsasi nadi di bagian distal oklusi berkurang< !-$}  _{Bruits< bising di area oklusi}

 _{Atr. tt}

 _Iske"ia   kerontokan rambut di distal oklusi& kuku menebal& kulit ti%is dan mengkilat& sianosis& akral dingin& ulserasi ! painful ulcer $& kebas& hi%ore)eksia

DIA%NOSIS PAPO

  _ANA-NESIS

 _{Ri,ayat &eala : klaudikasio& gangguan mobilitas& ulkus sulit sembuh}  K"r#i'  : %enyakit (antung< askular& #T& hi%erkolesterol& D& riwayat

bedah askular

  _{PE-ERIKSAAN FISIK} 

  Tanda-tanda oklusi ' iskemia

  Tekanan arteri  ankle-rachial inde! (A0I)

  _{PE-ERIKSAAN PENUN+AN%}

 Duple! ultrasono"raph# $D'  Sensitiitas =45 dan s%esitas >45

 (ranscutaneous o!#metr# 

 _{tress testin" $treadmill'}   analisis ob(ekti keterbatasan ungsional

ekstremitas yang mengalami oklusi arteri

 Di"ital utraction An"io"rph# $DA'  0old standard

 _1TA Sensitiitas dan s%esitas >8?>>5

ANKLE20RA13IAL INDE4 (A0I)

D1S

Keuntun&an$

 Bon inasi   Lebih murah

 udah diker(akan !rawat (alan atau kamar o%erasi$

 Terhindar dari resiko %otensial nerotoksik agen kontras

 Sensitiitas =45 dan s%esitas >45

Keru&ian$

 O%erator de%enden

ale L TangC& ason ,hin2 and elina  ibbeG2. Hdan*es in diagnosti* imaging or %eri%heral arterial disease E4pert 5e. 6ardioasc. !her. @!C4$& C66=? C688 !24C4$

Hrterial *olor )ow du%le.(A) Bormal %eroneal artery with tri%hasi* s%e*tral waeorm. (0) #eaily *al*ied

%osterior tibial artery with a mono%hasi* s%e*tral waeorm. The *al*i*ation interru%ts the *olor )ow

DSH

Keuntun&an$

 Se*ara %rimer ealuasi lumen arteri

Keru&ian$

 Inasi   ahal

 esiko alergi kontras dan %a%aran radiasi  7iscofort 

ale L TangC& ason ,hin2 and elina  ibbeG2. Hdan*es in diagnosti* imaging or %eri%heral arterial disease E4pert 5e.

6ardioasc. !her. @!C4$& C66=?C688 !24C4$

,TH

Keuntun&an$

Ealuasi arterial 2all dan (aringan

sekitarnya& deteksi aneurisme %erier& karakteristik plaue& kalsikasi&

ulserasi& thrombus atau soft plaue& intial hperplasia, in)stent restenosis dan raktur stent.

Sensitiitas dan s%esitas >8?>>5

Keru&ian$

  _{esiko alergi atau nerotoksik}

kontras

  _adiasi

ale L TangC& ason ,hin2 and elina  ibbeG2. Hdan*es in diagnosti* imaging or %eri%heral arterial disease E4pert 5e. 6ardioasc. !her. @!C4$& C66=?C688 !24C4$

+D re*onstru*tion o the aortoilia* arteries using LightS%eed Jolume1T i"a&e a56uisitin7 ,al*ied %laKues in the aorta and ilia*s are isuali;ed with high resolution& as are the

H

euntungan:

  _{Bo ioni;ing radiation e%osure}

  _{adolinium-based *ontrast agent 33}

less ne%hrotoi*

  _{Sensitiitas dan s%esitas @4?>45}

erugian:

  _{odalitas non inasi %aling mahal}   _{"aktu %emeriksaan dan toleransi}

%asien

  _{I: %a*emakers& automated}

im%lantable *ardioerter?debrillators& stent grats and brain aneurysm *li%s

Bui BT, Miller S, Mildenberger P, Sam A 2nd, Sheng R. Comparison of contrast-enhanced MR angiograph to intraarterial digital subtraction angiograph for e!aluation of peripheral arterial occlusi!e disease" results of a Phase ### multicenter trial.J. Magn. Reson. Imaging  $%&'(, %)*2+

