2. PERIPHERAL VASCULAR DISEASE ABDULAMEER M. HUSSEIN FICMS, FACS

3. Peripheral arteries Arteries outside of chest and abdomen Diseases Occlusive [OAD] Aneurysmal Inflamatory Others

4. WHAT IS THE PERIPHERAL VASCULAR SYSTEM?  The veins and arteries in the arms, hands, legs and feet  Peripheral arteries supply oxygenated blood to the body  Peripheral veins brings deoxygenated blood from the capillaries in the extremities back to the heart. > for Intravenous therapy, it is the most common access for a peripheral intravenous (IV) line

5. DIFFERENCE BETWEEN PVD AND PAD Peripheral Vascular Disease (PVD) - There are problems altering the blood flow through both the arteries and veins. Peripheral Artery Disease (PAD) - is a type of PVD - have problems only with arterial blood flow

6. Only 1 in 10 of thèse patients has classical symptômes of intermittent claudication (IC) 1 in 5 people over 65 has PAD † † ABI<0.9

7. Two types of PVD Functional  Doesn’t have an organic cause.  Doesn’t involve defects in blood vessels’ structure, usually short-term effects and come and go.  Ex: Raynaud’s disease. Organic  Caused by structural changes in the blood vessels, such as inflammation.  Ex: Peripheral artery disease, caused by fatty buildups in arteries.

8. Causes Atheromatous Risk Factors Smoking Diabetes Hypertension Overweight Inactive (sedentary) lifestyle Positive family history Hyperlipidemia Advanced age Inflammatory Trauma Structural defects

9. SYMPTOMS depend on: -What artery is affected -How severely the blood flow is reduced 1. Claudication ( dull, cramping pain in hips, thighs or calf muscle) 2. Numbness or tingling in leg, foot or toes 3. Changes in skin color (pale, bluish or reddish discoloration) 4. Changes in skin temperature, coolness 5. Impotence 6. Infection/sores that do not heal 7. Ulceration or gangrene 8. Uncontrolled hypertension (high blood pressure) 9. Renal failure

10. Clinical presentation Stage Clinical IAsymptomatic IIaMild claudication IIbModerate to severe claudication IIIIschemic rest pain IVUlceration or gangrene Critical limb ischemia Fontaine classification

12. COMPARISON OF CHARACTERISTICS OF ARTERIAL & VENOUS DISORDERS Arterial DiseaseVenous Disease Skincool or cold, hairless, dry, shiny, pallor on elevation, rubor on dangling warm, though, thickened, mottled, pigmented areas Painsharp, stabbing, worsens w/ activity and walking, lowering feet may relieve pain aching, cramping, activity and walking sometimes help, elevating the feet relieves pain Ulcersseverely painful, pale, gray base, found on heel, toes, dorsum of foot moderately painful, pink base, found on medial aspect of the ankle Pulseoften absent or diminished usually present Edemainfrequentfrequent, esp. at the end of the day and in areas of ulceration

13. Investigations General CBP, FBS, RFT, LIPID PROFILE, ECG, ECHO To localise and to plan intervention Ankle Brachial Index (ABI) Ultrasound Doppler Test CT/MR ANGIOGRAPHY Angiogram

14. Management  Medical Graded exercises Aspirin Lipid lowering drugs Cilostazol Pentoxifylline Foot care Stop smoking Aggressive control of co-morbid diseases

15. MANAGEMENT Non-invasive interventions 1. Exercise and diet Exercise -Supervised exercise programs to improve walking time and walking distance -walk until pain is felt, take a rest until the pain subsides (For 3x a week, repeat this cycle to a total of 30 minutes, and progress to 60 minutes per day) Diet - low salt - low fat

16. Non-invasive interventions 2. Positioning - avoid crossing of legs (interferes blood flow) - elevate feet at rest (manages swelling) > not above the heart level > extreme elevation slows arterial blood flow 3. Promoting Vasodilation (increasing the diameter of blood vessels) - provision of warmth to the affected extremity > maintain a warm environment at home > wear socks or insulated shoes at all times > Never apply direct heat to the limb (heating pad or extremely hot water) to reduce the risk of burns

