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ARTERIAL DISORDERS (I)

PROFESSOR SHAHID RASUL


Professor of General Surgery
JSMU
Surgical Unit IV, Ward 21 JPMC
ARTERIAL STENOSIS AND OCCLUSION

• Arterial stenosis or occlusion commonly


caused by atheroma

• Also occur acutely secondary to emboli or


trauma.
SYMPTOMS and SIGNS
• Lower limb (claudication, rest pain and
gangrene);

• Brain (transient ischaemic attacks and stroke);

• Myocardium (angina and myocardial infarction);

• Kidney (hypertension and renal failure)

• Intestine (abdominal pain and infarction).


CHRONIC ARTERIAL STENOSIS
• Intermittent claudication
• Rest pain
• Dependent rubor or sunset foot
• Ulceration
• Gangrene
• Diminished or absent Arterial pulsation
• Arterial bruit
• Slow capillary refilling
INVESTIGATIONS
• GENERAL INVESTIGATIONS

• Full blood count


• Blood glucose
• Lipid profile
• Serum Urea and Electrolytes
• ECG
• SPECIALIZED INVESTIGATIONS

• Doppler ultrasound and blood flow detection

• Duplex scanning

• Angiography
ANKLE BRACHIAL PRESSURE INDEX
(ABPI)
• Ratio of systolic pressure at ankle to that in
arm
• Resting or normal – 1.0
• Claudication -- <0.9
• Rest pain -- <0.5
• Necrosis -- <0.3
NON SURGICAL MANAGEMENT
• Avoid smoking
• Regular exercise
• Supervised exercise program
• Dietary advice
• Weight loss
MEDICATIONS
• Statins
• Antiplatelets agents
• Aspirin and clopidogral
SURGICAL MANAGEMNT
• Transluminal angioplasty and stenting
Surgical
• Surgical operations with or without graft
• Graft may be dacron or PTFE

• Aortofemoral bypass – aortoiliac disease


• Iliofemoral or femorofemoral crossover graft
• Femoropoplitial bypass- femoral artery
disease
CAROTID STENOSIS &
INDICATIONS FOR CAROTID
ENDARTERECTOMY
• Stenosis >70%
• Ipsilateral Amaurosis fugax or monocular
blindness
• Contralateral facial paralysis or paresthesia
• Arm / Leg paralysis or paresthesia
• Hemianopia
• Dysphasia
• Sensory or visual neglect
GANGRENE
• Death of macroscopic portions of tissue

• Tissues turn black secondary to hemoglobin


breakdown and iron sulphide formation.

• Most distal part of limb involved -- arterial


obstruction (from thrombosis, embolus or
arteritis).
• Dry gangrene – desiccated tissues secondary
to gradual decrease in blood supply
(atheromatous occlusion of arteries).

• Wet gangrene -- superadded infection and


putrefaction are present.
• May be Crepitus -- gas-forming organisms
commonly in diabetic foot
SEPARATION OF GANGRENE
• Zone of demarcation -- truly viable and dead or dying tissue
• Layer of granulation tissue develops between the dead and
the living parts.

• Dry gangrene -- blood supply to proximal tissues is


adequate, final demarcation appears and separation
occurs neatly.

• Moist gangrene – arterial supply to proximal living tissue is


poor, final demarcation is slow or does not develop at all.
Infection and suppuration extends into the neighbouring
living tissue,

• ‘skip’ areas – on other side of foot, heel, dorsum or even in


calf.
TREATMENT OF GANGRENE
• Depends on blood supply proximal to the
gangrene.

• Poor circulation -- improved by radiological or


surgical intervention -- more conservative
debridement or distal amputation.

• Major limb amputation -- presence of life-


threatening sepsis
SPECIFIC VARIETIES OF GANGRENE
• Diabetic gangrene
• Bed sores
• Frost bite
THANK YOU
ACUTE ARTERIAL OCCLUSION
• EMBOLIC OCCULUSION
• Embolus -- foreign body to bloodstream that become
lodged in a vessel cause obstruction and ischemic
symptoms
• Embolus may be a thrombus that has become
detached from the heart or more proximal vessel

• Left atrium (Atrial fibrillation),


• Left ventricular (mural thrombus),
• Vegetations on heart valves (infective endocarditis),
• Thrombi in aneurysms and atheroscerotic plaques.
SYMPTOMS AND SIGNS
• Arm and leg -- Pain, pallor, paralysis,Pulselessness
and paraesthesia

• Brain -- Middle cerebral artery (or its branches)


resulting in major or minor (TIA) stroke.

