Arterial ischemia acute and chronic Principles of Surgery
- Slides: 34
Arterial ischemia – acute and chronic. Principles of Surgery lecture series 20 October 2009 Barry Rubin MD Vascular Surgery UHN
1. Causes of acute leg ischemia. 2. How to differentiate causes of acute leg ischemia. 3. Natural history of the disease. 4. Therapy. 5. Chronic ischemia. 6. Differential diagnosis of leg ulcers.
Acute ischemia History Risk factors Embolic source Atherosclerosis Contra-lateral pulses Murmur Time for collaterals to develop Natural history Embolism in situ thrombosis
Iliac stenosis
Severe aorto-iliac disease
Aortic occlusion
Progression to in situ thrombosis – takes time
in situ thrombosis Plaque rupture
Multi-level peripheral vascular disease External iliac Superficial femoral Tibial
Risk factors for atherosclerosis • • • Smoking Hypertension Dyslipidemia Diabetes Chronic renal failure
in situ thrombosis History of claudication Yes Risk factors Embolic source No Atherosclerosis Yes Contra-lateral pulses No Murmur Unlikely Time for collaterals to develop Yes Natural history – better Or worse with time Better
Arterial embolus – artery blocked in seconds. Sources of arterial emboli?
Myocardial infarction and mural thrombosis
Thrombus in left atrium
Clot on bicuspid aortic valve
Bacterial endocarditis
Cardiac sources of emboli
Arterial to arterial embolization
Popliteal embolus Natural history of this lesion?
in situ thrombosis embolus History of claudication Yes No Risk factors Embolic source No Yes Atherosclerosis Yes No Contra-lateral pulses No Yes Murmur Unlikely Possibly Time for collaterals to develop Yes No Natural history – better Or worse with time Better Worse
Chronic ischemia
Iliac stenosis Therapeutic options?
Therapeutic options. 1. Do nothing (i. e. do no harm). 2. Angioplasty (+/- stent). 3. Bypass surgery.
Iliac stenosis - angioplasty
Iliac stenosis – post angioplasty and stent
Severe aorto-iliac disease - therapeutic options?
Aorto-bifemoral bypass
Types of foot ulcers Arterial Venous Neuropathic