PRISHANTINI PATHER

NNEAFOR CHARLES
FARIDA DIPA
SHALIZA ISHMAEL
GENERAL SURGERY CLERKSHIP 2017
 INTRODUCTION

Arterial disorders represent the most common cause of morbidity and

death in western societies.

Much of this is due to the effects of atheroma on the arteries supplying

the heart muscle (coronary thrombosis and myocardial infarction) and
brain (stroke), although atheroma is also common at other sites.

Atheroma
An abnormal mass of fatty or lipid material with a fibrous covering
which exists as a discrete, raised plaque within the intima of an artery.
 The Anatomy of Blood Vessels

Structure of vessel walls

Walls of arteries
and veins contain
three distinct
layers

Tunic intima Tunica media Tunica externa

Tunica externa (adventitia) - outermost layer made
of loose connective tissue. Serves to anchor, protect
and prevent overstretching

Tunica media - middle layer composed of smooth

muscle; functions in dilation and constriction of
blood vessels

Tunica interna(intima) - innermost layer made of

endothelium (s.squamous epithelium)
A Comparison of a Typical Artery and a Typical
Vein
 Blood flow through tissues

heart blood
Aorta Arteries
flows into

Venules Capillaries Arterioles

Superior/
Back to the
Veins Inferior Vena
heart
Cava
Blood Flow Through the Blood Vessels

As blood flows
from the aorta
toward the •Pressure decreases
capillaries and
from •Flow decreases
capillaries •Resistance increases
toward the
vena cava:
Histological Structure of Blood Vessels
ARTERIAL STENOSIS AND OCCLUSION
Cause and effect
 Arterial stenosis or occlusion is commonly caused by atheroma but can occur
acutely as a result of emboli or trauma.
 Stenosis or occlusion produces symptoms and signs that are related to the
organ supplied by the artery:
 lower limb – claudication, rest pain and gangrene
 brain– transient ischemic attacks and stroke
 myocardium – angina and myocardial infarction
 kidney – hypertension and renal failure
 intestine – abdominal pain and infarction
 The severity of the symptoms is related to the size of the vessel occluded and
the alternative routes (collaterals)available for blood flow
Features of lower limb arterial stenosis or
occlusion
 Intermittent claudication
 Rest pain
 Cold, numb, paresthesia, color change
 Ulceration
 Gangrene
 Assumes ambient temperature
 Sensation decreased
 Movement diminished or lost
 Arterial pulsation diminished or absent
 Arterial bruit
 Slow venous refilling
Investigation of arterial occlusive disease

Most patients with symptoms of

arterial disease do not need active
treatment, such as angioplasty or
surgical reconstruction, and the
decision whether or not to intervene
can often be made without recourse
to special investigations.
 General investigation
 Patients with arterial disease tend to be elderly and atherosclerosis is
a generalized disease
 if active intervention is contemplated then a full assessment is essential.
 Tests relevant to diabetes, abnormal lipid metabolism, anemia and conditions
causing high blood viscosity (e.g. polycythemia and thrombocythemia) include
a full blood count (including platelets), plasma fibrinogen, blood and urine
glucose, and a blood lipid profile (triglycerides, total cholesterol, and high-
and low-density lipoprotein cholesterol).
 Cardiac failure, myocardial ischemia, hypertension and age-related diseases
such as chronic obstructive pulmonary disease and neoplasia should also be
considered. Although a normal electrocardiogram (ECG) does not exclude
severe coronary artery disease, a grossly abnormal ECG may influence decision
making.
 An exercise ECG gives a more accurate assessment but
many patients are limited in their ability to exercise. In
such circumstances radioisotope ventriculography or
echocardiography may be attractive as a non-invasive
method of assessing left ventricular function.
 Patients must also be assessed for lung disease by chest
radiograph and, if necessary, pulmonary function tests.
Tests for renal function (serum creatinine) are also
required, especially if contrast agents are to be used at
angiography, as they may adversely affect kidney function
Doppler ultrasound blood flow detection