17. TREATMENT  Non-invasive interventions 4. Avoid exposure to cold temperatures 5. Avoid or limit intake of caffeine - causes vasoconstriction. 6. Medications - Given to patients with chronic PVD > Antiplatelet medications (such as Aspirin and Plavix) > Lipid lowering agents > Cilostazol(a phosphodiesterase III inhibitor) > Angiotensin converting enzyme inhibitor (ACEI) > Calcium channel blockers

18. 7. Hypertension - Controlling high blood pressure can improve blood flow through the blood vessels and reduce the constriction 8. Smoking cessation - improvement of walking distance - 5 year survival rate is doubled - Post-operative complications is reduced 9. Little evidence to support for the role of complementary therapies: - vitamin E - garlic

19. Indications for intervention 1. Disabling claudication 2. Rest pain 3. Tissue loss

20. intervention  Endovascular 1.Angioplasty 2.Stenting 3. Atherectomy  Surgical 1. Bypass 2. Endarterctomy 3. Embolectomy  Amputation 4.Thrombolytic Therapy 5. Stent-Grafts

21. Endovascular 1. Angioplasty 2. Stents 3. Atherectomy - a minimally invasive intervention procedure - excision and removal of blockages by catheters with miniature cutting systems. During these procedures: -the physician will periodically inject a contrast dye- x-ray pictures are taken to determine whether or not the artery is sufficiently open. 4.Thrombolytic Therapy 5.Stent-Grafts

22. Surgery -If blockage is extremely long - If blockage has become very hard and calcified with time - If blockage may be resistant to atherectomy or angioplasty and stents Purpose: > to bypass the problem area.

23. Surgical intervention in – advanced disease – ischemic changes and - pain severely impairs activity  Embolectomy  removal of a blood clot, done when large arteries are obstructed  Endarterectomy  is removal of a blood clot and stripping of atherosclerotic plaque along with the inner arterial wall.  Arterial by-pass surgery  an obstructed arterial segment may be bypassed by using a prosthetic material (Teflon) or the pt’s. own artery or vein (saphenous vein)

24. Endarterectomy

25. Bypass

26. Conduits 1. Autogenous saphenous vein 2. Synthetic PTFE DACRON(polyester)

27. Amputation  With advanced atherosclerosis & gangrene of extremities  Toes are the most often amputated part of the body  The surgical goal is the remove the least amount of tissue possible and create a stump adequate for the fitting of a prosthesis

28. POST – OPERATIVE CARE FOR ARTERIAL SURGERY pt. is monitored for signs of  circulation in the affected limb and interventions done to promote circulation & comfort 1.Assess and report changes in skin color and temperature distal to the surgical site, every 2-4 hrs. 2.assess peripheral pulses  sudden absence of pulse may indicate thrombosis  mark location of pulse with a pen to facilitate frequent assessment  use a dapper if pulse in difficult to palpate 3.assess wound for redness, swelling and drainage 4.promote circulation  reposition pt. every 2 hrs.  tell pt. not to cross legs  encourage progressive activity when permitted 5.medication with analgesics to reduce pain

29. ARTERIAL BY-PASS SURGERY Post-operative care o assess sensation and movement of the limb o monitor extremity for edema o monitor & report signs of complications – increase pain, fever, limitation of movement or paresthesia o avoid sharp flexion in the area of the graft to prevent decreased circulation to the graft.

30. Outcome Major cause of mortality in PVD is cardiac and cerebrovascular disease

31. THROMBOANGITIS OBLITERANS ( BUERGER’S DISEASE)  Characterized by acute inflammatory lesions and occlusive thrombosis of the arteries & veins  Has a very strong assoc. with cigarette smoking  Commonly occurs in male – bet. 20-40 y.  Usually affect the lower leg. toes, feet  May involve the arteries of the upper extremities (wrists)

32. CLINICAL MANIFESTATION Intermittent claudication in the arch of the foot Pain during rest – toes Coldness – due to persistent ischemia Paresthesia Pulsation in posterior tibial, dorsalis pedis – weak or absent Extremities are red or cyanotic Ulceration & gangrene are frequent complications – early  can occur spontaneously but often follow trauma

