Vascular Surgery Occlusive Peripheral Vascular Disease Adrian P

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Vascular Surgery Occlusive Peripheral Vascular Disease Adrian P. Ireland BA(mod) MB MCh BAO FRCS(I)

Vascular Surgery Occlusive Peripheral Vascular Disease Adrian P. Ireland BA(mod) MB MCh BAO FRCS(I) Beaumont Theatre Nurses 13 Jan 2004

Occlusive Peripheral Vascular Disease • Peripheral vascular disease – Includes any disease affecting the

Occlusive Peripheral Vascular Disease • Peripheral vascular disease – Includes any disease affecting the peripheral vascular system • Occlusive – essentially blocked arteries

Outline • • • Review of the circulation Pathogenesis of blocked arteries Manifestations of

Outline • • • Review of the circulation Pathogenesis of blocked arteries Manifestations of blocked arteries Monitoring the circulation Occlusive peripheral vascular disease – Acute Ischemia – Chronic Ischemia

Review Of Circulation • Cells need supply of nutrients and removal of by products

Review Of Circulation • Cells need supply of nutrients and removal of by products • In a unicellular organism this may occur via the cell membrane into say a pond or sea • Multicellular organisms need a circulatory system

William Harvey (1578 -1657) On the Motion of the Heart and Blood in Animals

William Harvey (1578 -1657) On the Motion of the Heart and Blood in Animals (1628)

Problem With Blocked Circulation • Tissues lack adequate supply of nutrients • Tissues suffer

Problem With Blocked Circulation • Tissues lack adequate supply of nutrients • Tissues suffer build of toxic by products • May cause symptoms and signs particularly when more blood flow is required; – To muscles during exercise – To tissues that are injured (more blood needed)

Pathogenesis Of Blocked Arteries • Atherosclerosis – Genes, hyperlipidemias – Lifestyle • Smoking •

Pathogenesis Of Blocked Arteries • Atherosclerosis – Genes, hyperlipidemias – Lifestyle • Smoking • High fat diet • Lack of exercise – Co-morbidities • Diabetes, hypertension, hypothyroidism, homocysteine

Manifestations Of Blocked Arteries • Depends on circulation affected – Heart • Stable angina,

Manifestations Of Blocked Arteries • Depends on circulation affected – Heart • Stable angina, unstable angina, myocardial infarction – Brain • Transient ischemic attact, stroke – Kidney • Hypertension, renal failure – Legs • Claudication, rest pain, necrosis

Principal causes of death in Ireland (males) Report on Vital Statistics Central Statistics Office

Principal causes of death in Ireland (males) Report on Vital Statistics Central Statistics Office Ireland, 1995

Annual Deaths Due to Cerebrovascular Disease and Ischemic Heart Disease Report on Vital Statistics

Annual Deaths Due to Cerebrovascular Disease and Ischemic Heart Disease Report on Vital Statistics Central Statistics Office Ireland, 1995

Manifestations Of Blocked Arteries • Depends on speed of development of blockage – Slow

Manifestations Of Blocked Arteries • Depends on speed of development of blockage – Slow blockage • Permits development of collateral blood supply so that occlusion may be asymptomatic – Rapid blockage • No time for development of collaterals – Symptoms/ signs depend on adequacy of preexisting collaterals

Monitoring Circulation • Mottling, colour, temperature, movements, sensation • Palpable pulses, doppler signals •

Monitoring Circulation • Mottling, colour, temperature, movements, sensation • Palpable pulses, doppler signals • Non invasive pressure studies (Doppler) • Duplex imaging • Angiography (IAA, DSA, MRA)

Non Invasive Pressure Studies (NIPS)

Non Invasive Pressure Studies (NIPS)

Duplex of carotid stenosis

Duplex of carotid stenosis

Angiography (DSA)

Angiography (DSA)

MRA

MRA

Occlusive Peripheral Vascular Disease • Classification based upon clinical presentation – Acute ischemia –