• Retina -- Amaurosis fugax

• Mesenteric vessels – gangrene of loop of


intestine
ACUTE LIMB ISCHAEMIA
• Embolic arterial occlusion is an emergency
• Ischaemia beyond 6 hours is usually irreversible and
results in limb loss.

• Leg is often affected, with pain, pallor, paralysis, loss of


pulsation and paraesthesia (or anaesthesia)
• limb is cold and the toes cannot be moved

• Diagnosis made clinically patient who has no history of


claudication and has a source of emboli, suddenly
develops severe pain or numbness
TREATMENT
• Immediate administration of heparin – 5000 U
IV

• Embolectomy – forgatry catheter


COMPARTMENT SYNDROME
• Limbs subject to sudden ischaemia followed by
revascularisation

• Muscles swell within fixed fascial compartments with


both local muscle necrosis and nerve damage

• renal failure secondary to liberation of muscle


breakdown products.

• Treatment -- Urgent fasciotomy .


INTRA-ARTERIAL THROMBOLYSIS
• Arteriography of ischaemic limb (usually via
the common femoral artery).

• Tissue plasminogen activator (TPA) is infused


for lysis of thrombus , successfully achieved
within 24 hours.

• Contraindications to thrombolysis -- Recent


stroke, bleeding diathesis and pregnancy
ACUTE MESENTERIC ISCHAEMIA
• Either thrombotic or embolic.
• Embolic occlusion -- sudden, severe abdominal pain,
with bowel emptying (vomiting and diarrhoea)

• Widespread infarction of the small and large bowel


• Resection of dead bowel and embolectomy of the
superior mesenteric artery, or bypass surgery

• A ‘second look’ laparotomy 24 hours later to check the


viability of the bowel
OTHER FORMS OF EMBOLI
• Infective emboli of bacteria or infected clot cause mycotic
aneurysms, septicaemia or infected infarcts.

• Parasitic emboli, caused by ova of Taenia echinococcus and Filaria


sanguinis hominis.

• Tumour cells (e.g. hypernephroma and cardiac myxoma).

• Fat embolism -- major bony fractures. Venous emboli that travel to


lungs and cause acute respiratory distress syndrome.

• Air embolism -- Air accidentally injected into venous circulation or


sucked into an open vein during head and neck surgery or a cut
throat. Fallopian tube insufflation or illegal abortion.
THERAPEUTIC EMBOLISATION
• Arrest haemorrhage from the gastrointestinal,
urinary ,gynaecological and respiratory tracts, to
treat arteriovenous malformations or to control
the growth of unresectable tumours.

• Arterial embolisation -- selective catheterisation


using the Seldinger technique.

• Gelfoam sponge, plastic microspheres, balloons,


ethyl alcohol, quick-setting plastics and metal
coils.
ANEURYSM
• Dilatations of localised segments of arterial system

• True aneurysms, three layers of the arterial wall (intima,


media, adventitia) in the aneurysm sac

• False aneurysms, single layer of fibrous tissue as wall of sac

• Aneurysms also grouped


• shape (fusiform, saccular)
• aetiology (atheromatous, traumatic, mycotic, etc.).

• Aneurysms occur in the aorta, iliac, femoral, popliteal,


subclavian, axillary, carotid, cerebral, mesenteric, splenic
and renal arteries and their branches.
ABDOMINAL AORTIC ANEURYSM
• Most common type of large vessel aneurysm
• 2 % population at autopsy
• 95 % associated atheromatous degeneration
• 95 % below the renal arteries

• Asymptomatic until rupture occurs


• Risk of rupture increases with increasing size
(diameter) of the aneurysm

• Incidentally found on physical examination,


radiography or ultrasound.
ASYMPTOMATIC ABDOMINAL AORTIC
ANEURYSM
• fit patient, if >55 mm in diameter (measured by
ultrasonography) considered for repair

• Risk of rupture rises from 1 per cent or less in


aneurysms that are <55 mm in diameter to a
significant level, as high as 20 per cent, in those
70 mm in diameter.

