Vascular Surgery Occlusive Peripheral Vascular Disease Adrian P
- Slides: 82
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 peripheral vascular system • Occlusive – essentially blocked arteries
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 • 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 (1628)
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 • High fat diet • Lack of exercise – Co-morbidities • Diabetes, hypertension, hypothyroidism, homocysteine
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 Ireland, 1995
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 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 • Non invasive pressure studies (Doppler) • Duplex imaging • Angiography (IAA, DSA, MRA)
Non Invasive Pressure Studies (NIPS)
Duplex of carotid stenosis
Angiography (DSA)
MRA
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
Acute Ischemia
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 • 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 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
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 – – – Aneurysm Thrombophilia Paradoxial embolism Anatomic variation Csytic adventitial disease
Thrombosis • Occlusive atherosclerosis • Aneurysm • Malignancy • Thrombophilia
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 – Perishing cold • Nerve becomes ischemic – Pain – Paresthesia / anesthesia – Paralysis
Thrombosis or Embolism?
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 doppler Inaudible • Venous doppler Inaudible Amputation
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 – immediately • Irreversible Ok if treated promptly Ok if treated immediately Dead leg
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 moderate • Arterial doppler Inaudible • Venous doppler Audible Restore perfusion
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 Angiogram Treat Amputation Embolectomy Thrombolyse Reconstruct +/- PTA
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
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 • 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, surgical) Iloprost Angioplasty +/- Stent (? Drug elute) Surgical
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 ankle pressure less than 50 mm Hg FOR • More than 2 weeks
Acute on Chronic Bypass
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 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 (diet) June 1999 dizzyness ? cause – Carotid duplex showed non critical stenosis
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 Normal examination of chest Normal examination of abdomen
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 MI • U+E - U 7. 7, Creatinine 118 • FBC - Normal • COAG - Normal
Non Invasive Pressure Studies
Digital Subtraction Angiogram
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. 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: 05 finished 19: 10 No transfusion
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
Post Operative Course • • Day 14 Palpable DP pulse in foot Wounds healing Discharge to Convalescence
Chronic Endarterectomy
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 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
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
- Occlusive velari
- Secondary growth in dicot stem
- Nonvascular plant diagram
- Nonvascular plants
- Vascular and non vascular difference
- Peripheral vascular system
- Peripheral arterial disease
- Communicable disease and non communicable disease
- Adrian mitchell back in the playground blues
- Adrian baguley
- Adrian malof
- Adrian hoti
- Adrian stoica jpl
- Adrian rohrbasser
- Herr dr. medic. (im tem.) adrian balint
- Usbdview
- Adrian's pizza
- Characters saving private ryan
- Adrian paschke
- Small culture
- Adrian schultz
- Adrian ferenc
- Adrian brasoveanu
- 608250254
- Adrian dul
- Adrian manapat
- Ignatius adrian mastan
- Adrian ciura
- Adrian bevan
- Adrian macko
- Madalin adrian
- Midsummer nights adrian
- Rcem audit
- Adrian badila
- Adrian feiguin
- Irongeek
- Adrian potts
- Adrian chadd
- Adrian fabich
- Adrian negrean
- Adrian miles
- Chirila adrian
- Adrian boyle
- Hornero ave nacional de argentina
- Adrian negrean
- Adrian taylor oxford
- Adrian muresan cluj
- Adrian smith spru
- Adrian leslie
- Ignatius adrian mastan
- Adrian duffield
- Adrian bastianelli
- Adrian gardener
- Jaanai michelle romero
- Adrian martin maya
- Dr adrian harrop wikipedia
- Oanaelisa
- Adrian fabich
- Adrian's magneto service
- Adrian snowball
- Adrian zbudował figury geometryczne
- Professor adrian smith
- Adrian lock
- Constexpr
- Adrian kamenitzer
- Adrian sotelo
- Ulnt
- Adrian martinez parents
- Adrian melott
- Adrian messer
- Ce sunt proteinele definitie
- Dr. adrian anil
- Adrian amariei
- Aisha nurtabina
- Adrian
- Haratau
- Adrian panozzo
- Adrian lorenzana
- Adrian golvano
- Adrian balint
- Adrian router
- Adrian pascu italia
- Cisco security ransomware