Download MBBS Final Year Surgery POVD Notes Notes

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PERIPHERAL


OCCLUSIVE

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VASCULAR

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DISEASE


S1 UNIT

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• Byabang Limli


• Chaithra Jayaprakash


• Chinky M

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• Cristoss Gregory


• Darsana Raj



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• Deepak Peter


• Deepak Roy


• Deepthi Roy S

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• Deepu Krishnan M

WHAT IS POVD?

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A Clinical disorder characterised by stenosis or

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occlusion of the arteries of periphery especially those


supplying limbs.

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Why are we so much concerned about POVD?


Peripheral artery disease has been

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estimated to affect about 20%

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individuals aged 55 to 75 years


Only 25% present with symptoms, most common

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of which is Intermittent Claudication.


1-2% of pts with IC progress to point where

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amputation or revascularisation is required.

• Mortality rate of people with IC is 2-3 times higher than general population.

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• Death-- due to MI or stroke- means- IC nearly always occur in association with
  
  
  widespread atherosclerosis.

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CONTENTS...

• ANATOMY OF ARTERIAL SYSTEM

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• ETIOPATHOGENESIS


• CLINICAL FEATURES



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• CLINICAL EXAMINATION


• INVESTIGATIONS


• MEDICAL THERAPY

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• SURGICAL MANAGEMENT


• ACUTE LIMB ISCHEMIA



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ANATOMY OF


ARTERIAL SYSTEM

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BYABANG LIMLI

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Roll No.42


ARTERIES OF UPPER LIMB

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SUBCLAVIAN ARTERY


AXILLARY ARTERY

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BRACHIAL ARTERY

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ARTERIES OF FOREARM


PALMAR ARCHES

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ARTERIES OF LOWER LIMB


Common Iliac Artery

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Internal Iliac Artery

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Abdominal Aorta


External Iliac Artery

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Femoral artery


Profunda femoris

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Lateral circumflex

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femoral artery


Ascending branch

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Inguinal ligament


External iliac artery

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Transverse branch

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Descending branch


Medial circumflex

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femoral artery


Muscular branches

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Perforating arteries

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Popliteal artery


Anterior tibial

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artery


Posterior tibial

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artery

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Fibular artery


Lateral plantar

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artery


Medial plantar

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artery

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Dorsalis pedis


artery (from top

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of foot)


Plantar arch

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Plantar

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metatarsal a.


Lateral

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plantar a.


Plantar digital aa.

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Digital branch

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Superficial branch


Deep branch

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Plantar


arch

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Deep plantar branch of

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dorsalis pedis a.


Medial

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plantar a.


Medial

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tarsal aa.

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Dorsalis


pedis a.

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Medial


Posterior

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tibial a.

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anterior


malleolar a.

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tibial a.


Dorsal

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digital aa.

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Dorsal


metatarsal a.

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Arcuate a.


Lateral tarsal a.

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Lateral

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anterior malleolar a.


Perforating

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branch of


peroneal a.

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ETIOPATHOGENESIS

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CHAITHRA JAYAPRAKASH


Roll No.43

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CAUSES OF POVD

• ATHEROSCLEROSIS



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• NON ATHEROSCLEROTIC CAUSES

ATHEROSCLEROSIS

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• Leading cause of occlusive arterial disease


• Usually localized in large and medium-sized vessels.