• Regular ultrasonographic assessment is indicated


for asymptomatic aneurysms <55 mm in
diameter.
INVESTIGATIONS
• Full blood count, electrolytes, coagulation profile
• liver function tests, blood lipid
• Blood should be cross matched

• Anaesthetic assessment
• Electrocardiogram and chest radiograph
• Echocardiography or isotope ventriculography,
• cardiopulmonary exercise testing and spirometry

• CT scan
• Duplex scanning
• MR or digital subtraction angiography
OPEN SURGICAL PROCEDURE
• General Anaesthesia , Full length midline incision
• Aorta is exposed, clamps applied above and below the
lesion.

• Aneurysm is opened longitudinally


• Upper and lower aortic necks are prepared

• Aortic prosthesis is then sutured end to end inside the


sac with a monofilament non-absorbable suture
• Aneurysm sac is closed around the prosthesis

• If Iliac vessels are also involved, necessary to construct


an aortobi-iliac or aortobifemoral bypass
ENDOVASCULAR ANEURYSM REPAIR
(EVAR)
• Radiologically guided placement of endovascular
prosthesis using femoral arteries (under general
or local anaesthetic)

• Endovascular prosthesis ‘stent graft’ is usually


made up of three separate parts – main body and
two limbs made from Dacron or PTFE with
integral metallic stents for support.

• EVAR patients require life-long follow up and


surveillance with duplex or CT scans
RUPTURED ABDOMINAL AORTIC
ANEURYSM ABDOMINAL
• Anterior rupture (20 %) results in free bleeding
into peritoneal cavity; very few patients reach
hospital alive.

• Posterior rupture (80 %)produces a


retroperitoneal haematoma, less than 50 %,
survive to reach hospital.

• Operative mortality is around 50 per cent and the


overall combined mortality (community and
hospital) is around 80–90 per cent.
MANAGEMENT
• Surgical emergency

• Early diagnosis (abdominal/back pain, pulsatile mass,


shock)

• Immediate resuscitation (oxygen, intravenous


replacement therapy, central line)

• Maintain systolic pressure, but not >100 mmHg,


consider permissive hypotension

• Urinary catheter and arterial line


• Cross-match six units of blood
• Rapid transfer to the operating theatre
SYMPTOMATIC ABDOMINAL AORTIC
ANEURYSM
• Abdominal and/or back pain.

• Thigh or groin pain secondary to nerve


compression. Gastrointestinal, urinary and
venous symptoms

• Pain may be a warning sign of stretching of the


aneurysm sac and imminent rupture

• Surgery should be performed as soon as possible


POSTOPERATIVE COMPLICATIONS
• OPEN REPAIR

• Cardiac (ischaemia and infarction)


• Respiratory (atelectasis and lower lobe consolidation).

• Colonic ischaemia
• Renal failure

• Neurological include sexual dysfunction and spinal cord


ischaemia.
• Aortoduodenal fistula
• Prosthetic graft infection
• ENDOVASCULAR REPAIR.

• Cardiac, respiratory, renal and neurological


complications are less common

• Complications unique to EVAR


• Endoleak
• Graft migration
• Metal stent fracture
• Graft limb occlusion.
PHERIPHERAL ANEURYSMS
• Femoral Aneurysm
• Popliteal Aneurysm
• Iliac Aneurysm
ARTERIOVENOUS FISTULA
• Communication between an artery and a vein (or veins)
• Congenital malformation or the result of trauma
• For haemodialysis access

• Structural and physiological effect


• Structural effect – veins become dilated, tortuous and thick
walled (arterialised).
• Physiological effect -- increase in cardiac output, left
ventricular enlargement and even cardiac failure.

• Signs and syptoms


• Pulsatile swelling with a thrill and continuous bruit
(‘machinery murmur’).
• Dilated veins with rapid blood flow.
• Investigations
• Duplex scan and/or angiography

• Management
• Embolisation
• Excisional surgery