 A hand-held Doppler ultrasound probe is most useful in the assessment

of occlusive arterial disease; many consider it essential
 Doppler ultrasound equipment can be used as a very sensitive type of
stethoscope in conjunction with a sphygmomanometer to assess
systolic pressure in small vessels. This is possible even when the
arterial pulse cannot be palpated.
 It is of the greatest importance to appreciate that, although a
‘Doppler signal’ indicates moving blood, it does not necessarily
indicate that the blood flow detected is sufficient to prevent limb
loss, i.e. a Doppler signal does not indicate viability.
 Doppler ultrasonography – high frequency sound waves directed to
artery or veins through a hand-held transducer moved evenly across
skin surface
 audible tone produced in proportion to blood velocity
 measure blood flow through vessels
 Duplex imaging
 This is a major investigative technique in vascular disease. A duplex scanner
uses B-mode ultrasound to provide an image of vessels
 This image is created through the different abilities of different tissues to
reflect the ultrasound beam.
 A second type of ultrasound, namely Doppler ultrasound, is then used to
insolate the imaged vessels and the Doppler shift obtained is analyzed by a
computer in the duplex scanner. Such shifts can give detailed knowledge of
vessel blood flow, turbulence, etc.
 Many scanners have the added sophistication of color coding, which allows
visualization of blood flow on the image. The various colors indicate change in
direction and velocity of flow; points of high flow generally indicate a stenosis
(consider that rivers flow fast where they are narrow). Duplex scanning is at
least as accurate as angiography in many circumstances. In terms of cost-
effectiveness and safety, it is generally to be preferred to any type of
angiography if the two tests are considered to be equally useful in any given
clinical context.
 Angiography (synonym: arteriography)

 Angiography is only appropriate if intervention is being contemplated. Even

then, it is often advisable to have a duplex scan first. Classical angiography
involves the injection of a radio-opaque solution into the arterial tree,
generally by a retrograde percutaneous catheter method (Seldinger
technique) usually involving the femoral artery.
 Hazards include thrombosis, arterial dissection, hematoma, renal
dysfunction and allergic reaction. Rather than taking simple films, nowadays
a computer system digitizes the images, allowing the image before injection
of contrast agent to be subtracted from the contrast image, thereby
removing extraneous background and providing great clarity.
Non-surgical management of arterial
stenosis or occlusion
• Many claudicants are content to live within the limitations
imposed by their condition. Spontaneous improvement occurs in
many patients over the first 6 months after an occlusive episode
as collateral vessels develop.
• Exercise is encouraged, particularly walking within the limits of
the disability; supervised exercise programmes are ideal.
• Stopping smoking is essential.

General • Dietary advice is required for those who are overweight and for
those with high blood lipids.
• Care of the ischemic foot is often required, especially in
diabetics.
 • Medication may be required for diseases
associated with arterial disorders, such as
hypertension and diabetes.
• some antihypertensive (particularly β-blockers)
may exacerbate claudication.
• Raised blood lipids require active drug treatment
but even when the lipid profile is normal a statin
should be prescribed (e.g.40mg/day of
pravastatin).

Drugs
• An antiplatelet agent is also necessary, usually
75mgday−1of aspirin, with 75mgday−1of
clopidogrel as an alternative for those who are
aspirin intolerant.
• Other agents, such as vasodilators, are unlikely to
prove beneficial.
Transluminal angioplasty and stenting

Arterial occlusive disease may be treated by inserting a balloon catheter into an

artery and inflating it within a narrowed or blocked area. This is usually done
percutaneously in the radiology department. Percutaneous transluminal
angioplasty (PTA) has proved very successful in dilating the iliac arteries and, to a
lesser extent, the arteries of the leg itself. The technique is also applicable at
other sites (upper limb vessels, renal arteries, gastrointestinal arteries, carotid
arteries) with variable outcomes.

An alternative type of stent is held compressed by a sheath of plastic in a delivery

system. The stent is positioned at the site of arterial dilatation and its sheath
withdrawn to allow the device to self-expand and so hold the lumen open..
 ACUTE ARTERIAL OCCLUSION

Sudden occlusion of an artery is commonly

caused by emboli. It may also happen when
thrombosis occurs on a plaque of preexisting
atheroma, but in this case collaterals are
likely to have built up in the face of chronic
arterial stenosis, making the effect of the
eventual occlusion less dramatic.
 Embolic occlusion

An embolus is a body that is foreign to the bloodstream and which may

become lodged in a vessel and cause obstruction.