• Characterized by intimal lesions called atheroma

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• Lesions occurs preferentially at
  
  
  
  • Arterial branch points
  
  

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  • Sites of increased turbulence
  
  
  • Sites of intimal injury
  
  
  
  

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Arteries become narrowed and blood

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flow decreases in arteriosclerosis


RISK FACTORS

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FIRMLY ESTABLISHED:

• Dyslipidemia



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• Cigarette smoking


• Hypertension


• Diabetes mellitus

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RELATIVE FACTORS:

• Age

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• Gender


• Family history



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• Hypothyroidism


• Sedentary lifestyle


• Homocysteinemia

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PATHOGENESIS OF ATHEROSCLEROSIS

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intima


Media

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Endothelium


Adventetia

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RESPONSE TO INJURY

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ENDOTHELIAL DYSFUNCTION


INITIATION OF FATTY STREAK

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FATTY STREAK


FIBRO-FATTY ATHEROMA

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5. Smooth muscle

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proliferation, collagen


and other ECM

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deposition, extracellular


lipid

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COMPLICATIONS

• Narrowing of lumen ISCHEMIA

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• Weakening of wall ANEURYSMS


• Thrombosis ATHEROEMBOLISM



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• Loss of elasticity ELEVATION OF DIASTOLIC BP

LATE CHANGES

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• Calcification


• Rupture, Ulceration


• Thrombus formation

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• Haemorrhage

NON ATHEROSCLEROTIC CONDITIONS

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CAUSING LIMB ISCHE?

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THROMBOANGITIS OBLITERANS (BUERGER DISEASE)


RAYNAUDS SYNDROME

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TAKAYASU'S DISEASE


CYSTIC MYXOMATOUS DEGENERATION

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POPLITEAL ARTERY ENTRAPMENT SYNDROME

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FIBROMUSCULAR DYSPLASIA


PRESSURE NECROSIS

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EMBOLISM


SCLERODERMA

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TRAUMA

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RADIATION


DIABETES MELLITUS

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THROMBOANGITIS OBLITERANS


(BUERGER' S DISEASE)

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It is a segmental inflammatory disease that most often affects small

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and medium-sized arteries, veins, and nerves of the upper and lower


extremities.

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Caused by idiosyncratic endothelial cell toxicity due to some


components of tobacco

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Seen in men of age group 20-40 years who smokes

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PATHOGENESIS:


Smoke contains carbon monoxide and nicotinic acid

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carboxyhaemoglobin


vasospasm and intimal hyperplasia

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Thrombosis and obliteration of vessels

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Panarteritis


Artery, vein, nerve together involved

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Rest pain and ischaemia features


collaterals develop depending on site of blockage compensatory

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smoking peripheral vascular disease

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collaterals block up decompensatory peripheral vascular disease


(rest pain, ulceration,gangrene)

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SHIANOYA'S CRITERIA FOR BUERGER'S


DISEASE:

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• Tobacco use : only in males


• Starts before 45 years



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• Distal extremity first involved without embolic or atherosclerotic
  
  
  features



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• Absence of diabetes mellitus or hyperlipidemia


• With or without thrombophlebitis

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RAYNAUD'S DISEASE

• Idiopathic condition


• Characterized by recurrent, episodic vasospasm
  

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  of small arteries and arterioles of digits due to cold
  
  
  

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  exposure or emotional stress, tobacco.


• Young women < 30 yrs.


• Due to abnormal sensitivity of arterioles to cold.

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Triphasic colour response

• White: arteriolar vasospasm &
  

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  reduced blood flow


• Blue: accumulation of
  

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  deoxyhemoglobin


• Red: return of blood flow after
  

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  release of Vasospasm

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TAKAYASU'S DISEASE


"Aortic arch syndrome"or the "pulseless

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disease".

• A form of idiopathic large vessel
  
  

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  granulomatous vasculitis with massive
  
  
  intimal fibrosis and vascular narrowing.

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• Usually affecting aorta & it's branches

POPLITEAL ARTERY ENTRAPMENT

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SYNDROME

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Symptomatic Compression /


occlusion of popliteal artery due

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to developmentally abnormal


relationship with medial head of

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gastrocnemius / popliteus

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muscle


CYSTIC MY?ATOUS DEGENERATION

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• Idiopathic accumulation of clear jelly like substances in the
  
  
  outer layers of main artery (like a synovial ganglion)



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• More common in popliteal artery.