Occlusive Peripheral Vascular Disease • Classification based upon clinical presentation – Acute ischemia – Chronic ischemia • Anatomic classifcation based upon site(s) of disease

OPVD Anatomic Classification • Aorto-iliac – Le-Riche • Femero-popliteal • Tibio-peroneal

OPVD Anatomic Classification • Aorto-iliac – Le-Riche • Femero-popliteal • Tibio-peroneal

Acute Ischemia

Acute Ischemia

Effects Of Acute Ischemia • Reduced blood flow – Pulseless, pallor, perishing cold •

Effects Of Acute Ischemia • Reduced blood flow – Pulseless, pallor, perishing cold • Nerve ischemia – Pain, paralysis, Paresthesia • Muscle ischemia – Rhabdomyolysis • Compartment syndrome • Ischemia reperfusion syndrome

Compartment Syndrome • Pathophysiology • Diagnosis • Management

Compartment Syndrome • Pathophysiology • Diagnosis • Management

Compartment Syndrome Pathophysiology • Strong fascia encases the limb to aid muscle function and

Compartment Syndrome Pathophysiology • Strong fascia encases the limb to aid muscle function and return of venous blood • Injury results in swelling • Swelling raises pressure • Pressure occludes lymphatic return, then venous return, then arterial inflow – Result is dead or severly damaged tissues due to pressure and ischemia

Compartment Syndrome Diagnosis • Strong index of suspicion – Nature of injury and duration

Compartment Syndrome Diagnosis • Strong index of suspicion – Nature of injury and duration of ischemia • Clinical manifestations – Nerve and muscle dysfunction – Decreased perfusion – Tense compartment • May measure compartment pressure as adjunct to treatment > 40 mm hg

Compartment Syndrome Management • Fasciotomy

Compartment Syndrome Management • Fasciotomy

Acute Ischemia • Causes – Thrombosis – Embolism • • The P’s Thrombosis or

Acute Ischemia • Causes – Thrombosis – Embolism • • The P’s Thrombosis or embolism? Clinical assessment of severity Clinical algorithm

Causes of Acute Ischemia • Trauma • Thrombosis • Embolism • Small print –

Causes of Acute Ischemia • Trauma • Thrombosis • Embolism • Small print – – – Aneurysm Thrombophilia Paradoxial embolism Anatomic variation Csytic adventitial disease

Thrombosis • Occlusive atherosclerosis • Aneurysm • Malignancy • Thrombophilia

Thrombosis • Occlusive atherosclerosis • Aneurysm • Malignancy • Thrombophilia

Embolism • Macro-embolism – arterial side – venous side (patent foramen ovale) • Micro-embolism

Embolism • Macro-embolism – arterial side – venous side (patent foramen ovale) • Micro-embolism – ulcerated atherosclerotic plaques – aneurysm

The P ’s • No flow in artery – Pallor – Pulse absent –

The P ’s • No flow in artery – Pallor – Pulse absent – Perishing cold • Nerve becomes ischemic – Pain – Paresthesia / anesthesia – Paralysis

Thrombosis or Embolism?

Thrombosis or Embolism?

Clinical Assessment of Severity • Viable • Threatened no immediate threat – Marginally ok

Clinical Assessment of Severity • Viable • Threatened no immediate threat – Marginally ok if treated promptly – Immediately ok if treated immediately • Irreversible dead leg

Irreversible Ischemia • Sensory loss Profound, anaesthetic • Muscle weakness Profound, paralysis • Arterial

Irreversible Ischemia • Sensory loss Profound, anaesthetic • Muscle weakness Profound, paralysis • Arterial doppler Inaudible • Venous doppler Inaudible Amputation

Viable no immediate threat • • Sensory loss None Muscle weakness None Arterial doppler

Viable no immediate threat • • Sensory loss None Muscle weakness None Arterial doppler Audible Venous doppler Audible Restore perfusion

Clinical Assessment of Severity • Viable No immediate threat • Threatened – marginally –