33. THROMBOANGITIS OBLITERANS

34. MANAGEMENT  Advise the person to stop smoking  vasodilators  Prevent progression of disease  Avoid trauma to ischemic tissues  Relieve pain  Provide emotional support  Whiskey or brandy may be of some value during periods of exacerbations  vasodilation  Advise pt. to avoid mechanical, chemical or thermal injuries to the feet  Amputation of the leg is done only when the ff. occurs :  gangrene extends well into the foot  pain is severe and cannot be controlled  severe infection or toxicity occurs

35. RAYNAUD’S PHENOMENON  Refers to intermittent episodes during which small arteries or arterioles of L and R arm constrict (spasm) causing changes in skin color and temperature  Generally unilateral and may affect only 1 or 2 fingers  May occur after trauma, neurogenic lesions, occlusive arterial disease, connective tissues disease  Charac. by reduction of blood flow to the fingers manifested by cutaneous vessel constriction and resulting in blanching (pallor )

36. RAYNAUDS’ DISEASE  unknown etiology, may be due to immunologic abnormalities  common in women 20-40 y.  maybe stimulated by emotional stress, hypersensitivity to cold, alteration in sympathetic innervation

37. Raynauds’ Disease

38. CLINICAL MANIFESTATIONS  Usually bilateral –(both arms or feet are affected)  During arterial spasm – sluggish blood flow causes pallor, coldness, numbness, cutaneous cyanosis and pain  Following the spasm – the involve area becomes intensely reddened with tingling and throbbing sensations  With longstanding or prolonged Raynaud’s disease – ulcerations can develop on the fingertips and toes

39. Raynauds’ Disease

40. MEDICAL MANAGEMENT  Aimed at prevention  Person is advised to protect against exposure to cold  Quit smoking  Drug therapy – Calcium channel blockers, vascular smooth muscle relaxants Vasodilators – to promote circulation and reduce pain  Sympathectomy ( cutting off of sympathetic nerve fibers)  to relieve symptoms in the early stage of advanced ischemia  If ulceration/gangrene occur, the area may need to be amputated

41. Acute limb ischemia Abulameer M. Hussein

42. Definition Sudden interruption of arterial blood supply the with no time for collateral to form. Sudden interruption of arterial blood supply the with no time for collateral to form. The extent of ischemia & final outcome depends upon 1. Size & location of clot 2. Extent of collateral circulation 3. Time between onset of occlusion & treatment

43. Causes of acute arterial ischemia An arterial embolus - most common cause heart as a source - 70 %An arterial embolus - most common cause heart as a source - 70 % Thrombosis on an atheromatous plaqueThrombosis on an atheromatous plaque Thrombosis of an aneurysmThrombosis of an aneurysm Arterial dissectionArterial dissection Traumatic disruptionTraumatic disruption External compression e.g cervical rib, popliteal entrapmentExternal compression e.g cervical rib, popliteal entrapment

44. Arterial embolus Abnormal undissloved material carried in the blood stream from one part of vascular system to impact in distance part. Abnormal undissloved material carried in the blood stream from one part of vascular system to impact in distance part. Types Types 1-Thrombus 1-Thrombus It is the thrombus that dislodged from its source & circulate in blood stream & impact in BV It is the thrombus that dislodged from its source & circulate in blood stream & impact in BV 2-Air 2-Air 3-Fat 3-Fat 4-Neoplastic 4-Neoplastic Common source is mural thrombus that follow MI, mitral stenosis & aneurysm Common source is mural thrombus that follow MI, mitral stenosis & aneurysm Emboli tend to lodge at bifurcation of vessels Emboli tend to lodge at bifurcation of vessels Large emboli straddling in aortic bifurcation Lower limb ischemia Large emboli straddling in aortic bifurcation Lower limb ischemia

45. Trauma Could be 1. 1. Penterating 2. Blunt 2. Blunt 3. Iatrogenic 3. Iatrogenic Commonly in femoral or brachial artery at arterial catheterization Commonly in femoral or brachial artery at arterial catheterization

46. Symptoms and Signs ( Ps ) Symptoms Symptoms Painless ( numbness ) PainParaesthesiaeParalysis Signs SignsPallorPulslessness Perishingly cold to the touch * Muscle tenderness is bad diagnostic especially in muscle of anterior & posterior compartment of the calf