FIBROMUSCULAR DYSPLASIA

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• Developmental anomaly characterized by
  
  
  irregular thickening in medium and large
  
  

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  arteries


• Due to Medial and intimal hyperplasia & fibrosis



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CLINICAL FEATURES


CHINKY M

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Roll No. 44

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A CLINICAL SCENARIO

• A 60 year old man comes to OPD with history of cramp like pain in the
  
  
  

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  left leg during walking for the past 5yrs, which used to relieve on
  
  
  taking rest, now presented with continuous severe aching type of
  
  

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  pain even at rest on the same limb. There is also blackish
  
  
  discolouration of left big toe.

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Patient may present with...

• Claudication pain

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• Rest pain


• Ischemic ulcer



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• Pre gangrene


• gangrene

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INTERMITTENT CLAUDICATION


CRAMP LIKE PAIN FELT IN THE MUSCLE THAT IS ;

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• brought on by walking


• not present on taking the first step


• relieved by standing still

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• reproducible

CLAUDICATION DISTANCE

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The distance at which patient complains of pain after walking

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MAXIMUM WALKING DISTANCE


Distance the patient can walk maximally with pain

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BOYD'S CLASSIFICATION OF CLAUDICATION PAIN


Patient experiences pain after walking some

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GRADE 1

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distance. The person continues to walk and


pain disappears

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GRADE 2


Pain persists and still continues to walk with

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effort.

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GRADE 3


Pain compels the patient to take rest.

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CLAUDICATION SITE ACCORDING TO THE


LEVEL OF OBSTRUCTION

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REST PAIN

• Continuous aching type of pain in foot at rest
  

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  cry of dying nerves


• Aggravated by elevation of leg above level of heart, lying
  

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  down


• Reduced on hanging down

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• worse at night

ISCHEMIC ULCER

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• Inadequate blood supply


• Tender; punched out edge;



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• Deep-Base rests on bone/ligament/tendon


• Surrounding skin – cold, blue grey

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PRE GANGRENE


Changes in tissue which indicates that blood supply is

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inadequate to keep the tissue alive

• Rest pain



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• Colour changes


• Oedema


• Hyperaesthesia

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With or without ischaemic ulceration

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GANGRENE

• Macroscopic death of tissue with superadded putrefaction


• Common site is distal part of limb

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• Others:
  
  
  
  • Appendix
  
  

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  • Loop of intestine
  
  
  • Testis
  
  
  • Gall bladder

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CLINICAL FEATURES

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• Colour changes


• Absence of pulsation



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• Loss of sensation


• Loss of function


• Line of demarcation

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• Lack of venous return

CLINICAL TYPES OF GANGRENE

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• DRY GANGRENE


• WET GANGRENE



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WET GANGRENE

• Occurs when venous as well as arterial occlusion is present



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• Or when artery is suddenly occluded as in ligature or embolus


• Or in diabetes


• Infection and putrefaction is always present

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• Affected part becomes swollen,
  
  
  discoloured and epidermis may
  

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  be raised as blebs


• Crepitus may be palpated due to
  

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  infection by gas forming organisms

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DRY GANGRENE

• Gradual slowing of blood stream as in
  
  
  

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  atheromatous occlusion


• Affected part becomes dry, desiccated and
  
  
  

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  mummified


• Discoloration of affected part

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SEPARATION OF GANGRENE

• Line of demarcation between viable and dying tissues


• Band of hyperaemia or hyperaesthesia

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• Development of a layer of granulation tissue


• Ulceration follows & final line of demarcation develops



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FONTAINE CLASSIFICATION OF LIMB


ISCHAEMIA

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CRITICAL LIMB ISCHEMIA

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Persistent ischemic rest pain


requiring regular analgesics for >2 weeks

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with or without ulceration or gangrene of the feet or toes


Ankle systolic pressure < 50mm Hg or Toe systolic pressure < 30mm Hg and

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Ankle brachial pressure index < 0.3