Clinical Assessment of Severity • Viable No immediate threat • Threatened – marginally – immediately • Irreversible Ok if treated promptly Ok if treated immediately Dead leg

Threatened Marginally • Sensory loss Minimal (toes) to none • Muscle weakness None •

Threatened Marginally • Sensory loss Minimal (toes) to none • Muscle weakness None • Arterial doppler Inaudible • Venous doppler Audible Restore perfusion

Threatened Immediately • Sensory loss More than toes, Pain • Muscle weakness Mild to

Threatened Immediately • Sensory loss More than toes, Pain • Muscle weakness Mild to moderate • Arterial doppler Inaudible • Venous doppler Audible Restore perfusion

Practical Questions • Is this ischemia? (DDx stroke, TIA, cord) • Is the limb

Practical Questions • Is this ischemia? (DDx stroke, TIA, cord) • Is the limb viable, threatened or lost? • If threatened how long can reperfusion be delayed? • Is there a need for duplex or angiography? • Should the patient be immediately heparinised?

acute non traumatic ischemia Irreversible Threatened Viable Clear embolus ? Thrombosis Duplex Adequate Inadequate

acute non traumatic ischemia Irreversible Threatened Viable Clear embolus ? Thrombosis Duplex Adequate Inadequate Angiogram Treat Amputation Embolectomy Thrombolyse Reconstruct +/- PTA

Prognosis • Embolism – Overall 60% dead within three years – One episode 15

Prognosis • Embolism – Overall 60% dead within three years – One episode 15 -20% mortality (in hospital) – Two episodes 40% mortality (in hospital) • Thrombosis – Overall 40% dead within three years

Chronic Ischemia

Chronic Ischemia

La. Fontaine Classification Stage 1 Stage 2 Stage 3 claudication rest pain necrosis/ulceration

La. Fontaine Classification Stage 1 Stage 2 Stage 3 claudication rest pain necrosis/ulceration

Prognosis in Claudicants • About 15% will progress to requiring revasculartion or amputation •

Prognosis in Claudicants • About 15% will progress to requiring revasculartion or amputation • Much higher risk of death from IHD and stroke • Rule out diabetes, hypertension and hypercholesterolemia • Exercise, Smoking cessation, Aspirin and a Statin + control of risks

Re-Vascularisation ? • • Risk factor control, aspirin, statin Pain control Dressing Sympathectomy (chemical,

Re-Vascularisation ? • • Risk factor control, aspirin, statin Pain control Dressing Sympathectomy (chemical, surgical) Iloprost Angioplasty +/- Stent (? Drug elute) Surgical

Surgical Re-Vascularisation • • • Embolectomy and Thrombolysis Patchplasty (synthetic/ autogenous) Endarterectomy (open/closed/eversion) Bypass

Surgical Re-Vascularisation • • • Embolectomy and Thrombolysis Patchplasty (synthetic/ autogenous) Endarterectomy (open/closed/eversion) Bypass with synthetic material Bypass with autogenous material

Definition Of Critical Ischemia • Presence of tissue loss OR • Rest pain with

Definition Of Critical Ischemia • Presence of tissue loss OR • Rest pain with ankle pressure less than 50 mm Hg FOR • More than 2 weeks

Acute on Chronic Bypass

Acute on Chronic Bypass

J. C. 68 year old male • Emergency admission 24. 3. 2000 to vascular

J. C. 68 year old male • Emergency admission 24. 3. 2000 to vascular service SVUH, via A/E – Ischemic right foot

History of Presenting Complaint • Awoke with coldness and numbness in the right foot

History of Presenting Complaint • Awoke with coldness and numbness in the right foot 2 hours ago • Gradually sensation returned and foot became warm again • Worsening claudication for two years, 100 metres

Past History • • 1996 angina, failed angioplasty (aspirin) 1996 hypertension (atenalol) 1996 Hypercholesterolemia