 Thromboangiitis Obliterans !THO$<

"iniwarter-urger Disease

 

_{Hleander on "iniwarter !C@=>$: rst}

*ase o 8= y.o. male with oot %ain leading

to gangrene

 

_{Mathologi* s%e*imen showed intimal}

%rolieration& thrombosis& and brosis

 

_{Suggested that essel *hanges distin*t}

rom atheros*lerosis

 

_{Leo uerger !C>4@$: detailed des*ri%tion o}

CC am%utated limbs at t. Sinai with

endarteritis ' endo%hlebitis

Etiologi

  _1BBO"BN

  Distin*t rom other as*ulitis

  C. thrombus is highly *ellular with less intense *ellular rea*tion in essel wall

  2. normal immunologi* markers

  _{Strong asso*iation with smoking}   _{Bo gene asso*iation ound yet}

  _{,on)i*ting studies regarding hy%er*oagulable states}

  _{In*reased urokinase %lasminogen a*tiator}

  _{Im%aired endothelium-de%endent asorelaation}

  _{Immunologi* me*hanisms may be *ontributory}

  _{In*reased *ellular sensitiity to Ty%es I and III}

e(ala linis

  _{,lassi*ation Systems}

  _{a(or ,riteria}

  Onset o distal etremity is*hemi* sym%toms %rior to aKe 68   Toba**o abuse

  1ndiseased arteries %roimal to bra*hial ' %o%liteal   Ob(e*tie do*umentation o distal o**lusie disease by

%lethysmogra%hy

  E*lusion o %roimal emboli* sour*e& trauma& autoimmune disease& hy%er*oagulable state& atheros*lerosis

  inor ,riteria

  igratory su%er*ial %hlebitis   aynauds syndrome

  1%%er etremity inolement   Inste% *laudi*ation

Hrteriogra

  _{Small and}

medium-si;ed essels

  _{Digital arteries o}

ngers and toes

  _{Malmar& %lantar&}

tibial& %eroneal& radial& and ulnar

  _Segmental

o**lusie lesions

  _{ore seere disease}

distally

  _,orks*rew

*ollaterals

  _{Bormal %roimal}

arteries

H& DSH: ,orks*rew *ollaterals around the area o o**lusions. D1S:  Yuichi Fujii et al. Circulation. 2007;116:e539-e540

 Tera%i

  _{STOM HLL SOIBN}

   _{The only way to sto% %rogression o disease '}

%reent uture am%utation

  _{Hll other thera%ies are %alliatie}

  _{Mrostaglandin or %rosta*y*lin analogue !ilo%rost&}

bera%rost$

  _{,al*ium *hannel blo*kers or asos%asm}   _{Mentoi%hylline}

   _{Thrombolyti* thera%y}   _{Sym%athe*tomy}

  _{Surgi*al reas*ulari;ation !limited due to ski%}

lesions ' distal disease& 7C45 by%ass *andidates$

 Ta ayas us Hrter t s TH <

Horti* Hr*h Synd.<Mulseless

Disease

 

_{In)ammatory ' stenoti* disease o medium}

and large si;ed arteries *hara*terised by a

strong %redili*tion or the aorta ' its bran*hes.

 

_{Dr. ikito Takayasu !C>48$}



  the retinal

*hanges

o

the

disease

!the

Hnnual

O%hthalmology So*iety meeting& a%an$.

