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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

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vascular surgery occlusive peripheral vascular disease

Vascular SurgeryOcclusivePeripheral Vascular Disease

Adrian P. Ireland BA(mod) MB MCh BAO FRCS(I)

Beaumont Theatre Nurses 13Jan 2004

occlusive peripheral vascular disease
Occlusive Peripheral Vascular Disease
  • Peripheral vascular disease
    • Includes any disease affecting the peripheral vascular system
  • Occlusive – essentially blocked arteries
outline
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
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
slide5

William Harvey (1578-1657)

On the Motion of the Heart and Blood in Animals (1628)

problem with blocked circulation
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
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
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
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
Annual Deaths Due toCerebrovascular Disease andIschemic Heart Disease

Report on Vital Statistics Central Statistics Office Ireland, 1995

manifestations of blocked arteries12
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
Monitoring Circulation
  • Mottling, colour, temperature, movements, sensation
  • Palpable pulses, doppler signals
  • Non invasive pressure studies (Doppler)
  • Duplex imaging
  • Angiography (IAA, DSA, MRA)
occlusive peripheral vascular disease19
Occlusive Peripheral Vascular Disease
  • Classification based upon clinical presentation
    • Acute ischemia
    • Chronic ischemia
  • Anatomic classifcation based upon site(s) of disease
opvd anatomic classification
OPVD Anatomic Classification
  • Aorto-iliac
    • Le-Riche
  • Femero-popliteal
  • Tibio-peroneal
effects o f acute i schemia
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
Compartment Syndrome
  • Pathophysiology
  • Diagnosis
  • Management
compartment syndrome pathophysiology
Compartment SyndromePathophysiology
  • 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 di agnosis
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
acute ischemia27
Acute Ischemia
  • Causes
    • Thrombosis
    • Embolism
  • The P’s
  • Thrombosis or embolism?
  • Clinical assessment of severity
  • Clinical algorithm
causes of acute ischemia
Causes of Acute Ischemia
  • Trauma
  • Thrombosis
  • Embolism
  • Small print
    • Aneurysm
    • Thrombophilia
    • Paradoxial embolism
    • Anatomic variation
    • Csytic adventitial disease
thrombosis
Thrombosis
  • Occlusive atherosclerosis
  • Aneurysm
  • Malignancy
  • Thrombophilia
embolism
Embolism
  • Macro-embolism
    • arterial side
    • venous side (patent foramen ovale)
  • Micro-embolism
    • ulcerated atherosclerotic plaques
    • aneurysm
the p s
The P ’s
  • No flow in artery
    • Pallor
    • Pulse absent
    • Perishing cold
  • Nerve becomes ischemic
    • Pain
    • Paresthesia / anesthesia
    • Paralysis
clinical assessment of severity
Clinical Assessment of Severity
  • Viable no immediate threat
  • Threatened
    • Marginally ok if treated promptly
    • Immediately ok if treated immediately
  • Irreversible dead leg
irreversible i schemia
Irreversible Ischemia
  • Sensory loss Profound,anaesthetic
  • Muscle weaknessProfound, paralysis
  • Arterial doppler Inaudible
  • Venous doppler Inaudible

Amputation

viable no immediate threat
Viable no immediate threat
  • Sensory loss None
  • Muscle weakness None
  • Arterial doppler Audible
  • Venous doppler Audible
  • Restore perfusion
clinical assessment of severity37
Clinical Assessment of Severity
  • Viable No immediate threat
  • Threatened
    • marginally Ok if treated promptly
    • immediately Ok if treated immediately
  • Irreversible Dead leg
threatened marginally
Threatened Marginally
  • Sensory loss Minimal (toes) to none
  • Muscle weakness None
  • Arterial doppler Inaudible
  • Venous doppler Audible
  • Restore perfusion
threatened immediately
Threatened Immediately
  • Sensory loss More than toes, Pain
  • Muscle weakness Mild to moderate
  • Arterial doppler Inaudible
  • Venous doppler Audible

Restore perfusion

pra c tical questions
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?
slide41

acute non traumatic ischemia

Irreversible

Threatened

Viable

Clear embolus

?Thrombosis

Duplex

Adequate

Inadequate

Angiogram

Treat

Amputation

Embolectomy

Thrombolyse

+/- PTA

Reconstruct

prognosis
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
lafontaine classification
LaFontaine Classification

Stage 1 claudication

Stage 2 rest pain

Stage 3 necrosis/ulceration

prognosis in claudicants
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
Re-Vascularisation ?
  • Risk factor control, aspirin, statin
  • Pain control
  • Dressing
  • Sympathectomy (chemical, surgical)
  • Iloprost
  • Angioplasty +/- Stent (? Drug elute)
  • Surgical
surgical re vascularisation
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
Definition Of Critical Ischemia
  • Presence of tissue loss

OR

  • Rest pain with ankle pressure less than 50 mm Hg

FOR

  • More than 2 weeks
j c 68 year old male
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
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
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
Social History
  • Retired
  • Lives with wife
  • Ex smoker 20 cigarettes per day for 20 years (gave up 20 years ago)
clinical examination
Clinical Examination
  • No distress, vitals normal
  • Regular pulse
  • Left carotid bruit
  • Normal examination of chest
  • Normal examination of abdomen
examination right foot
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
Investigations
  • CXR - normal
  • ECG BSR, Left axis deviation
    • Old lateral MI
  • U+E - U 7.7, Creatinine 118
  • FBC - Normal
  • COAG - Normal
summary
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
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
Vascular Reconstruction
  • Right fem pop below knee bypass
  • General anaesthesia
  • Commenced 16:05 finished 19:10
  • No transfusion
vascular reconstruction63
Vascular Reconstruction
  • Conduit - thin wall 6mm 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
post operative course
Post Operative Course
  • Day 14
  • Palpable DP pulse in foot
  • Wounds healing
  • Discharge to Convalescence
chronic

Chronic

Endarterectomy

chronic77

Chronic

In situ distal bypass

Fem to distal 1/3 posterior tibial with insitu long saphenous vein

critical limb ischemia sweedish data
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
Critical Limb Ischemia - Finnish Data

Ann Chir Gyn 86:213, 1997

effect of vein cuff on patency of ptfe fempop bypass
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