It is often a thrombus that has become detached from the heart or a

more proximal vessel. Sources are
• The left atrium in cardiac arrhythmia (particularly atrial fibrillation)
• Mural thrombus following myocardial infarction

Less common sources are

• Aneurysms and thrombi formed on atheromatous plaques (so-called artery-to-artery
embolism).

Emboli may lodge in any organ and cause ischemic symptoms.

 • Pain, pallor, paresis, pulselessness and paresthesia. Acute

Leg
arterial occlusion due to an embolus differs from occlusion due
to thrombosis on a pre-existing atheroma; in the latter case, a
collateral circulation has often built up over time. It is essential
to differentiate between the two as they require different
management.

Brain • The middle cerebral artery (or its branches) is most commonly
affected, resulting in major or minor (TIA) stroke.

• Amaurosis fugax

Retina • Is fleeting blindness caused by a minute thrombus emanating

from an atheromatous plaque in the carotid artery passing into
the central retinal artery. Lasting obstruction causes permanent
blindness.
Mesenteric • possible gangrene of the
vessels corresponding loop of intestine.

Spleen • causing local pain.

• causing loin pain and

Kidneys hematuria.
Air embolism
Air may be accidentally injected into the venous circulation or sucked into an open vein.

Venous air embolism is a rare complication of neck surgery if a large vein is inadvertently opened
and it maybe an accessory cause of death following a cut throat.

Care should also be taken when infusing intravenous fluids.

If a large volume of air is allowed to reach the right side of the heart it may form an air lock within
the pulmonary artery and cause right heart failure.
The treatment of air embolism is to put the patient in a head-down (Trendelenburg) position to
encourage the air to enter the veins in the lower part of the body.
The patient should also be placed on the left side to help the air to float to the ventricular apex,
away from the ostium of the pulmonary artery.
In extreme cases air may be aspirated from the heart through a needle introduced below the left
costal margin.
Oxygen should, of course, be administered. Air may rarely enter the left side of the heart at open
heart surgery or if a pulmonary vein is punctured when inducing a therapeutic pneumothorax.
It may also enter via a patent foramen ovale (a common
anomaly) as a paradoxical embolism. Air then may reach
the coronary and/or the cerebral circulation.

Treatment is along similar lines as for right heart air

entry.

Finally, air embolism may occur after fallopian tube

insufflation or illegal abortion. Air may travel to the brain
via the paravertebral veins.
Other forms of emboli

These include infective emboli of masses of bacteria

or an infected clot, which may cause mycotic
aneurysms, pyemia or infected infarcts.

emboli of malignant cells (e.g. hypernephroma and

cardiac myxoma) are rare but well recognized.

Finally, fat embolism may follow major bony

fractures. It is treated by the trauma orthopedic
surgeon, rather than the vascular surgeon.
 Clinical features
Embolic arterial occlusion is an emergency that requires immediate treatment.

The leg is often affected.

The limb is cold and the toes cannot be moved, which contrasts with venous occlusion when muscle
function is not affected.

The diagnosis can be made clinically in a patient who has

• no history of claudication
• has a source of emboli
• suddenly develops severe pain or numbness of the limb
• limb becomes cold and mottled.
• Movement becomes progressively more difficult
• sensation is lost.
• Pulses are absent distally but the femoral pulse may be palpable, even thrusting, as distal
occlusion results in forceful expansion of the artery with each pressure wave despite the
lack of flow.
 Treatment

Because of the ensuing stasis, a thrombus can extend distally and

proximally to the embolus.

The immediate administration of 5000U of heparin intravenously can

reduce this extension and maintain patency of the surrounding
(particularly the distal) vessels until the embolus can be treated.

The relief of pain is essential because it is severe and constant.

Embolectomy and thrombolysis are the treatments available for patients

with limb emboli.
 Compartment syndrome

In limbs that have been subject to sudden ischemia followed by

revascularization, edema is likely.