 

_In*iden*e:

_un*ommon

_disease&

_annual

in*iden*e rate C.2-2.A *ases<million

 

_{Mrealent in adoles*ent and young women}

!@45$

Matologi



_{Manarteritis& in)ammmatory mononu*lear}

inltrates& o**asionally giant *ells

 

_{arked intimal %rolieration& brosis&}

s*arring and as*ularisation o media

 

_{Disru%tion& degeneration o elasti* lamina}

 

_{Barrowing o lumen 9<- thrombus}

 

_{Immuno%athologi*al me*hanismRR}

e(ala linis

,onstitutional:

 

_{#eada*he !845-=45$}

 

_{alaise !+85-A85$}

 

_{Hrthralgias !2@5-=85$}

 

_{Feer !>5-+85$}

 

_{"eight loss !C45-C@5$}

ardiak ' askular

 

_{ruit& most *ommon lo*ation: *arotid artery}

!@45$

 

_{M dieren*e o etremities !685-A>5$}

 

_{,laudi*ation !+@5-@C5$}

 

_{,arotodynia or essel tenderness}

!C+5-+25$

 

_{#y%ertension !2@5-8+5 8@5 with renal}

artery stenosis in one series$

 

_{Horti* regurgitation !245-265$}

 

_{aynauds syndrome !C85$}

 

_{Meri*arditis !7 @5$}

Beurologi

 

_{#eada*he !845-=45$}

 

_{Jisual disturban*e !CA5+85$}

-Strong asso*iation with *ommon

*arotid and ertebral artery disease

 

_{Stroke !85->5$}

 

 _{Transient is*hemi* atta*ks !+5-=5$}

Dermatologi

 

_{Erythema nodosum !A5-C>5$}

 

_{1l*erated suba*ute nodular lesions}

!7 2.85$

Memeriksaan Fisik

  _{Meri%heral %ulses& M o 6 etremities& o%hthalmologi*}

eamination.

  _{SM dieren*e !3C4 mm #g$ between arms.}

  _#y%ertension  renal artery inolement !845$.

  _{Hbsent or diminished %ulses are the *lini*al hallmark}

o Takayasu arteritis& but %ulses are normal in many %atients ' u%%er limbs 3 lower limbs.

  _{O%hthalmologi* eam: retinal hemorrhages&}

*otton-wool eudates& enous dilatation ' beading&

mi*roaneurysms o %eri%heral retina& o%ti* atro%hy& itreous hemorrhage& and *lassi* wreathlike

%eri%a%illary arterioenous anastomoses !etremely rare$.

Artery er5ent 1lini5al "anifestatins

C. Sub*laian >+ H ,LH1IDH,TIOB&

HUBH1DS M#EBOEBOB 2. ,ommon

*arotid

8@ JIS1HL ,#HBES& TIH& STOE& SUB,OME +. Hbdominal

aorta

6= HDOIBHL MHIB& BH1SEH& JOITIB

6. enal +@ #TB& EBHL FHIL1E

8. Horti* ar*h<root

+8 HOTI, IB,OMETEB,E& ,,F

ARTERY 8 1LINI1AL

-ANIFESTATIONS

C. JETEHL +8 Jisual *hanges&

Di;;iness

2. ,OELIH, HVIS C@ Hbdominal %ain

Bausea& omiting

+. S1MEIO

ESEBTI,

C@ Hbdominal %ain&

nausea& omiting

6. ILIH, C= Leg *laudi*ation

8. M1LOBHU C4-64 Hty%i*al *hest%ain&

dys%nea

riteria Diagnosis

Hrend& ". M.& et al. !C>>4$. WThe Hmeri*an ,ollege o heumatology C>>4 *riteria or the *lassi*ation o Takayasu arteritis.W Hrthritis heum 99(:)$ ;;<=2;;9>7

Memeriksaan Menun(ang

 

_{Hrteriogram< angiogram}

 

_{,om%lete blood *ount !,,$}

 

_{,-rea*tie %rotein !,M$}

 

_{Ele*tro*ardiogram !E,$}

 

_{Erythro*yte sedimentation rate !ES$}

 

_{agneti* resonan*e}

angiogra%hy !H$

 

_1ltrasound

lasikasi !angiogram$

 

 _{Ty%e I - ran*hes o the aorti* ar*h}

 

 _{Ty%e IIa - Hs*ending aorta& aorti* ar*h& and}

its bran*hes

 

 _{Ty%e IIb - Ty%e IIa region %lus thora*i*}

des*ending aorta

 

 _{Ty%e III - Thora*i* des*ending aorta&}

abdominal aorta& renal arteries& or a

*ombination

 

 _{Ty%e IJ - Hbdominal aorta& renal arteries& or}

both

EDI,HL ,HE

 _{,hallenging: *lini*al& biologi*& and radiologi*} inormation do not always *orrelate.