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HISTORY

• Age and gender


• Limbs affected

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• Bilateral or unilateral


• Mode of onset



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• Pain


• Effects of warmth and cold


• Impotence

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• Paresthesia


• Superficial phlebitis



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• Involvement of other arteries
  
  
  Chest pain, transient blurring of vision,
  
  

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  weakness of body, abdominal pain, decreased
  
  
  urine output

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• Diabetes, hypertension, dyslipidemia


• Smoking



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• Family history of atherosclerosis

CLINICAL EXAMINATION

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CRISTOSS GREGORY


Roll No. 45

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INSPECTION

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SIGNS OF CHRONIC ISCHAEMIA

• THINNING OF SKIN


• DIMINISHED GROWTH OF HAIR

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• LOSS OF SUBCUTANEOUS FAT,SHININESS


• TROPHIC CHANGES IN NAILS



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• MINOR ULCERATIONS


• MUSCLE ATROPHY

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BUERGER'S POSTURAL TEST


The patient is asked to raise his legs one after the other keeping the

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knees straight


Ischemic limb - certain degree will cause marked pallor

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BUERGER'S ANGLE- angle

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between limb and horizontal


plane at which pallor appears

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<30 - SEVERE ISCHAEMIA


CAPILLARY FILLING TIME

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• After elevating the legs, patient is asked
  
  
  to situp and hang his legs

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• Time taken for the foot to become pink


• >20-30 sec indicate severe ischaemia



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VENOUS REFILLING

• After keeping the leg elevated for 30 sec then
  
  

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  laid flat on bed


• Normal refilling-<5 seconds



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• Ischaemia-veins collapse & guttered at 10-15

FUCHSIG'S CROSSED LEG TEST

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• Sits with the legs crossed one above the other


• The crossed leg- show oscillatory movements of the foot


• Synchronous to popliteal pulse

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• If popliteal artery blocked-movements absent

PALPATION

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• Skin Temperature
  
  
  palpated with back of fingers
  

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  temp is cold at ischemic site

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CAPILLARY REFILLING TIME

• Tip of the nail pressed for few seconds and the pressure
  
  
  

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  released


• Time taken blanched area become pink


• Normal -2-3 seconds

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• Longer in case of ischemic limb

VENOUS REFILLING/HARVEYS SIGN

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• Two index finger- side by side on a vein-pressed firmly


• the finger nearer to the heart is moved proximally so as to emptv



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• Distal pressure released


• Refilling observed


• POOR- ISCHAEMIA

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PALPATION OF

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BLOOD VESSELS


LOCATION OF RADIAL PULSE

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Felt at the wrist on lateral


aspect against lower end

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of front of radius

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LOCATION


OF ULNAR

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PULSE


Felt at the wrist on medial

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aspect against lower end of

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front of ulna


LOCATION

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OF


BRACHIAL

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PULSE

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Felt in front of elbow, just


medial to the biceps brachii

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tendon


AXILLARY

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PULSATION

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Felt in the apex of the axilla


against shaft of the humerus

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SUBCLAVIAN


PULSATION

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Felt against the first rib just

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above the middle of clavicle


SUPERFICIAL

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TEMPORAL


ARTERY

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PULSATION

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Felt in front of the tragus of the ear


against the zygomatic bone.

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DORSALIS


PEDIS ARTERY

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PULSATION

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Felt just lateral to tendon of extensor


halluces longus at the proximal end of

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first web space, felt against navicular


and middle cuneiform bones.

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ANTERIOR

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TIBIAL


ARTERY

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PULSATION


Felt anteriorly in midway between

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the malleoli against the lower end

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of the tibia just above the ankle


joint, lateral to extensor hallucis

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longus tendon


Posterior Tibial

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Artery

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Medial Malleolous


POSTERIOR

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TIBIAL ARTERY


Pulsation is felt against calcaneum just

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behind medial malleolus midway between it

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and tendo-achilles


POPLITEAL

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ARTERY


1. Knee flexed to 40 degrees with

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heel resting on couch.