47. Physical Examination Heart rhythm:Heart rhythm: Presence of atrial fibrillation or other arrhythmias Apex beat (ventricular aneurysm) Auscultation for evidence of valvular disease Inspection of limbs:Inspection of limbs: Pallor of the skin Tense, tender calf with impaired dorsiflexion (compartment compression)Tense, tender calf with impaired dorsiflexion (compartment compression)

48. Physical Examination Venous guttering:Venous guttering: Veins are so empty to appear as shallow grooves or gutters Buerger’s test: rapid pallor as arterial supply is poor.Buerger’s test: rapid pallor as arterial supply is poor. Delayed capillary refill.Delayed capillary refill. Skin temperature: a difference of as small as 1˚C can be ascertained.Skin temperature: a difference of as small as 1˚C can be ascertained.

49. Physical Examination Absent peripheral pulses:Absent peripheral pulses: Important to delinate a blockage in the arteries (e.g. presence of femoral pulse and absent distal pulses indicate superficial femoral block. Ankle brachial pressure index (ABPI)Ankle brachial pressure index (ABPI) It is the ratio of pressure at foot pulse to that at the brachial artery. < 0.5 indicate significant ischemia.

50. complication Leg become mottled & marbled Leg become mottled & marbled Muscle hardness Muscle hardness Skin become blister Skin become blister Gangrene which usually start in toes before spreading distally Gangrene which usually start in toes before spreading distally

51. Differential Diagnosis Arterial embolusArterial embolus Acute arterial thrombosisAcute arterial thrombosis Thrombosed aneurysmThrombosed aneurysm Aortic dissectionAortic dissection Traumatic arterial disruptionTraumatic arterial disruption Cervial ribCervial rib Acute venous thrombosisAcute venous thrombosis Spinal cord compression or infarctionSpinal cord compression or infarction

52. Investigation Critical ischemia needs investigating with great urgency to relieve the patient’s pain and to prevent irreversible damage.Critical ischemia needs investigating with great urgency to relieve the patient’s pain and to prevent irreversible damage. They include:They include: Duplex ultrasonography C-T Angiography Arteriography ECG to exclude associated coronary diseases Serum cholesterol: raised in atherosclerosis Urine for sugar and blood glucose: to exclude DM

53. Therapeutic Strategies in Acute Ischemia Most common vascular emergency 1. Intra arterial thrombolysis 1. Intra arterial thrombolysis 2. Thrombo-aspiration with catheter 2. Thrombo-aspiration with catheter 3. Mechanical thrombolysis 3. Mechanical thrombolysis 4. Surgical Embolectomy – Fogarty catheter 4. Surgical Embolectomy – Fogarty catheter

54. INITIAL TREATMENT  Ischaemia beyond 6 hours is usually irreversible and results in limb loss.  Stasis may cause a thrombus to extend distally and proximally to the embolus.  The immediate administration of 5000 U of heparin intravenously can reduce this extension and maintain patency of the surrounding (particularly the distal) vessels until the embolus can be treated.  IV fluid  Analgesia

55. THROMBOLYSIS  At arteriography :, a narrow catheter is passed into the occluded vessel and left embedded within the clot.  Tissue plasminogen activator (TPA) is infused through the catheter and regular arteriograms are carried out to check on the extent of lysis, which, in successful cases, is achieved within 24 hours.  The method should be abandoned if there is no progression of dissolution of clot with time. Contraindications to thrombolysis recent stroke bleeding diathesis Pregnancy results in those over 80 years old are poor.

56. OPERATIVE TREATMENT Embolectomy  Local or general anaesthesia may be used.  The artery (usually the femoral), bulging with clot, is exposed and held in slings.  Through a longitudinal or transverse incision, the clot begins to extrude and is removed, together with the embolus  Fogarty balloon catheter is introduced both proximally and distally until it is deemed to have passed the limit of the clot.  Postoperatively, heparin therapy is continued until long-term anticoagulation with warfarin is established.

