ARTERIAL DISORDERS

ARTERIAL DISEASESObjectives: TO UNDERSTAND THE NATURE OF OCCLUSIVE ARTERIAL DISEASE AND ITS ASSOCIATED SYMPYOMS AND SIGNS

TO ABLE TO ASSESS ACUTE AND CHRONIC ARTERIAL INSUFFICIENCY AND KNOW TREATMENT OPTIONS.

TO KNOW ABOUT GANGRENE AND ITS MANAGEMENT

TO KNOW OTHER ARTERIAL DISEASES LIKE ANEURYSMS, ARTERITIS AND VASOSPASTIC DISEASES & AVFistula

Arterial Occlusion

Occlusive arterial diseaseTypes

Acute arterial occlusion

Chronic arterial occlusionACUTE ARTERIAL OCCLUSION CAUSES-EMBOLICTHROMBOTICHeart diseases-Atrial fibrillation,mural thrombus, Post MIRheumatic valvular heart diseasesParadoxical embolism- venous thromboembolism due to patent foramen ovaleArterio- arterial embolism- dislodgement of atheromatous plaquesAngiographic proceduresAccidental- intraarterial injection- Ergot,thiopentalTrauma.

EmbolismBrain-MCARetina-Amaurosis fugaxMesenteric vessel-SpleenKidneysLungs-pulmonary embolism

ACUTE ARTERIAL OCCLUSION-Embolism C/F FIVE PsPAINPARALYSISPALLORPULSELESSNESSPARAESTHESIA

Relation ship of symptoms to the site of obstruction

Aorto-iliac obstruction

Iliac obstruction

Femoro-popliteal obstruction

Distal obstruction

ankle pulses absentCaludication in both buttocks,thighs & calves. Femoral & distal pulses absent in both limbs. Impotence.bruit over aortoiliac region.

U/l claudication in thigh & calf buttocks.Bruits over iliac region

U/L absence of femoral or distal pulses.

U/L claudication in calf. Femoral pulse palpable with absent u/l distal pulsesFemoral & Popliteal pulse palpable

claudication in calf & footArterial StenosisInvestigations:General- CBC,ESR,PLASMA -fibrinogen, protein, electrophoresis,Glucose- blood n urine.Lipid profileDoppler -USG blood flow detectionDuplex imaging.EchocardiographyArteriographyDSAECG

Hand held Doppler

COLOUR DUPLEX

ARTERIOGRAM

DSA

Angioscope

Treatment.

Embolic arterial occlusion is an emergency!!!

THROMBOLYSIS Immediate -Intra Venous Heparin 5000U to prevent distal and proximal extension of thrombus. Contraindications Recent stroke Active peptic ulcer Bleeding disorders Pregnancy Hydration EMBOLECTOMYTHROMBECTOMY.

Fogarty catheterization- for removing proximal and distal extension of thrombus.Postoperatively- heparin and oral anticoagulationIntrarterial ThrombolysisOnly if ischemia is not so severe that immediate operation is mandatory, it is possible to treat thrombus or embolus by intra arterial thrombolysisAgents-TPA-tissue plasminogen activator**StreptokinaseUrokinaseIdentify and treat the basic cause.

SFA thrombolectomy

Removed thrombus

Arterial Catheters

Chronic Arterial Insufficiency EtiologyAtherosclerosisBuergers diseaseArtritisArterisclerosisDiabetesRisk FactorsHypertensionDiabetesStrong family historySmokingLipid abnormalities

Chronic Limb IschemiaIschemia of the lower limb may be minimal to criticalAlso called Chronic arterial insufficiency or Peripheral Vascular disease-PVD.Clinical presentation-Intermittant Claudication-commonest complaint. Fatigue, aching or crampy pain occuring with exertion and relieved by rest, reproducible at the same distance.Claudication distance- distance at which the pain appearsRest painCritical ischemia- severe ischemia with actual or potential tisssue loss.

Signs of chronic ishemiaLoss of muscle mass/bulkLoss of subcutaneous fatSkin shiny Loss of hairBrittle nailsGangrene and ulcers of foot.

???

GANGRENE

Def: death, often with putrifaction of macroscopic portion of tissues.

VARIETIES ACCORDING TO THE CAUSE-Secondary:Thrombus in atherosclerotic artery.ATRIAL FIBRILLATION-embolus.Arteritis from NEUROPATHYBUERGERS DISEASERAYNAUDS DISEASE/ERGOTISM- causing arterial shutdown INTRARTERIAL INJECTIONS- thiopentone & cytotoxic materials.

GANGRENE

Primary:INFECTIVE- boils, carbuncles, gas gangrene, gangrene of scrotum (Fourniers gangrene)TRAUMATIC- crush, pressure sores & constriction groovesPHYSICAL- burns, scalds,frostbite,chemical irradiation & electricity.VENOUS-

C/F Pulseless,painnless,funtionless, with colour change.Lacks capillary refill and venous return.Black,brown, greenish black.

