peripheral vascular disease pdf - د. عبدالامير

Cardiothoracic

Dr. Abdulameer

Surgery

“

PERIPHERAL VASCULAR

DISEASE

”

Dr.Abdulameer

Lecture

Total Lec: 28

PERIPHERAL VASCULAR DISEASE

Peripheral arteries : Arteries outside of chest and abdomen

Diseases



Occlusive [OAD]



Aneurysmal



Inflamatory



Others

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

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

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.

Causes

1. Atheromatous

a. Risk Factors

1.  Smoking
2.  Diabetes
3.  Hypertension
4.  Overweight
5.  Inactive (sedentary) lifestyle
6.  Positive family history
7.  Hyperlipidemia
8.  Advanced age

b.  Inflammatory
c.  Trauma
d.  Structural defects

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

Comparison of characteristics of Arterial & Venous Disorders

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

ulceration

Management

Medical

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

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

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

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

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

Indications for intervention

1. Disabling claudication

2. Rest pain

3. Tissue loss

Intervention

 Endovascular

1.Angioplasty

2.Stenting

3. Atherectomy

4.Thrombolytic Therapy

5. Stent-Grafts

 Surgical

1. Bypass

2. Endarterctomy

3. Embolectomy

 Amputation

Endovascular

1. Angioplasty

2. Stents

3. Atherectomy

4.Thrombolytic Therapy

5.Stent-Grafts

- 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.

Surgery

1.  -If blockage is extremely long
2.  If blockage has become very hard and calcified with time
3.  If blockage may be resistant to atherectomy or angioplasty and stents

Purpose:

> to bypass the problem area.

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)

›

Endarterectomy

›

Bypass

Conduits

1. Autogenous

saphenous vein

2. Synthetic

PTFE

DACRON (polyester)

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

Post – operative care for arterial surgery

pt. is monitored for signs of  circulation in the affected limb and interventions done to
promote circulation & comfort

Assess and report changes in skin color and temperature distal to the surgical site,
every 2-4 hrs.

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

assess wound for redness, swelling and drainage

promote circulation

›

reposition pt. every 2 hrs.

›

tell pt. not to cross legs

›

encourage progressive activity when permitted

medication with analgesics to reduce pain

Arterial by-pass surgery

Post-operative care

1. assess sensation and movement of the limb

2. monitor extremity for edema

3. monitor & report signs of complications – increase pain, fever, limitation of

movement or paresthesia

4. avoid sharp flexion in the area of the graft to prevent decreased circulation to the

graft.

Outcome

Major cause of mortality in PVD is cardiac and cerebrovascular disease

Thromboangitis Obliterans
( Buerger’s Disease)

1. Characterized by acute inflammatory lesions and occlusive thrombosis of the

arteries & veins

2. Has a very strong assoc. with cigarette smoking

3. Commonly occurs in male – bet. 20-40 y.

4. Usually affect the lower leg. toes, feet

5. May involve the arteries of the upper extremities (wrists)

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

Thromboangitis Obliterans

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:

1. gangrene extends well into the foot

2. pain is severe and cannot be controlled

3. severe infection or toxicity occurs

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)

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

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

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

Acute limb ischemia

Definition

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

Causes of acute arterial ischemia

1. An arterial embolus - most common cause heart as a source - 70 %

2. Thrombosis on an atheromatous plaque

3. Thrombosis of an aneurysm

4. Arterial dissection

5. Traumatic disruption

6. External compression e.g cervical rib , popliteal entrapment

Arterial embolus

• Abnormal undissloved material carried in the blood stream from one part of

vascular system to impact in distance part

• Types

1Thrombus

It is the thrombus that dislodged from its source

& circulate in blood

stream

& impact in BV

•

- Air

•

- Fat

•

- Neoplastic

• Common source is mural thrombus that follow MI, mitral stenosis

& aneurysm

• Emboli tend to lodge at bifurcation of vessels

• Large emboli straddling in aortic bifurcation Lower limb ischemia

Trauma

Could be

1.  Penterating
2.  Blunt
3.  Iatrogenic

Commonly in femoral or brachial artery at arterial catheterization

Symptoms and Signs (Ps )

• Symptoms

1. Painless ( numbness

(

2.  Pain
3.  Paraesthesiae
4.  Paralysis

• Signs

1.  Pallor
2.  Pulslessness
3.  Perishingly cold to the touch

*Muscle tenderness is

bad

diagnostic especially in muscle of anterior

& posterior

compartment of the calf

Physical Examination

• 1-Heart rhythm:

•  Presence of atrial fibrillation or other arrhythmias
•  Apex beat (ventricular aneurysm)
•  Auscultation for evidence of valvular disease

• 2-Inspection of limbs:

• Pallor of the skin

• 3- Tense, tender calf with impaired dorsiflexion

( compartment compression)

• 4- Venous guttering:

• Veins are so empty to appear as shallow grooves or gutters

• 5- Buerger’s test: rapid pallor as arterial supply is poor.

