NANDA NURKUSUMASARI

Two types
1. Claudicatio intermittent : Pain on activity
2. Critical Chronic Limb Ischemia : Rest Pain

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 Symptoms : cramp or pain may be in leg,
thigh, gluteal area , shoulder or arm
 Patophysiology : not only reduce flow , but
also due to disorder of metabolism in skeletal
muscle
 Pain in activity and relieve after take a rest
 Etiology :
◦ PAD ( the most common)
◦ Coarctatio aorta , takayasu, Buerger

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 Weak pulsation in arteri (upper or lower limb)
 ABI < 0.9 = arterial obstruction
 ABI > 1.3 = non compressible (arterial wall
stiffness, most common in elderly or diabetic
patient) Continue with Toe Brachial Index if
TBI <0.9 = arterial obstruction

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 Antiplatelet : Cilostazol 2 x100 mg
 Supervised limited exercise : increase dose to
6 month (hoping that there will be collateral
circulation)  If Failed  Revascularization
 Modified the atherosclerotic risk factors

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 Same with claudication
intermittent; except
Rest pain
Tissue loss

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 Revascularization : Stenting or Bypass
Grafting
 Oral medication : Statin, anti platelet
 Modified the atherosclerosis risk factors

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 Insufficiency of blood flow in distal artery due
to Run-off arterial blood flow to the other
channel (A-A or A-V)

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 Distal hypoperfusion ischemic syndrome
(DHIS), commonly referred to as hand
ischemia or 'steal' after dialysis access
placement, occurs in 5-10% of cases when
the brachial artery is used, or 10 times that of
wrist arteriovenous fistulas (AVFs) using the
radial artery.

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 These three causes of steal may occur alone
or in concert. The diagnosis of steal is based
on an accurate history and physical
examination and confirmed with tests
including an arteriogram, duplex Doppler
ultrasound (DDU) evaluation with finger
pressures and waveform analysis..

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 It is typically seen in elderly women with
diabetes, and may carry severe morbidity
including tissue or limb loss if not recognized
and treated.
 Three distinct etiologies include (1) blood flow
restriction to the hand from arterial occlusive
disease either proximal or distal to the AV
access anastomosis, (2) excess blood flow
through the AV fistula conduit (true steal), and
(3) lack of vascular (arterial) adaptation or
collateral flow reserve (ie atherosclerosis) to
the increased flow demand from the AV
conduit.

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 Treatment of steal includes observation of
developing symptoms in mild cases. Balloon
angioplasty is the appropriate intervention for
an arterial stenosis. At least three distinct
surgical corrective procedures exist to
counteract the pathophysiology of steal

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 With exercise, innate and metabolite-induced
vasodilatation leads to a drop in peripheral
resistance in upper-limb vessels, and the
mismatch between arterial inflow and
metabolic demand may lead to claudication
of the arm. Furthermore increased retrograde
flow through the ipsilateral vertebral artery
may “steal” blood away from the cerebral
circulation. This may be more likely if there is
concomitant stenotic disease of the other
extracranial or intracranial vessels.
 Neurologic disorder is common (dizziness,
vertigo, blurred vision, diplopia, and near- 27
 Physical examination
 Chest X-ray
 ECG  related to coronary heart disease
 USG Doppler vascular
 CT – angiography
 Trans catheter – angiography
 Magnetic Resonance Angiography

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 Stenting and bypass with/out conduit
 Modified the atherosclerotic risk factors

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 Acute Limb Ischemia
 Non Haemorrhagic Stroke

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 Cardiac , eg : LV thrombus from advanced
Heart Failure, AF
 And Non Cardiac, eg Aortic dissection related
thrombus, Vascular Trauma related
thrombus

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 Acute limb ischemia occurs due to a sudden
decrease in the blood flow to a limb, resulting
in a potential threat to the viability of the
extremity.
 Unfortunately, the threat is not only to the
limb, but these patients are also at high risk
for death. Limb hypoperfusion results in
systemic acid-base and electrolyte
abnormalities that impair cardiopulmonary
and renal function.
 Successful reperfusion may result in the
release of highly toxic free radicals, further
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 pain, pallor, paralysis, pulse deficit,
paresthesia, and poikilothermia
 In history taking should find any involvement
of cardiac disease or not

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 PIAT (percutaneous intra arterial
thrombolysis)
 Thrombectomy/embolectomy ( transcatheter
or surgery)
 Amputation
 Additonal Therapy :anticoagulation,
“atherosclerotic medicine”

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 Dilatation of the aortic pipe ( Aortic root –
Abdominal aorta)

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 Atherosclerosiswhich weakens arterial walls.
 Hypertension (high blood pressure).
 Local injury to the artery.
 Congenital abnormality. A number of
conditions, such as Marfan syndrome or
bicuspid aortic valves are present at birth and
can cause weakness of the artery walls.
 Aging
 Syphilis used to be a common cause of
thoracic aneurysms, but it is no longer as
common.
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 Mostly no symptoms until expansion to the
other organ or after a complication
 Tearing pain in the chest, abdomen, and/or
middle of the back between the shoulder
blades.
 Thoracic aneurysms may cause shortness of
breath, hoarseness, cough (due to pressure
on the lungs and airways), and difficulty
swallowing (pressure on the esophagus)
 Rupture of an aneurysm can cause loss of
consciousness, stroke, shock, or a heart
attack
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 Physical examination
 CXR
 Echocardiography
 CT-Aorta
 MRI
 Trancatheter angiography

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 Aorta replacement with conduit
 Or, EVAR / TEVAR

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