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Examiner's thumb placed over


tibial tuberosity and fingers

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placed over lower part of


popliteal fossa.

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2. Patient is prone. Examiner

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feels along the line of artery


with fingertips after flexing the

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knee passively with another


hand

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FEMORAL

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PULSATION


At the groin just below ingunal

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ligament midway between the


symphysis pubis and the anterior

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superior iliac spine against the neck

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of femur


COLD AND WARM WATER TEST

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• Raynaud's disease


• Asked to put hand in ice cold water-
  
  
  

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  Hands become white


• Then hands put in hot water-Hands
  
  
  

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  become blue due to cyanotic
  
  
  congestion



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ELEVATED ARMS TEST

• Thoracic outlet syndrome suspected



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• Shoulder is abducted to 90 degree, arms
  
  
  externally rotated, hands opened and
  
  

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  closed for 5 min


• Fatigue, pain, numbness, paresthesia,
  
  

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  tingling sensation in forearms and
  
  
  fingers

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ALLENS TEST

• To test the patency of radial and ulnar arteries

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• Clench the fist tightly, radial and ulnar arteries obliterated for 1 min
  
  
  now the fist is openened and hand appears white

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• Relieving the preassure on either of the arteries if artery is patent the
  
  
  hand will regain normal colour

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COSTOCLAVICULAR COMPRESSIVE

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MANOEUVRE

• Radial pulse is felt shoulders moved backwards and downwards


• This compresses the subclavian artery leading t
  

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  disappearance of radial pulse

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ADSONS TEST

• Positive in case of cervical rib and scalenus anticus
  
  
  

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  syndrome


• Patient asked to take a deep breath and turn head to
  
  
  

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  the affected side radial pulse is diminished due to
  
  
  compression of subclavian artery



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AUSCULTATION


Arterial bruit

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• Due to turbulent blood flow through a stenotic artorial
  
  
  segment.

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• Transmitted distally along artery

INVESTIGATIONS

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DARSANA RAJ

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Roll No.45


NON INVASIVE

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INVESTIGATIONS


GENERAL INVESTIGATIONS

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BLOOD ROUTINE – Hemoglobin, TC, DC, Platelet count, ESR

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RISK FACTORS


DM - FBS,PPBS, HbA1C

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ATHEROSCLEROSIS - Lipid profile


CHEST X RAY

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PULMONARY FUNCTION TESTS

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BASELINE ECG, EXERCISE ECG


ECHOCARDIOGRAM

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RENAL FUNCTION TEST


ANKLE BRACHIAL PRESSURE

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INDEX(ABPI)

• ABPI = Ankle systolic pressure
  

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  Brachial systolic pressure

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DOPPLER ULTRASOUND


Indicates moving blood

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Can assess systolic pressure in small


vessels

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Measure segmental difference in BP in

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limb


PRINCIPLE : DOPPLER SHIFT

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1.Sharp systolic upstroke


3.Low amplitude forward

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flow throughout the diastole

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2. Reversal of flow in early diastole


due to vessel compliance

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DOPPLER WAVEFORM


DOPPLER WAVEFORM

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1.Sharp systolic upstroke

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3.Low amplitude forward flow throughout the


diastole

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2. Reversal of flow in early diastole due to vessel compliance


PROGRESSIVE

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SEVERE DISEASE

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BIPHASIC PATTERN/


MULTIPHASIC PATTERN

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Diastolic reversal lost


MONOPHASIC PATTERN

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Blunting of arterial waveform

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&Increased diastolic flow


DUPLEX SCANNING

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• Doppler + B mode ultrasound(images vessels)


• Second beam insonates imaged vessel


• Doppler shift is assessed

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Colour doppler: colours indicate change in direction and velocity of flow.