Muscles swell within fixed fascial compartments and this can itself be a
cause of ischemia, with both local muscle necrosis and nerve damage
due to pressure, and distal effects such as renal failure secondary to the
liberation of myocyte breakdown products.

The treatment is urgent fasciotomy to release the compression.

The usual site at which such surgery is necessary is the calf (especially
the anterior tibial compartment), but compartment syndrome may
occasionally affect the thigh and the arm.
 Gangrene
Gangrene is a condition that involves the death and decay of
tissue, usually in the extremities due to loss of blood supply.

Dry gangrene Wet gangrene

• no infection
• little tissue liquefaction
• In early stages, dull, aching
pain, extremely painful to
palpate, cold, dry and
wrinkled.
• In later stages, skin gradually
changes in color to
• dark brown, then
• dark purplish-blue, then
• completely black
• Bacterial infection
• copious tissue
liquefaction
• offensive odor
• swollen, red and warm.
• usually develops rapidly
due to blockage of
venous and/or arterial
blood flow

Treatment is surgical debridement and amputation.

Specific varieties of gangrene
Diabetic gangrene

Diabetic gangrene is related to three factors:

• trophic changes from peripheral neuropathy,
• ischemia as a result of atheroma
• low resistance to infection because of excess sugar in the
tissues.

The neuropathy impairs sensation and thus favors

the neglect of minor injuries and infections.
Treatment consists of bringing the diabetes under control by
diet and drugs.

The gangrene is treated as, with a conservative approach if

there is no major arterial obstruction.

A rapid spread of infection requires drainage by incision and

the removal of any obviously dead tissue. This may require
quite extensive laying open of infected tissue planes.

Good drainage and the control of infection should be followed

by rapid healing if the blood supply is adequate.
 Bedsores

A bedsore is gangrene caused by local pressure.

Bedsores are predisposed to by five factors:
• pressure
• injury
• anemia
• malnutrition
• moisture.

They can appear and extend rapidly in immobile

patients and in those with debilitating illness.
Prophylactic measures must be taken, including the avoidance of pressure over
bony prominences by the use of foam blocks or similar, regular turning, and
nursing on specially designed beds that reduce the pressure to the skin. A water
bed or a ripple bed is sometimes desirable.

Injury from wrinkled sheets and maceration of the skin by sweat, urine or pus
must be prevented by skilled nursing and the use of an adhesive film dressing.

A bedsore can be expected if erythema appears that does not change color on
pressure.

The affected area must be kept dry and an aerosol silicone spray may be used.

Once pressure sores develop, they are difficult to heal. They may be treated by
lotions or by exposure to keep them as dry as possible. They should be kept
clean and debrided if necessary.
 Frostbite
Frostbite is caused by exposure to cold. It is seen both in climbers at
high altitudes and in the elderly or the vagrant during cold, windy
spells.

Vessel walls are damaged, leading to transudation and edema. The

sufferer experiences a severe burning pain in the affected part, which
later assumes a waxy appearance as the pain disappears. Blistering and
then gangrene follow.
Frostbitten parts must be warmed gradually; any temperature higher
than that of the body is detrimental. The part should be wrapped in
cotton wool and kept at rest. Friction, e.g. rubbing with snow, may
damage already devitalized tissues.

Warm drinks and clothing should be provided and powerful analgesics

given to relieve the pain that heralds the return of circulation.
Amputations should be conservative.
 Ainhum

Ainhum is a disease of unknown etiology that usually affects black men

(and occasionally women) who have run barefoot in childhood.

It is recorded in central Africa, central America and the Orient. A fissure

appears at the level of the interphalangeal joint of a toe, usually of the
little toe.

The fissure is followed by a fibrous band that encircles the digit and
causes necrosis.

The treatment in the early stage is by Z-plasty and in the later stages by
amputation
 Ergot

Ergot is a cause of gangrene in those who eat

rye bread infected with Claviceps purpura.
Certain groups living on the Mediterranean
coast or the Russian steppes are particularly
at risk. It may also occur in migraine
sufferers who take ergot preparations as
prophylaxis over a long period
 Indications for amputation
Dead limb
Gangrene
Deadly limb
Indications for

Wet gangrene
amputation

Spreading cellulitis

Arteriovenous fistula

Other (e.g. malignancy)

‘Dead loss’ limb

Severe rest pain

Paralysis
Amputation = removal of a body extremity by surgery or trauma

"to cut away", from ambi- ("about", "around") and putare ("to
prune").