 _{err et al !BI#$& assess disease a*tiity in %atients} with Takayasu arteritis. Bew onset or worsening o Y2 ollowing eatures indi*ates a*tie disease:

C. Systemi* eatures: eer ' arthralgias !no identied *ause$

2. ↑↑ ES

+. Jas*ular is*hemia or in)ammation: *laudi*ation& diminished or absent %ulse& bruit& *arotodynia& or asymmetri* blood %ressure in either u%%er or lower limbs !or both$

Treat"ent

 

_DiZ*ult.

 

_{Early dete*tion is im%ortant.}

 

_{Steroids ' immunosu%%ressie drugs:}

*orti*osteroid thera%y with or without

*ytotoi* agents.

 

_{Stri*t management o dysli%idemia& #T& '}

liestyle

 

_{Low-dose as%irin}

Mub ED.go& 244C

  _{,orti*osteroids: oral %rednison or %rednisolon& started at C}

mg<kg daily or diided twi*e daily and ta%ered oer week-months. Long-term low-dose may be reKuired. Osteo%orosis %reention.

  _{,ytotoi* agents:  steroid-resistant or rela%sing. ,ontinued or}

at least one year ater remission and are then ta%ered to dis*ontinuation.

  _{ethotreate !heumatre$ - =.8-28 mg<wk oral}   _{H;athio%rine !Imuran$- C-2 mg<kg<d oral}

  _{,y*lo%hos%hamide !,ytoan$- 2 mg<kg<d oral !most seere '}

rera*tory disease states$

  _{Hnti TBF Hgent: rela%sing ater steroids ' immunosu%%ressie}

t.

  _{Etaner*e%t 28 mg twi*e weekly& and in)iimab + mg<kg initially}

S1I,HL ,HE

S1I,HL ,HE

 

  _{,riti*al stenoti* lesions should be treated by,riti*al stenoti* lesions should be treated by}

angio%lasty or

angio%lasty or surgisurgi*al *al reas*reas*ulari;ationulari;ation during %eriodsduring %eriods

o remission

o remission..

 

  _{Surgi*al re%air or angio%lastySurgi*al re%air or angio%lasty indi*ationindi*ation::}

C. enoas*ular stenosis *ausing hy%ertension C. enoas*ular stenosis *ausing hy%ertension 2. ,oronary artery stenosis leading to

2. ,oronary artery stenosis leading to myo*ardialmyo*ardial is*hemia

is*hemia

+. Etremity *laudi*ation indu*ed by routine a*tiity +. Etremity *laudi*ation indu*ed by routine a*tiity 6. ,erebral is*hemia and<or *riti*al

6. ,erebral is*hemia and<or *riti*al stenosis Y + stenosis Y + *ereb*erebralral essels

essels

8. Horti* regurgitation 8. Horti* regurgitation

A. Thora*i* or abdominal aneurysms 38 *m in diameter A. Thora*i* or abdominal aneurysms 38 *m in diameter =. Seere *oar*tation o the aorta





aynauds

aynauds

Disease&

Disease&

Syndr

Syndr

ome&

ome&

Mhenomenon

Mhenomenon

 

  _{,hro,hroni* ni* e%isodi* e%isodi* atta*ks atta*ks oo digital is*hemiadigital is*hemia}

%rooked by e%osure to *old or emotional stress. %rooked by e%osure to *old or emotional stress.

 

  _{,hara*teri;ed by seKuential *olour *hanges: white,hara*teri;ed by seKuential *olour *hanges: white}

!!%allor%allor$$ blue !*yanosis$blue !*yanosis$  red !rubor$. red !rubor$.

 

  _{C45 o %o%ulation& emale:ale 8:C& age C45 o %o%ulation& emale:ale 8:C& age betweenbetween}

C8 - 64 y.o. C8 - 64 y.o.