57. COMPARTMENT SYNDROME Reduced organ / tissue perfusion as a result of increased intracompartmental pressure Happen in tight compartments Results in vicious cycle of ischemia and swelling and eventual muscle death

58. PERIPHERAL VASCULAR TRAUMA

59. MECHANISM Blunt –Orthopaedic # –Dislocation (knee) –Isolated Penetrating –High velocity –Low velocity Iatrogenic

60. TYPES ARTERIAL DAMAGE 1.Spasm (or compression) 2.Intimal injury 3.Transection 4.Intramural haematoma 5.Pseudoaneurysm

61. PRESENTATION 1. Bleeding / haematoma 2.Ischaemia 3.Complications of vascular injury (Refer later)

62. COMPLICATIONS Ischemia reperfusion injury Compartment syndrome Arteriovenous fistula False aneurysm Death

63. IMMEDIATE TREATMENT Control bleeding Replace volume loss Cover wounds Reduce fractures/dislocations Splint Re-evaluate

64. SIGNS OF ARTERIAL INJURY HARD SIGNS 1.External (arterial bleeding) 2.Rapidly expanding haematoma 3.Palpable thrill/audible bruit 4.Obvious ischaemia 5 P’s

65. INDEX OF SUSPICION SOFT SIGNS 1. History of arterial bleeding 2. Proximity of # / wound to artery 3. Diminished pulse (BP) 4. Small non-pulsatile haematoma 5. Neurologic deficit 6. Hypotension

66. IMMEDIATE REFERRAL Hard signs  Immediate (vascular) surgery referral  Early transfer to theatre  Immediate exploration

67. SOFT SIGNS, OTHER INJURIES 1. Resuscitate 2. Apply compression 3. immobilize 4. Reduce 5. Reassess asymmetry Consult

68. PROBLEMS WITH DIAGNOSING DISTAL ISCHAEMIA AFTER TRAUMA 1.pain could be due to injury itself, may not have pain due to associated nerve injury 2.pallor may be pale due to blood loss 3. Absent pulse may be absent due to low blood pressure. Compare with other limb. 4.paresthesia, paresis may occur due to associated nerve, muscle injury or unresponsive confused patient

69. DOPPLER No signal = no perfusion Signal ≠ normal arteries Investigations

70. CAUTION …. No signal = no perfusion Signal ≠ normal arteries

71. INVESTIGATIONS 2. Duplex scan 3. CT ANGIOGRAPHY - Helps to locate, to assess the extent of injury, to identify associated injuries and to plan the treatment. 4. On table angiography - in cases needing urgent exploration and having multilevel injuries. i.e trap gun injury

72. IN HOSPITALS WHEREFACILITIES FOR REPAIR IS NOT AVAILABLE Urgent transfer after stabilizing ABCDE FASCIOTOMY

73. OPERATIVE MANAGEMENT Angiography In theatre Diagnostic Therapeutic Covered stent Embolization Open exploration Repair Bypass

74. OPERATIVE STRATEGY Position Access Angio Maintain compression Exposure & Control Separate (anatomical) incision Distal Damage limitation intraoperative shunt

75. PROCEDURE Thrombectomy Heparinize Multisystem trauma Coagulopathy Repair deficit Lateral suture Resection and end-end Interposition –autologous vein –Synthetic Ligation Lateral suture Resection and end-end Interposition –autologous vein –Synthetic Ligation

76. VENOUS TRAUMA Repair (vs ligation) Popliteal Massive soft tissue injury Large veins

77. KEY STEPS Direct pressure Subtle signs Early transfer to theatre Angiogram Endovascular Open Fasciotomy

78. ISCHEMIC AND REPERFUSION INJURIES During ischemia Anaerobic metabolism – lactic acidosis Reduced ATP – reduced activity of ion pump – accumulation of intracellular Ca2+, Na+ and other ions, increased permeability Ca2+ - activation of phospholipases and proteases Activation of Xanthine oxidase Increased membrane adhesiveness and Stasis leading to prothrombotic effects

79. ISCHEMIC AND REPERFUSION INJURIES Local Influx of O2 and cells resulting in production of oxygen radicals Adhesion of cells leading to congestion and edema Systemic Acidosis Acute kidney injury ARDS Hyperkalemia Hypotension DIC