Disarticulation is removing the limb through a joint.

It is one of the most ancient surgeries of all the surgical

procedures.

Chemotherapeutic agents & antibiotics have made it possible to

control invading infection & mortality rate has fallen.
 Amputation levels ( lower limbs )
 Foot Amputations
 Amputation of greater toes and other toes
 Amputation through the metatarsal bones
 Lisfranc`s operation : at the level of the
tarsometatarsal joints
 Chopart`s operation : through the midtarsal joints
 Transtibial Amputations (below the knee)
Amputation occurs at any level from the knee to the
ankle
 Knee Disarticulation
Amputation occurs at the level of the knee joint
 Transfemoral Amputations (above knee )
Amputation occurs at any level from the hip to knee
joint
 Hip Disarticulation
Amputation is at the hip joint with the entire thigh
and lower portion of the leg being removed.
Determination of level of amputation

Zone of Injury (trauma)

Adequate margins (tumor)

Adequate circulation (vascular disease)

Soft tissue envelope

Bone and joint condition

Control of infection

Nutritional status
 Complications
Early complications include hemorrhage, which requires return to the operating room for
hemostasis, hematoma, which requires evacuation, and infection, usually in association with a
hematoma.

Any abscess must be drained and appropriate anti-biotics given.

Gas gangrene can occur in a mid-thigh stump from fecal contamination.

Wound dehiscence and gangrene of the flaps are caused by ischemia; a higher amputation may
well be necessary.

Amputees are at risk of deep vein thrombosis and pulmonary embolism in the early
postoperative period and prophylaxis with subcutaneous heparin is essential for several weeks
after operation.
 ANEURYSM

Dilatations of localized segments of the arterial system are called aneurysms.

They can either be true aneurysms, containing the three layers of the arterial wall
(intima, media, adventitia) in the aneurysm sac

False aneurysms, having a single layer of fibrous tissue as the wall of the sac, e.g.
aneurysm following trauma.
Aneurysms can also be grouped according to their shape (fusiform, saccular,
dissecting) or their etiology (atheromatous, traumatic, syphilitic, mycotic, etc.).

The term mycotic is a misnomer because, although it indicates infection as a

causal element in the formation of the aneurysm, this is due to bacteria, not
fungi.

Aneurysms occur all over the body in major vessels, including the aorta, and the
iliac, femoral, popliteal, subclavian, axillary and carotid arteries. They may also
occur in cerebral, mesenteric, splenic and renal arteries and their branches.

The majority are true fusiform atherosclerotic aneurysms

Fusiform aneurysm – spindle shaped, involves the entire
circumference of the arterial wall

Saccular aneurysm – involves only part of the

circumference of the artery, it takes the form of a sac or
pouch-like dilation attached to the side of the artery

Dissecting aneurysm – involves hemorrhage into a vessel

wall, which splits and dissects the wall causing a
widening of the vessel
• caused by degenerative defect in the tunica media and tunica intima
 Clinical features

All aneurysms can cause symptoms, as a result of expansion, thrombosis, rupture or the
release of emboli.

The symptoms relate to the vessel affected and the tissues it supplies. Most aneurysms
of clinical significance can be palpated and, typically, an expansile pulsation is felt.

Transmitted pulsation through a mass lesion, cyst or abscess lying adjacent to a large
artery may be mistaken for aneurysmal pulsation.

Before incising a swelling believed to be an abscess it is essential to make sure that it

does not pulsate.
 Abdominal aortic aneurysm

Abdominal aortic aneurysm is by far the most common type of large

vessel aneurysm and is found in 2% of the population at autopsy;95%
have associated atheromatous degeneration and 95% occur below the
renal arteries.

Symptomatic aneurysms may cause minor symptoms, such as

• back and abdominal discomfort, before sudden, severe back and/or

abdominal pain develops from expansion and rupture.