 

  _{First des*ribed by auri*e aynaud !C@A2$First des*ribed by auri*e aynaud !C@A2$}

 

Matosiologi

Matosiologi

E%ose to *old < E%ose to *old < triggering a*tor triggering a*tor Small arteries at Small arteries at ngers and toes ngers and toes

asos%asm asos%asm

e*ome %ale or e*ome %ale or white then blue& less white then blue& less blood )ow and low blood )ow and low

O2 su%%ly O2 su%%ly "arm u% !arteries "arm u% !arteries dilate$ dilate$ lood )ow

lood )ow in*reasein*rease&& high O2 su%%ly high O2 su%%ly ,olor *hange to ,olor *hange to bright red bright red He*ted area is He*ted area is warm

warm and and turn turn red&red& throbing %ain& tingle& throbing %ain& tingle&

burn& or eel numb burn& or eel numb !e%isodes last about !e%isodes last about

olster & ari*K #&

olster & ari*K #& LeLe

L. OZ*e ealuation and

L. OZ*e ealuation and

treatment o aynaud[s

treatment o aynaud[s

%henomenon.

%henomenon. 6lee 6lin 96lee 6lin 9

Med.

Matosologi

 

_{Bot ully understood but *entered on a}

un*tional unit *om%osed o as*ular

endothelium& smooth mus*le *ells and nere

endings.

 

_{Skin o digits su%%lied by both}

thermoregulatory and nutritional blood )ow.

 

 _{Thermoregulatory system is *ontrolled by}

sym%atheti* nerous system while nutritie

)ow is su%%lied by *a%illary network.

 

_{Se*ondary raynauds *an lead to hy%oia}

and is*haemia.

 

_{Jas*ular dee*ts both stru*tural '}

un*tional !%rimary aynaud$.

 

_

_{,al*itonin gene related %e%tide !,M$}

whi*h is a %otent asodialator.

 

_{Intraas*ular dee*ts in*ludes}

ollowing:- 

_{Mlatelets a*tiation}



 thrombaane '

serotonin 0.

 

_{Dee*tie brinolysis}



 brin 0



 

_{Hberrant e%ression o endogenous}

asodilatory substan*es !nitri* oide&

%rosta*y*lin& %rostaglandin ' leukotrienes$

and aso*onstri*tors !endothelin&

angiotensin II and thromboane H2$.

 

_{", a*tiation}

 

_

_{, deormability}



im%airment o blood

)ow.

 

_{Oidatie stress}

lasikasi !Hllen and rown$

_{Priar aynauds disease: the *auses is not known}

!idio%athi*$& symmetri*al and inoles seeral digits& milder& reersible s%asm o the smallest arteries and arterioles& no abnormalities o the endothel.

_{;econdar aynaud[s syndrome: only one or a ew} digits are ae*ted and asymmetry is not unusual& more seere& asos%asm& endothelial *ell *hanges& essel obstru*tion& and hemorheologi* deormations. _{,EST syndrome: *al*inosis& aynaud[s}

%henomenon& eso%hageal dysmotility& s*leroda*tyly& and telangie*tasia  limited *utaneous orm

 _{Trauma or}

ibration:-  e)e sym%atheti* dystro%hy   Jibration e%osure

  Hrterioenous stula

  #y%othenar hammer syndrome !ulnar artery thrombosis$

  _{Intra-arterial drug administration}  _{,onne*tie tissue disease}

and as*ulitis

  Systemi* s*lerosis   SLE

  heumatoid arthritis   S(\grens syndrome

  ied *onne*tie tissue disease   Dermatomyositis

   Tem%oral arteritis

  #e%atitis  antigen as*ulitis

 _{Obstru*tie arterial} disease   _{Htheros*lerosis}    _{Thromboangiitis obliterans} !THO$!uergers disease$   _{#y%othenar hammer}

syndrome !ulnar artery thrombosis$

 _{Beurologi*al disease}

   _{Thora*i* outlet syndrome}

!*eri*al rib$

  _{,ar%al tunnel syndrome}

  _{#y%othenar hammer}

syndrome

 _{#aematologi*al disease}   _{,ryoglobulinaemia}   ,old agglutinins   Maroysmal haemoglobinuria   "aldenstr\ms ma*roglobulinaemia