• 6- Delayed capillary refill .

• 7-Skin temperature: a difference of as small as

˚ C can be ascertained .

• 8- 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 .

• 9-Ankle brachial pressure index (ABPI)

• It is the ratio of pressure at foot pulse to that at the brachial artery

1.5

indicate significant ischemia .

complication

1. Leg become mottled

& marbled

2. Muscle hardness

3. Skin become blister

4. Gangrene which usually start in toes before spreading distally

• Differential Diagnosis

1.  Arterial embolus
2.  Acute arterial thrombosis
3.  Thrombosed aneurysm
4.  Aortic dissection
5.  Traumatic arterial disruption
6.  Cervial rib
7.  Acute venous thrombosis
8.  Spinal cord compression or infarction

Investigation

• Critical ischemia needs investigating with great urgency to relieve the patient’s

pain and to prevent irreversible damage .

• They include :

1. Duplex ultrasonography

2. C-T Angiography

3. Arteriography

4. ECG to exclude associated coronary diseases

5. Serum cholesterol: raised in atherosclerosis

6. Urine for sugar and blood glucose: to exclude DM

Therapeutic Strategies in Acute Ischemia

Most common vascular emergency

1. Intra arterial thrombolysis

2. Thrombo-aspiration with catheter

3. Mechanical thrombolysis

4. Surgical Embolectomy – Fogarty catheter

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

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

1. recent stroke

2. bleeding diathesis

3. Pregnancy

4. results in those over 80 years old are poor.

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.

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

peripheral Vascular Trauma

Mechanism

1-Blunt

Orthopaedic #

Dislocation (knee)

Isolated

2-Penetrating

High velocity

Low velocity

3-Iatrogenic

Types arterial damage

1. Spasm (or compression)

2. Intimal injury

3. Transection

4. Intramural haematoma

5. Pseudoaneurysm

Presentation

1.Bleeding / haematoma

2.Ischaemia

3.Complications of vascular injury (Refer later)

Complications

1.  Ischemia reperfusion injury
2.  Compartment syndrome
3.  Arteriovenous fistula
4.  False aneurysm
5.  Death

Immediate treatment

1.  Control bleeding
2.  Replace volume loss
3.  Cover wounds
4.  Reduce fractures/dislocations
5.  Splint
6.  Re-evaluate

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

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

Immediate referral

Hard signs

 Immediate (vascular) surgery referral

 Early transfer to theatre

 Immediate exploration

Soft signs, other injuries

1.  Resuscitate
2.  Apply compression
3.  immobilize
4.  Reduce
5.  Reassess

a. asymmetry

2. Consult

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

Investigations

Doppler

No signal = no perfusion

Signal ≠ normal arteries

Caution ….

No signal = no perfusion

Signal ≠ normal arteries

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

*In hospitals where facilities for repair is not available

Urgent transfer after stabilizing ABCDE

FASCIOTOMY

Operative management

Angiography

•  In theatre
•  Diagnostic
•  Therapeutic
•  Covered stent
•  Embolization

Open exploration

• Repair
• Bypass

Operative strategy

1-Position

• Access
• Angio

2-Maintain compression

3-Exposure & Control

• Separate (anatomical) incision
• Distal

4-Damage limitation

• intraoperative shunt

Procedure

Thrombectomy

Heparinize caution with :

1. Multisystem trauma

2. Coagulopathy

Repair deficit

• Lateral suture

• Resection and end-end

• Interposition

– autologous vein

– Synthetic

• Ligation

Venous trauma

Repair (vs ligation)

• Popliteal

• Massive soft tissue injury

• Large veins

Key steps

Direct pressure

Subtle signs

Early transfer to theatre

• Angiogram

• Endovascular

• Open

Fasciotomy

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

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