Dr Arvind Kohli
6th August is observed as Vascular disease Awareness day and on this day we must analyze measures to counter tremendous increase in number of vascular ailments in our country and minimize the morbidity and mortality related to these diseases by prevention ,timely detection and management Spectrum of vascular diseases – Disorders of blood vessels and blood circulation in our body – is found to be increasing in India over the past decade. Atherosclerosis and allied causes like arteriopathies lead to involvement of aorta and arteries resulting in aneurysmal or occlusive diseases with potential risk to limb, organ and or life. Advanced age, smoking habit, consumption of alcohol, over eating, obesity, physical inactivity coupled with diabetes and hypertension are found to enhance the disease process. Varicose veins and deep vein thrombosis with serious potential complications involving veins are also on the rise. Accidents with injury involving major vessel are rapidly increasing with socioeconomic changes in the community.
Vascular Disease Awareness Day
Vascular Diseases Prevalence
Peripheral Vascular Disease is an important cause of morbidity and affects 10 million people in India. It is a common condition with variable morbidity affecting men and women over the age of 45 years. Therefore it becomes very important for the physicians and health providers to know the pathology, clinical presentations and treatment of common vascular disorders. Increasingly, peripheral vascular disease is becoming a focus of involvement for primary care physicians and vascular specialists who must work in unison. Awareness and interest in peripheral vascular disease is growing in India because of the following reasons:o Advancing age of the general population, resulting in increase prevalence of the peripheral vascular disease. Unwillingness of patients to accept the limitations and associated morbidity of vascular disease when therapeutic options are available. o The realization that vascular disease in one system should prompt investigation of other areas for coexistent disease Further Diseases of Venous System like Deep vein thrombosis (DVT) may lead to chronic venous insufficiency, in which there is edema, pain, stasis pigmentation, stasis dermatitis and stasis ulceration.on legs.. DVT is usually benign but can cause lethal pulmonary emboli or chronic venous insufficiency. For DVT, the objectives of treatment are prevention of pulmonary embolism and chronic venous insufficiency. .Varicose Veins are other condition in which dilated and tortuous superficial veins(usually in the legs) with incompetent valves, permitting reversed flow are the hall mark of this condition. This condition is a fairly common in India. Valve failure at the saphenofemoral junction permits reflux into the saphenous vein from deep veins causing persistent ambulatory venous hypertension, Patients present with restless legs and venous ulcers which are difficult to treat
Public Awareness In India Peripheral vascular disease is under diagnosed and undertreated, and there is evidence that guideline recommendations are not being adequately followed in practice. The Health providers and vascular specialists should consider the creation of national vascular disease quality initiatives such as a PAD or VTE registries , setup the Guidelines and introduce a System of Care for peripheral vascular disease. Like . important findings from the Reduction of Atherothrombosis for Continued Health (REACH) and PAD Awareness, Risk and Treatment: New Resources for Survival (PARTNERS) registries. Information on simple diagnostic tools to aid early PAD detection and therapeutic options for global atherosclerosis risk factor management are also presented. Awareness Programs for control of these diseases at primary level and patient education about risk factors could significantly improve the identification and treatment of patients with vascular disease
Management of Vascular ailments
Lifestyle modifications
Smoking cessation is an important modifiable behaviour. The degree of damage caused by smoking is directly related to the amount of tobacco consumed Smoking cessation improves walking distance, and reduces the incidence of post-operative complications and reocurrences
Exercise and diet
Promotion of physical activity is also an important intervention. Supervised exercise programs have been consistently demonstrated to improve walking time and walking distance. Exercise is beneficial, even among asymptomatic PAD patients. It improves overall wellbeing and is cardioprotective.
A well balanced diet with a low salt, low fat, and moderate amounts of added sugar intake reduces the risk of chronic disease in general, and vascular diseases in particular, and should be followed.
Obesity has been linked with complications of PAD, and diet and exercise should be focused on obtaining a healthy weight.
Pharmacotherapy
Cilostazol, a phosphodiesterase III inhibitor . is well tolerated and has been shown to improve walking distance in people with .. Another agent to improve walking distance is pentoxifylline, although current data indicate that its benefit is marginal
Antiplatelet agents reduce all-cause mortality and fatal cardiovascular events in patients with PAD
Lipid lowering agents improve pain-free walking distance and reduce total cardiovascular events, due primarily to an overall reduction in vascular events..
Patients with diabetes are at increased risk of cardiovascular events, therefore good glycaemic and CVD risk factor control is desirable.
The role of anticoagulation in Venous diseases. Anticoagulant inpatient medications should include heparin or a low-molecular-weight heparin (LMWH), followed by the initiation of an oral coumarin derivative. . The predominant coumarin derivative in clinical use. is warfarin sodium.
Apixaban, dabigatran, rivaroxaban, edoxaban, and betrixaban are alternatives to warfarin for prophylaxis or treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE). Apixaban, edoxaban, rivaroxaban, and betrixaban inhibit factor Xa, whereas dabigatran is a direct thrombin inhibitor
Surgical intervention
Patients with CLI (rest pain, tissue loss, or gangrene) usually require revascularisation to prevent limb loss. Patients with lifestyle limiting symptoms that do not improve with medical management should also be considered for intervention. The main options include endovascular angioplasty or stenting, or open surgical reconstruction by peripheral bypass or endarterectomy. The choice of procedure will depend on the anatomic location of the stenotic/occlusive disease, its extent, and the patient’s comorbidities.
Similarly advent of mechanical clot thrombolysis like angiojet technique for venous thrombus and thermal and non thermal methods for manangement of Varicose veins have revolutionized the management in venous disorders
Take home message on Vascular day Vascular diseases are silent killers and preventing them to happen or progress is the best advice
Whether arterial PAD or venous thrombosis can suddenly create a dire situation for a patient and quiet often results in morbidity and mortality .Creating Awareness in general population about serious nature of these ailments if they are not attended well in time and controlling various risk factors responsible for these conditions are need of this hour and day.
(The author is Vascular Surgeon GMC Jammu)
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