Penyakit Arteri Perifer Oklusif Sal

PENYAKIT ARTERI PERIFER OKLUSIF

Dr. Dion Faisal

DEFINISI Penyakit Arteri Perifer Oklusif (PAPO)/ Peripheral Occlusive Arterial Disease (POAD)/ Peripheral Arterial Disease (PAD) Disease  (PAD):: Sindroma klinis yang disebabkan oleh adanya stenosis atau oklusi lumen aorta atau arteriarteri ekstremitas bawah.

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

DEFINISI Penyakit Arteri Perifer Oklusif (PAPO)/ Peripheral Occlusive Arterial Disease (POAD)/ Peripheral Arterial Disease (PAD) Disease  (PAD):: Sindroma klinis yang disebabkan oleh adanya stenosis atau oklusi lumen aorta atau arteriarteri ekstremitas bawah.

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

ETIOLOI  

 

 

Arterisklersis  sklersis  !"#O$: kelainan %ada tunika intima arteri yang kom%leks& terdiri dari %enyumbatan setem%at oleh berbagai bahan li%ida& karbohidrat& darah ' kom%onen darah&  (aringan ikat ' de%osit kalsium diikuti diikuti kelainan tunika media. Arteritis: Arteritis: %roses keradangan !in)amasi$ dinding arteria yang menyebabkan %enebalan dinding dan memberi sumbatan arteria yang kronis T!r"#e"#li$ bagian ke*il dari blood clot  yang terle%as menyebabkan sumbatan %embuluh Puruhito. Buku Ajar Prier Ilu Bedah !oraks, "ardiak, # darah. $askular. askular. edisi edi si 1. %&1'

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 nyeri distal lesi !iskemia$  0a'ensin iske"ik  Lesi: %er*abangan arteri& turbulensi& shear stress& ' intimal in(ury. 1sia tua ' D 333 Lokasi: Femoral & popliteal 80-90% !ibial # peroneal (&)*&+ Ilia*a ' abdominal aorta +45







 

   

  



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

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 -RA Sensitiitas dan s%esitas @4?>45 









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 +D re*onstru*tion o the aortoilia* arteries using LightS%eed ale L TangC& ason ,hin2 and elina  ibbeG2. Hdan*es Jolume 1T i"a&e a56uisitin7 ,al*ied %laKues in the aorta in diagnosti* imaging or %eri%heral arterial disease E4pert and ilia*s are isuali;ed with high resolution& as are the 5e. 6ardioasc. !her. @!C4$& C66=?C688 !24C4$ relationshi% o the arteries to bony landmarks

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 *ollagen

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 Bo ty%i*al lab abnormalities

Hrteriogra  

 

 

 

 

 Yuichi Fujii et al. Circulation. 2007;116:e539-e540

H& DSH: ,orks*rew *ollaterals around the area o o**lusions. D1S:

Small and mediumsi;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

 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.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+

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