Past History • • 1996 angina, failed angioplasty (aspirin) 1996 hypertension (atenalol) 1996 Hypercholesterolemia (diet) June 1999 dizzyness ? cause – Carotid duplex showed non critical stenosis

Social History • Retired • Lives with wife • Ex smoker 20 cigarettes per

Social History • Retired • Lives with wife • Ex smoker 20 cigarettes per day for 20 years (gave up 20 years ago)

Clinical Examination • • • No distress, vitals normal Regular pulse Left carotid bruit

Clinical Examination • • • No distress, vitals normal Regular pulse Left carotid bruit Normal examination of chest Normal examination of abdomen

Examination - Right foot • • Absent pulses below femoral Pallor at 30 degrees

Examination - Right foot • • Absent pulses below femoral Pallor at 30 degrees Movements and sensation intact Hand held doppler reveals arterial signals over dorsalis pedis and peroneal, posterior tibial signal absent

Investigations • CXR - normal • ECG BSR, Left axis deviation – Old lateral

Investigations • CXR - normal • ECG BSR, Left axis deviation – Old lateral MI • U+E - U 7. 7, Creatinine 118 • FBC - Normal • COAG - Normal

Non Invasive Pressure Studies

Non Invasive Pressure Studies

Digital Subtraction Angiogram

Digital Subtraction Angiogram

Summary • 68 year old male • Acute on chronic ischemia right foot •

Summary • 68 year old male • Acute on chronic ischemia right foot • Previous, MI, OCD (dizzy turn) • Critical ischemia • Probable poor run off on angiogram

Pre operative course • Elected initial conservative management • Anticoagulation with Heparin • 28.

Pre operative course • Elected initial conservative management • Anticoagulation with Heparin • 28. 3. 2000 decision to proceed to elective surgery (next list 6. 4. 2000) • 29. 3. 2000 further episodes of numbness, twice, and pallor on the flat – proceed to urgent vascular reconstruction

Vascular Reconstruction • • Right fem pop below knee bypass General anaesthesia Commenced 16:

Vascular Reconstruction • • Right fem pop below knee bypass General anaesthesia Commenced 16: 05 finished 19: 10 No transfusion

Vascular Reconstruction • Conduit - thin wall 6 mm PTFE – Long saphenous vein

Vascular Reconstruction • Conduit - thin wall 6 mm PTFE – Long saphenous vein thrombosed below knee – Poor quality vein in groin • Inflow - CFA s/e 5/0 prolene • Outflow – Miller cuff to BK pop 6/0 prolene – e/s PTFE to cuff 6/0 prolene

Miller Cuff - technique

Miller Cuff - technique

Miller Cuff - technique

Miller Cuff - technique

Post Operative Course • • Day 14 Palpable DP pulse in foot Wounds healing

Post Operative Course • • Day 14 Palpable DP pulse in foot Wounds healing Discharge to Convalescence

Chronic Endarterectomy

Chronic Endarterectomy

Chronic In situ distal bypass Fem to distal 1/3 posterior tibial with insitu long

Chronic In situ distal bypass Fem to distal 1/3 posterior tibial with insitu long saphenous vein

Critical Limb Ischemia Sweedish Data • 30 d mortality 5. 3% • 1 year

Critical Limb Ischemia Sweedish Data • 30 d mortality 5. 3% • 1 year mortality 22. 9% • For those aged > 75 – 30 d mortality 6. 4% – 1 year mortality 26. 4% Eur J Vasc Endovasc Surg 16: 137 -141, 1998

Critical Limb Ischemia Finnish Data Ann Chir Gyn 86: 213, 1997

Critical Limb Ischemia Finnish Data Ann Chir Gyn 86: 213, 1997

Effect of Vein Cuff on patency of PTFE fempop Bypass n = 261 Randomised,

Effect of Vein Cuff on patency of PTFE fempop Bypass n = 261 Randomised, BK 84: 62% 2 y salvage cuff: nocuff Stonebridge, Prescott and Ruckley. J Vasc Surg 26(4): 543 -50, Oct 1997