Asymptomatic aneurysms are found incidentally on physical

examination, radiography or ultrasound investigation.
Symptomatic abdominal aortic aneurysm

Patients most commonly present with back and/or abdominal dis-comfort. Pain
may also occur in the thigh and groin because of nerve compression.

Gastrointestinal, urinary and venous symptoms can also be caused by pressure

from an abdominal aneurysm.

An operation is indicated in patients who are otherwise reasonably fit. The risk of
operation is particularly increased in the presence of hypertension, chronic
airway disease, recent myocardial infarction and impaired renal function.

Chronological age is not a bar to surgery but only a few patients are fit enough
for this type of procedure once over the age of 80.
Asymptomatic abdominal aortic aneurysm

An aneurysm found incidentally on clinical examination,

radiography or ultrasonography in an otherwise fit
patient should be considered for repair if >55mm in
diameter (measured by ultrasonography).

Regular ultrasonographic assessment is indicated for

asymptomatic aneurysms <55mm in diameter.
 Management of ruptured abdominal aortic
aneurysm

Early diagnosis (abdominal/back pain, pulsatile mass, shock)

Immediate resuscitation (oxygen, intravenous replacement therapy,

central line)

Maintain systolic pressure, but not >100mmHg

Urinary catheter

Cross-match six units of blood

Rapid transfer to the operating room

 Investigations

chest & abdominal x-rays – helpful in

preliminary diagnosis of aortic aneurysm

Ultrasound – is useful in determining the

size, shape and location of the aneurysm
 Peripheral aneurysm
Popliteal aneurysm

Popliteal artery aneurysm accounts for 70% of all peripheral aneurysms; two-thirds are bilateral.

Examination of the abdominal aorta is indicated if a popliteal aneurysm is found because one-
third are accompanied by aortic dilatation.
Popliteal aneurysms present as a swelling behind the knee or with symptoms caused by
complications, such as severe ischemia following thrombosis or distal ischemic ulceration as a
result of emboli.
Urgent surgery, possibly with intra-arterial thrombolysis, is indicated in the acute situation.

An asymptomatic aneurysm should be considered for elective repair to prevent future

complications, especially if it exceeds 25mm in diameter.

Ultrasonography and CT or magnetic resonance imaging can be helpful in confirming the diagnosis.

Treatment is either a bypass with ligation of the aneurysm or an inlay graft.

 Femoral aneurysm

True aneurysm of the femoral artery is uncommon.

Complications occur in less than 3% so conservative treatment is generally indicated,

but it is important to look for aneurysms elsewhere as over half are associated with
abdominal or popliteal aneurysms.

False aneurysm of the femoral artery occurs in 2% of patients after arterial surgery at
this site. Some are infective in origin and rupture is possible; these require surgical
correction. Local repair with re anastomosis at the groin under suitable antibiotic
cover may be successful, but bypass, clear of the infected area, with subsequent
excision of the infected graft is often the only way of preventing further problems.
 Iliac aneurysm

This usually occurs in conjunction with aortic aneurysm

and only rarely on its own.

On its own, it is difficult to diagnose clinically so about

half present already ruptured.

Operation is indicated, with bypass and exclusion of the

aneurysm by ligation above and below the dilatation.
 Arteriovenous fistula
Communication between an artery and a vein (or veins) may be either a congenital
malformation or the result of trauma.

Arterio-venous fistulas for hemodialysis access are also created surgically. All
arteriovenous communications have a structural and a physiological effect.

The structural effect of arterial blood flow on the veins is characteristic;

• they become dilated,
• tortuous
• thick walled (arterialized).

The physiological effect, if the fistula is big enough, is

• an increase in cardiac output.
• In extreme circum-stances this can cause left ventricular enlargement and even cardiac failure.
A pulsatile swelling may be present if the lesion is superficial.

A thrill is detected on palpation and auscultation reveals a

buzzing continuous bruit (‘machinery murmur’).

Dilated veins may be seen, in which there is a rapid blood flow.

Pressure on the artery proximal to the fistula reduces the swelling
and the thrill and bruit cease.