 _{Drugs and toins}   _Ergot   _]-lo*kers   ethysergide   leomy*in   Hm%hetamines   Imi%ramine   romo*ri%tine   ,lonidine   _,y*los%orin   _{Oral *ontra*e%ties}   _{Jinyl *hloride}   _{Bitrogly*erin withdrawal}   _{#eay metals}   _{Intereron ala}  _{is*ellaneous}   _{Maraneo%lasti* syndrome}   _{,hroni* renal ailure}

  _{Mrimary %ulmonary}

hy%ertension

  _{#y%othyroidism}   _{Hnoreia nerosa}

Dia&nsis

  _{,riteria or diagnosis o %rimary aynauds}

%henomenon:-C. Intermittent atta*ks o dis*oloration o etremities

2. Hbsen*e o eiden*e o organi* %eri%heral arterial o**lusion +. Symmetri*al or bilateral distribution

6. E*lusion o any disease& o**u%ation& trauma or drug

ingestion that *ould gie rise to asos%asti* abnormalities

8. Hbsen*e o immunologi*al abnormalities eg. Begatie HBH A. Female se& age under 28 years

=. #istory o *old intoleran*e sin*e *hildhood @. Bormal nail old *a%illaries

>. Bormal ES

Memeriksaan Menun(ang



_{,old Stimulation Test}



_{Bailold ,a%illaros*o%y}



_{Hntinu*lear antibody !HBH$}



_{Erythro*yte sedimentation rate !ES$}



_{,-rea*tie %rotein !,M$}

 Tera%i



_{edi*al treatment: *al*ium *hannel}

blo*kers& al%ha blo*kers& asodilators



_{Surgi*al treatment: sym%athe*tomy}

!rera*ter and unres%onsie to other

t$& *hemi*al in(e*tion& am%utation.



_{#ealth edu*ation: sto% smooking&}

e*er*ise& stress *ontrol& aoid

*aeine& dress warmly outdoors

Penyakit Arteri Perifer O#struktif  EKSTRE-ITAS 0A?A3 Iskemia Akut  $A)I' Tr"#sis E"#lisasi Iskemia *ronis $+)I' Oklusi atersklertik 

PAPO EKSTRE-ITAS

0A?A3

KLASIFIKASI PAPO

EKSTRE-ITAS 0A?A3

KLASIFIKASI FONTAINE KLASIFIKASI RUT3ERFORD Sta&e Te"uan Klinis %ra'

e

Kate& ri

Te"uan Klinis

I Hsim%tomatik 4 4 Hsim%tomatik IIH laudikasio ringan I C laudikasio ringan II laudikasio sedang-berat I 2 laudikasio sedang

III Byeri iskemik saat beristirahat

I + laudikasio berat IJ 1lkus ' gangren II 6 Byeri iskemik saat istirahat III 8 erusakan (aringan minor III A erusakan (aringan luas<mayor

KLASIFIKASI PAPO

EKSTRE-ITAS 0A?A3

Lesi Tie A $

C. Stenosis tunggal dengan %an(ang ^ C4 *m

2. Oklusi tunggal dengan %an(ang ^ 8 *m Lesi Tie 0 $

C. Lesi multi%le !oklusi<stenosis$& _ ^ 8*m

2. Stenosis<oklusi tunggal ^ C8 *m yg tdk melibatkan H. Mo%litea

inragenikulatum

+. Lesi tunggal<multi%le tan%a bantuan by%ass distal dari Ha. tibiales

6. Lesi oklusi terkalsikasi se%an(ang ^ 8*m

8. Stenosis %o%liteal tunggal Lesi Tie 1 $

C. Lesi multi%le dengan total 3 C8*m& dengan<tan%a kalsikasi

2. Stenosis<oklusi rekuren yang teta% memerlukan %enanganan setelah 2 interensi endoaskuler

Lesi Tie D $

C. Oklusi total kronis& 324*m s<d H.%o%litea 2. Oklusi total kronis s<d H. Mo%litea '

A1UTE LI-0 IS13E-IA (ALI)

