1. ARTERIAL DISEASES Objectives:
TO UNDERSTAND THE NATURE OF OCCLUSIVE ARTERIAL DISEASE AND ITS ASSOCIATED SYMPYOMS AND SIGNS
TO ABLE TO ASSESS ACUTE AND CHRONIC ARTERIAL INSUFFICIENCY AND KNOW TREATMENT OPTIONS.
TO KNOW ABOUT GANGRENE AND ITS MANAGEMENT
TO KNOW OTHER ARTERIAL DISEASES LIKE ANEURYSMS,
ARTERITIS AND VASOSPASTIC DISEASES & AVFistula

2. Arterial Occlusion

3. Occlusive arterial disease
Types
Acute arterial occlusion
Chronic arterial occlusion

4. ACUTE ARTERIAL OCCLUSION
CAUSES-
EMBOLIC
THROMBOTIC
Heart diseases-Atrial fibrillation,mural thrombus, Post MI
Rheumatic valvular heart diseases
Paradoxical embolism- venous thromboembolism due to patent foramen ovale
Arterio- arterial embolism- dislodgement of atheromatous plaques
Angiographic procedures
Accidental- intraarterial injection- Ergot,thiopental
Trauma.

5. Embolism Brain-MCA Retina-Amaurosis fugax Mesenteric vessel- Spleen
Kidneys
Lungs-pulmonary embolism

6. ACUTE ARTERIAL OCCLUSION-Embolism
C/F FIVE Ps
PAIN
PARALYSIS
PALLOR
PULSELESSNESS
PARAESTHESIA

7. Relation ship of symptoms to the site of obstruction
Aorto-iliac obstruction
Iliac obstruction
Femoro-popliteal obstruction
Distal obstruction
ankle pulses absent
Caludication in both buttocks,thighs & calves. Femoral & distal pulses absent in both limbs. Impotence.bruit over aortoiliac region.
U/l claudication in thigh & calf buttocks.
Bruits over iliac region
U/L absence of femoral or distal pulses.
U/L claudication in calf. Femoral pulse palpable with absent u/l distal pulses
Femoral & Popliteal pulse palpable
claudication in calf & foot

8. Arterial Stenosis General- Investigations: CBC,ESR,
PLASMA -fibrinogen, protein, electrophoresis,
Glucose- blood n urine.
Lipid profile
Doppler -USG blood flow detection
Duplex imaging.
Echocardiography
Arteriography
DSA
ECG

9. Hand held Doppler

10. COLOUR DUPLEX

11. ARTERIOGRAM

12. DSA

13. Angioscope

14. Treatment. Embolic arterial occlusion is an emergency!!!
THROMBOLYSIS – Immediate -Intra Venous Heparin 5000U
to prevent distal and proximal extension of thrombus.
Contraindications
Recent stroke
Active peptic ulcer
Bleeding disorders
Pregnancy
Hydration
EMBOLECTOMY
THROMBECTOMY.

15. Fogarty catheterization- for removing proximal and distal extension of thrombus.
Postoperatively- heparin and oral anticoagulation
Intrarterial Thrombolysis
Only if ischemia is not so severe that immediate operation is mandatory, it is possible to treat thrombus or embolus by intra arterial thrombolysis
Agents-TPA-tissue plasminogen activator**
Streptokinase
Urokinase
Identify and treat the basic cause.

16. SFA thrombolectomy

17. Removed thrombus

18. Arterial Catheters

19. Chronic Arterial Insufficiency
Etiology
Atherosclerosis
Buerger’s disease
Artritis
Arterisclerosis
Diabetes
Risk Factors
Hypertension
Strong family history
Smoking
Lipid abnormalities

20. Chronic Limb Ischemia
Ischemia of the lower limb may be minimal to critical
Also called Chronic arterial insufficiency or
Peripheral Vascular disease-PVD.
Clinical presentation-
Intermittant Claudication-commonest complaint. Fatigue, aching or crampy pain occuring with exertion and relieved by rest, reproducible at the same distance.
Claudication distance- distance at which the pain appears
Rest pain
Critical ischemia- severe ischemia with actual or potential tisssue loss.

21. Signs of chronic ishemia
Loss of muscle mass/bulk
Loss of subcutaneous fat
Skin shiny
Loss of hair
Brittle nails
Gangrene and ulcers of foot.

22. ???

23. GANGRENE
Def: death, often with putrifaction of macroscopic portion of tissues.
VARIETIES ACCORDING TO THE CAUSE-
Secondary:
Thrombus in atherosclerotic artery.
ATRIAL FIBRILLATION-embolus.
Arteritis from NEUROPATHY
BUERGERS DISEASE
RAYNAUDS DISEASE/ERGOTISM- causing arterial shutdown
INTRARTERIAL INJECTIONS- thiopentone & cytotoxic materials.

24. GANGRENE
Primary:
INFECTIVE- boils, carbuncles, gas gangrene, gangrene of scrotum (Fournier’s gangrene)
TRAUMATIC- crush, pressure sores & constriction grooves
PHYSICAL- burns, scalds,frostbite,chemical irradiation & electricity.
VENOUS-
C/F
Pulseless,painnless,funtionless, with colour change.
Lacks capillary refill and venous return.
Black,brown, greenish black.