Duplex scan and/or angiography confirms the lesion.

 Management

Treatment is by embolization.

Excisional surgery can be advocated only rarely, perhaps for

severe deformity or recurrent hemorrhage.

It is important to realize that ligation of a ‘feeding’ artery on

its own is of no lasting value and is actually detrimental as it
may preclude treatment by embolization.
 ARTERITIS AND VASO SPASTIC CONDITIONS
Thrombo angitis obliterans (Buerger’s disease)

This is characterized by occlusive disease of the small- and medium-sized

arteries (plantar, tibial, radial, etc.), thrombophlebitis of the superficial or
deep veins, and Raynaud’s syndrome;
• it occurs in male smokers, usually under the age of 30 years.

Often, only one or two of the three manifestations are present. Histologically,
there are inflammatory changes in the walls of arteries and veins, leading to
thrombosis.

Treatment is total abstinence from smoking, which arrests, but does not
reverse, the disease. Established arterial occlusions are treated as for
atheromatous disease, but amputations may eventually be required.
 Other types of arteritis

Arteritis occurs in association with many connective tissue disorders, e.g. rheumatoid
arthritis, systemic lupus erythematosus and polyarthritis nodosa.

Temporal arteritis is a disease in which localized infiltration with inflammatory and giant
cells leads to arterial occlusion, ischemic headache and tender, palpable, pulseless
(thrombosed)arteries in the scalp. Irreversible blindness occurs if the ophthalmic artery
becomes occluded.

The surgeon may be required to perform a temporal artery biopsy, but this should not delay
immediate steroid therapy to arrest and reverse the process before the ophthalmic artery is
involved.
 Cystic myxomatous degeneration

This is typified by an accumulation of clear jelly (like a synovial

ganglion) in the outer layers of a main artery, especially the
popliteal artery.

The lesion may narrow the vessel causing claudication.

Duplex scan is the investigation of choice.

Decompression, by removal of the myxomatous material, is often all

that is required, but the ‘ganglion’ may recur, necessitating excision
of part of the artery with interposition vein graft repair.
 Raynaud’s disease

This idiopathic condition usually occurs in young women and affects the hands more than
the feet.

There is abnormal sensitivity in the arteriolar response to cold.These vessels constrict and
the digits (usually the fingers) turn white and become incapable of fine movements. The
capillaries then dilate and fill with slowly flowing deoxygenated blood, resulting in the
digits becoming swollen and dusky. As the attack passes off, the arterioles relax,
oxygenated blood returns into the dilated capillaries and the digits become red. Thus, the
condition is recognized by the characteristic sequence of
• blanching
• dusky cyanosis
• red engorgement
• accompanied by pain.
Superficial necrosis is very uncommon. This condition must be
distinguished from Raynaud’s syndrome, which has similar
features.

Treatment of Raynaud’s disease consists of protection from

cold and avoidance of pulp and nailbed infection.

Calcium antagonists, such as nifedipine, may also have a role

to play and electrically heated gloves can be useful in winter.
 Raynaud’s syndrome

The term Raynaud’s syndrome is most often used for a peripheral arterial manifestation
of a collagen disease such as systemic lupus erythematosus or rheumatoid arthritis.

The clinical features are as for Raynaud’s disease but they may be much more
aggressive. Raynaud’s syndrome may also follow the use of vibrating tools. In this
context it is a recognized industrial disease and is known as ‘vibration white finger’.

Treatment is directed primarily at the underlying condition, although the conservative

measures outlined above are often helpful. The syndrome when secondary to collagen
disease leads frequently to necrosis of digits and multiple amputations.

Nifedipine, steroids and vasospastic antagonists may all have a role in treatment.
Patients with vibration white finger should avoid vibrating tools.
 Acrocyanosis

Acrocyanosis may be confused with

Raynaud’s disease but it is painless and
not episodic. It tends to affect young
women and the mottled cyanosis of the
fingers and/or toes may be accompanied
by paresthesia and chilblains.
 References

Baileys and Love’s short practice of surgery 26th

Edition edited by Norman S. Williams et.al

Toronto notes 2016

Medscape