 _{Denisi: %enurunan %erusi ekstremitas inerior}

se*ara mendadak atau dalam 2 minggu %as*a ke(adian inisasi

 _{e(adian inisasi yang men(adi %redis%osisi:}

 _E"#lisasi  HF<JF& thrombosis intramural&

kardioersi& gangguan katu% (antung<M

 _{Tr"#sis}  lesi aterosklerotik lokal&

hi%erkoagulasi

 _{Prse'ur reaskularisasi}

 _Trau"a  him%itan<entra%ment %embuluh

darah dalam kom%artemen

-ANIFESTASI KLINIS ALI

 

_{,P $andin"kan den"an ekstremitas}

kontralateral'

%ain



 nyeri iskemik %ada

otot %aha<betis& %allor& %aresthesia& %aralysis&

%ulselessness& %oikilothermia

Para"eter Kate&ri

.iale (hreatened Irreversile

Deskrisi >ot iediatel threatened ;ala0eable dgn tindakan segera erusakan  (aringan luas  indikasi am%utasi +apillar# return aik !9$& melambat !-$  tanda : marbling Kele"a!an tt

!-$ Marsial<ringan Maralisis ' rigor %an&&uan

sensris

!-$ ingan Marestesia<anesth esia !9$ Te"uan a'a  Audible Audible-inaudi Inaudible

AL%ORIT-A

-ANA+E-EN ALI

TRO-0OLISIS

  A0ent of choice : rTMH Stre%tokinase atau 1rokinase !IJ$

 "elas I)IIA serta %asien dengan oklusi asa kecil  melarutkan

trombus ke*il di area %er*abangan ' mengurangi (e(as endotelial %as*a administrasi

 Menurunkan kejadian reperfusion injur karena en0uran0i besar trobus secara 0radual

 _{KI$ riwayat stroke& tumor intrakranial& D nero%ati& insusiensi} gin(al& gangguan koagulasi

ANTIKOA%ULASI

 _{Disarankan untuk segera diberikan}  ence0ah propa0asi throbus

ke dindin0 asa sekitarna

 _KI$

 I ' ,BS leeding

 D nero%ati

 Hl*oholi* lier disease

 Hlergi obat

 

_{Smooking *essation}

 

_{Liestyle modi*ation}

 

_Eer*ise

 

_{M/:  blo*ker& H,EI}

 

_{,holesterol /: LDL 7C44mg<dl& statin}

 

_{Hs%irin or ,M}

 

_{,ilosta;ole: 0 *laudi*ation distan*e 64-A45}

 

_{Mentoy%hylline: /blood is*osity& 0,}

)eybility& blood )ow ' tissue oygenation

T3RO-0E1TO-Y 

Eksisi trombus dari dinding asa !dilakukan sebagai tambahan %ada %asien yang telah men(alani trombolisis$ 

epercepat rekanalisasi dan reaskularisasi ke

 (aringan yang mengalami iskemia

E-0OLE1TO-Y 

engeluarkan emboli dari dalam lumen asa dengan *ara

membuat insisi %ada dinding

asa& diikuti insersi kateter untuk mengeluarkan emboli

0YPASS %RAFT T3RO-0E1TO-Y 

engeluarkan trombus dari dalam lumen asa dengan *ara membuat insisi& dilakukan bersamaan dengan %emasangan MTFE 0raft  melewati

KO-PLIKASI ALI

  _{Reerfusin inury : %erusi kembali setelah %eriode iskemia} 

%ermeabilitas ka%iler 0 la(u diusi ke (aringan 33  %roduksi

OS oleh sel endotel 33  imbalan*e %roduksi OS ' BO di

 (aringan  in)ammatory damage ' hi%erkalemia

  _{Sin'r" k"arte"en : iskemia lama}  re%erusi  kebo*oran

isi ka%iler ke area interstitial  tekanan intrakom%artemen 0

!3tekanan %erusi ka%iler$  iskemia

 _{e(ala : nyeri iskemik !9$ saat dilakukan} passie stretchin0 %ada kom%artemen& %ulsasi !9$& kebas antara (ari kaki C ' 2 !kom%resi B. Meroneus %roundus$