GANGRENE

CLINICAL TYPES- DRY & MOISTDRY gangrene- dessicated tissues,part becomes dry and wrinkled. Wrinkled ,discolourd from disintegration of Hb. & greasy to touch.MOISTgangrene:when venous & arterial obstruction is present, when artery is suddenly occluded by a ligature or embolus & in diabetes..Infection & putrifaction is present.Part is swollen& discoloured.Crepitus may be present.

GANGRENESEPERATION OF GANGRENE-SEPERATION BY DEMARCATIONSEPERATION WITHOUT DEMARCATION.Vague DEMARCATION & skip lesions.

TREATMENT OF GANGRENE-GENERAL PRINCIPLES- limb saving attitude.Cardiac failureAtrial fibrillation anaemia. Nutritious diet.Control of diabetes.Analgesics. LOCAL TREATMENT-dry.protection of pressure areas. Cleanniess.

VARIETIES OF GANGRENE

DIABETIC GANGRENE- three factors-Trophic changes from peripheral neuritis.Atheroma of artries causing ischemiaExcess sugar decreases resistance to infections esp. fungal infection

DIRACT TRAUMATIC GANGRENE BEDSORES-(Decubitus Ulcers) 5 factorsPressureInjuryAnemiaMalnutritionMoisture

Pressure Sore

GangreneINDIRECT TRAUMATIC GANGRENE-Interference with blood vessels from pressure by a fractured bones/ strangulationThrombosis of an arteryLigation of an artery poor technique for digital anesthesia

ERGOT- claviceps purpurea.Fingers,nose & ears .Seen in migrane suffers.

PHYSICAL AND CHEMICAL CAUSE OF GANGRENE. FROST BITE- cold+wind. Damage to Vessel wall with transudation & edema. Pain initially later painless & gangreneTRENCH FOOT-cold+ moist+ muscular inactivity.Ill fitting boots.

I/V INJECTION OF THIOPENTONEDRUG ABUSE CHEMICAL GANGRENE- carbolic acid(phenol).Frost bite

ANEURYSMS ANEURYSMS- dilatation of a localised segment of the arterial system.True- all three layers involved. False- single layer of fibrinous tissue as the wall of the sac. According to the shape-fusiform-Saccular-DissectingEti0logy-traumatic/atherosclerotic/syphilitic/collagen disease(Marfan,syndrome), mycotic(bacterial)

ANEURYSMS Symptoms- due to expansion, thrombosis, rupture or release of emboli.Symptom relate to the vessel affected, the site supplies or the tissue compressed. Clinical featuresIntrinsic-expansile pulsation along the course of an artery. proximal compression decreases pulsationsPalpation- thrillAuscultation-bruits??Extrinsic- neighboring or distal structures are affected.NerveVeinsTubes-trachea ,esophagus

D/DSwelling under an artery- cervical rib(subclavian)Swelling over an artery-pancreatic cystPulsatile tumors-sarcoma,osteoclastoma & metastsis from hypernephroma. abscess serpentine artery- innominate,carotid.

ANEURYSMSAbdominal aortic aneurysm-Commonest large vessel aneurysm2% population95% atherosclerotic95% below the renal arteriesSymptomatic/asymptomaticSymptoms-back pain, sudden mild-sudden severe.

ANEURYSMSRuptured AAA-AnteriorPosteriorFree bleeding into the peritoneal cavity(20%)Retroperitoneal hematoma(80%)Profound hypotensionSevere pain

ANEURYSMSInvestigation:USG abdomenCT Chest & abdomen.AORTOGRAM

ANEURYSMSProcedureOpen surgical procedureEndoluminal stent graft procedure.Complications:RespiratoryHgeColonic ischemiaRenal failure Infection of the graft.Sexual dysfunctionFistula formation.Spinal cord ischemia.Peripheral aneurysmsPopliteal aneurysms- most commonFemoral IliacAscending aorta & arch

AVF:

Communication between an artery & vein.Congenital Acquired- trauma, penetrating wound or sharp blow, surgical for renal failure.Structural effect- arterialized veins. Dilated tortuous veinsPhysiological effect- Increased VR, Increased VP, Increased HR- Increased CO.PP-HIGHLVFCardiac failureCong Fistula- Overgrowth of limb. Persistent ulcer due to distal ischemia.

???

AVFClinical signs:Pulsatile swellingThrill on palpationBruits on ausculatationDilated veinsNicoladoni-Branhams test- Decreased thrill, reduction in size and bradycardia on pressing the artery proximal to fistulaTreatmentEmbolizationLigation of feeding artery???Surgery- Separation of artery & veinARTERITIS

Thromboangitis obliterans/ Buergers disease Small & medium sized arteries.Occlusive diseaseThrombophebitis of superficial/ deep veins.Raynauds syndrome, male, young patients

VASOSPASTIC CONDITIONS:

Reynaud's syndrome: Primary/ idiopathic form.Secondary

Pallor- blanchingBlue- cyanosisRedness-red engorgement.Accompanied by pain.

Treatment - conservativeTab. nicotinamide

Secondary Reynaud's syndrome- due to some other problem like-collagen disease, atherosclerosis, thoracic outlet syndrome, carpal tunnel syndrome