25. GANGRENE CLINICAL TYPES- DRY & MOIST DRY gangrene-
dessicated tissues,part becomes dry and wrinkled. Wrinkled ,discolourd from disintegration of Hb. & greasy to touch.
MOISTgangrene:
when venous & arterial obstruction is present, when artery is suddenly occluded by a ligature or embolus & in diabetes..
Infection & putrifaction is present.
Part is swollen& discoloured.
Crepitus may be present.

26. GANGRENE SEPERATION OF GANGRENE- SEPERATION BY DEMARCATION
SEPERATION WITHOUT DEMARCATION.
Vague DEMARCATION & skip lesions.
TREATMENT OF GANGRENE-
GENERAL PRINCIPLES- limb saving attitude.
Cardiac failure
Atrial fibrillation anaemia. Nutritious diet.
Control of diabetes.
Analgesics.
LOCAL TREATMENT-
dry.protection of pressure areas. Cleanniess.

27. VARIETIES OF GANGRENE DIABETIC GANGRENE- three factors-
Trophic changes from peripheral neuritis.
Atheroma of artries causing ischemia
Excess sugar –decreases resistance to infections esp. fungal infection
DIRACT TRAUMATIC GANGRENE
BEDSORES-(Decubitus Ulcers) 5 factors
Pressure
Injury
Anemia
Malnutrition
Moisture

28. Pressure Sore

29. Gangrene INDIRECT TRAUMATIC GANGRENE-
Interference with blood vessels from pressure by a fractured bones
/ strangulation
Thrombosis of an artery
Ligation of an artery
poor technique for digital anesthesia
ERGOT- claviceps purpurea.
Fingers,nose & ears .
Seen in migrane suffers.

30. PHYSICAL AND CHEMICAL CAUSE OF GANGRENE.
FROST BITE- cold+wind. Damage to Vessel wall with transudation & edema. Pain initially later painless & gangrene
TRENCH FOOT-cold+ moist+ muscular inactivity.
Ill fitting boots.
I/V INJECTION OF THIOPENTONE
DRUG ABUSE
CHEMICAL GANGRENE- carbolic acid(phenol).

31. Frost bite

32. ANEURYSMS
ANEURYSMS- dilatation of a localised segment of the arterial system.
True- all three layers involved.
False- single layer of fibrinous tissue as the wall of the sac.
According to the shape
-fusiform
-Saccular
-Dissecting
Eti0logy-traumatic/atherosclerotic/syphilitic/collagen disease(Marfan,syndrome), mycotic(bacterial)

34. ANEURYSMS
Symptoms- due to expansion, thrombosis, rupture or release of emboli.
Symptom relate to the vessel affected, the site supplies or the tissue compressed.
Clinical features
Intrinsic-expansile pulsation along the course of an artery. proximal compression decreases pulsations
Palpation- thrill
Auscultation-bruits??
Extrinsic- neighboring or distal structures are affected.
Nerve
Veins
Tubes-trachea ,esophagus

35. D/D
Swelling under an artery- cervical rib(subclavian)
Swelling over an artery-pancreatic cyst
Pulsatile tumors-sarcoma,osteoclastoma & metastsis from hypernephroma.
abscess
serpentine artery- innominate,carotid.

36. ANEURYSMS Abdominal aortic aneurysm- Commonest large vessel aneurysm
2% population
95% atherosclerotic
95% below the renal arteries
Symptomatic/asymptomatic
Symptoms-back pain, sudden – mild-sudden severe.

37. ANEURYSMS Ruptured AAA- Anterior Posterior
Free bleeding into the peritoneal cavity(20%)
Retroperitoneal hematoma(80%)
Profound hypotension
Severe pain

38. ANEURYSMS
Investigation:
USG abdomen
CT Chest & abdomen.
AORTOGRAM

39. ANEURYSMS Procedure Open surgical procedure
Endoluminal stent graft procedure.
Complications:
Respiratory
H’ge
Colonic ischemia
Renal failure
Infection of the graft.
Sexual dysfunction
Fistula formation.
Spinal cord ischemia.

40. Peripheral aneurysms Popliteal aneurysms- most common Femoral Iliac
Ascending aorta & arch

41. AVF: Communication between an artery & vein. Congenital Acquired-
trauma, penetrating wound or sharp blow, surgical
for renal failure.
Structural effect arterialized veins. Dilated tortuous veins
Physiological effect- Increased VR, Increased VP, Increased HR-
Increased CO.
PP-HIGH
LVF
Cardiac failure
Cong Fistula- Overgrowth of limb.
Persistent ulcer due to distal ischemia.

42. ???

43. AVF Clinical signs: Pulsatile swelling Thrill on palpation
Bruits on ausculatation
Dilated veins
Nicoladoni-Branham’s test- Decreased thrill, reduction in size and bradycardia on pressing the artery proximal to fistula
Treatment
Embolization
Ligation of feeding artery???
Surgery- Separation of artery & vein

44. ARTERITIS Thromboangitis obliterans/ Buerger’s disease
Small & medium sized arteries.Occlusive disease
Thrombophebitis of superficial/ deep veins.
Raynauds syndrome, male, young patients

45. VASOSPASTIC CONDITIONS:
Reynaud's syndrome:
Primary/ idiopathic form.
Secondary
Pallor- blanching
Blue- cyanosis
Redness-red engorgement.
Accompanied by pain.
Treatment - conservative
Tab. nicotinamide
Secondary Reynaud's syndrome-
due to some other problem like-collagen disease, atherosclerosis, thoracic outlet syndrome, carpal tunnel syndrome