 _{Diagnosis : ukur tekanan intrakom%artemen !intraarterial line/}  _{ana(emen : /asciotom#  !(ika tekanan intrakom%artemen 324}

mm#g$ 9 alkalinisasi urin 9 diuresis %aksa  men*egah

rhabdomyolisis ' de%osisi myoglobin di tubulus gin(al

  _{Re2t!r"#sis}   _{Re2e"#lisasi}

13RONI1 LI-0 IS13E-IA

%E+ALA 1LI on )im (hreatenin" laudikasio intermiten %ada

betis !calf pain$

)im (hreatenin" Byeri hebat saat tidak beraktiitas 1lserasi ' gangren

  _{+hronic )im Ischemia}

$+)I' adalah suatu kondisi dimana ge(ala

iskemi ekstremitas bawah meneta% selama 32

minggu& umumnya disertai %erburukan

ge(ala !rest pain '

ulserasi<gangren$

  _{Lkasi terserin&: A7} Fe"ralis suer.5ial

!saat melewati *analis addu*torius$

anagemen ,LI

 

_{edah askular arteri %erier tungkai:}

atherektomi& endarterektomi&

am%utasi

 

_{Mintas askular !by%ass grating$:}

 

_{edah endoaskular: angio%lasti}

%erkutan< %er*utaneous transluminal

angio%lasty !MTH$

 

_{edah %aliati: sim%atektomi}

PER1UTANEOUS TRANSLU-INAL AN%IOPLASTY 

Memasangan kateter melewati area %lak

 mengembangkan

balon untuk eks%ansi %osisi stent  ksasi

stent  menarik

kateter ' balon keluar dari lumen asa

AT3EREKTO-I

 ateter dengan u(ung ta(am dimasukkan ke dalam arteri 

mengikis %lak atherom dengan blade %ada

ENDARTEREKTO-I

emisahkan %lak atherom dari

y%ass

Sur&i5al #yass fr art2ilia5 'isease7 A$ Horto-biemoralby%ass. 0$ Ilio-emoral by%ass. 1$ Femoral-emoral by%ass. D$ Hillo-emoral by%ass *ombined with

A-PUTASI

embuang bagian ekstremitas yang tidak iable

In'ikasi a"utasi $

/ erusakan (aringan mayor ireersibel !e.g. Mosttrauma$

/ erusakan neuroaskular ireersibel !e.g. 1lkus ' gangrene$

/ eganasan

A"utasi -inr $

C. Digital am%utation  %ada (ari

tertentu

2. Martial oot am%utation +. Disartikulasi ankle A"utasi -ayr $ 6. elow-knee am%utation !H$ 8. Disartikulasi lutut A. Hboe-knee am%utation !HH$ =. Disartikulasi %anggul @. #emi%ele*tomy

Sym%athe*tomy

DorsalT2sympathectomyapproachwith removalofT2transverse%ro*ess and

proximalT3rib.

Dorsalsympathectomyand removaloftheT2ganglion

Endos*o%i* Thora*i*

Sym%athe*tomy !ETS$

 T+ ganglion u%%er and

lower *onne*tions seered& leading to retra*tion o the *ut edges

Hlternatie method: T+

anglion Rese5tin. Hll

*onne*tions seered. ,ut edges o rami

*ommuni*antes isible in the *enter o the image. elatiely reKuent lo*ation o the T+

ganglion below the +rd interstitial s%a*e& oerlying the lower hal o the 6th rib& its grey *ommuni*ating bran*h *rossing the 6th rib ba*k u%wards

MOBOSIS

  _{,oeisting ,HD ' ,JD}

  _{,HD on MHD: C<+-C<2 based on *lini*al %resentation}

' E,& 3C<2 by *oronary angiogra%hy.

  _{C8?+45 8-year mortality rate and 2-A in*reased}

risk o death rom *oronary heart disease.

  _{=8?@45 o nondiabeti* %atients with}

mild-moderate *laudi*ation remain sym%tomati*ally stable. C?25 deelo%ing *riti*al limb is*hemia.

  _{28?+45 o %atients with *riti*al limb is*hemia}

surie ' undergo am%utation within C year.