• MORE COST EFFECTIVE AND SAFE COMPARED TO ANGIOGRAPHY

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Blue-flow away from the

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transducer


Red-flow towards

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transducer


Brighter the

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colour, faster the

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velocity


USES OF DUPLEX

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a) Precise anatomical localisation of lesions


b)Quantitative severity of disease

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c)Assess plaque morphology

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SEGMENTAL PLETHYSMOGRAPHY

• Non invasive


• Detect changes in blood
  

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  volume between systole and diastole


• Photoplethysmography
  

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  cutaneous microcirculation

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INVASIVE INVESTIGATIONS


DIAGNOSTIC ARTERIOGRAPHY

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• Gold standard investigation prior to intervention


• Involves injection of radiopaque solution into
  
  
  

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  arterial tree


• Retrograde percutaneous catheterization
  
  
  

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  (Seldinger technique) commonly used


• Usually involves femoral artery

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CONTRASTS USED


Sodium diatrizoate

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(Hypaque45)


Meglumine diatrizoate

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? lonohexal

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SELDINGER TECHNIQUE


ARTERIOGRAPHIC INFORMATION

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Site of occlusion


Extent & Nature of occlusion

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Patency of vessel proximal/distal to

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occlusion


State of collateral circulation

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COMPLICATIONS


Puncture site or Catheter related

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• Hemorrhage


• Pseudoaneurysm



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• AV fistula


• Thrombosis&
  
  
  

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  Embolism


• Neurological
  
  
  

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  complications

Contrast agent related

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• Anaphylactoid


• Allergic reactions


• Vasodilation

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• Nephrotoxicity

DIGITAL SUBTRACTION ANGIOGRAPHY

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Employs computer system to digitise angiographic image

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Precontrast images subtracted from contrast image


Remove extraneous background ? clarity

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Intra- arterially or intravenously(multilevel occlusion)


Disadvantages : cost factor and availability

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Complications: anaphylaxis, bleeding, thrombosis

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CT ANGIOGRAPHY


Contrast dependant

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Rendered in 3D format, can be rotated and


viewed in different directions

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Disadvantage: Exposure to radiation

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Advantage: More rapid than MRA


It shows entire vessel

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MAGNETIC RESONANCE ANGIOGRAPHY

• Principle: Rearrangement of protons in a strong
  
  

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  magnetic field & multiplanar imaging


• Dye used: Gadolinium



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• Contraindications:Patients with pacemakers,
  
  
  intracerebral shunts, cochlear implants



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• Disadvantages: Poor visibility of peripheral
  
  
  circulation& collateral circulation



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INVESTIGATION FOR VASOSPASM

• Method: nerve block with local anaesthetic



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• Nerve block relieves sympathetic vasospasm rise in skin temperature


• Rise in skin temperature recorded & compared with mouth temperature.
  
  
  

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  Brown's vasomotor index =
  
  
  Rise in skin temperature – rise in mouth
  
  

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  temperature
  
  
  Rise in mouth temperature

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• Sympathectomy done only when index is 3.5 or more.

Medical MANAGEMENT

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OF POVD

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DEEPAK PETER


Roll No. 47

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GENERAL MEASURES

• STOP SMOKING
  
  

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  Smoking - Progression of atheroma Bypass graft failure


• CARE OF FOOT (CHIROPODY)
  
  

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  -Well fitting footwear
  
  
  -Heel raise
  

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  -Avoid exposure to more cold warm temperature, trauma

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Taking care of your


feet in diabetes

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Control of diabetes and hypertension, hyperlipidemia


Reduction of weight

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Regular exercise (Walking within limits of disability)

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Buergers position and Exercise


Regular graded isometric exercises up to the point of

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claudication improves the collateral circulation.


In buergers position head end of bed is raised foot

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end of bed is lowered to improve circulation

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SPECIFIC DRUGS


ASPIRIN Nonselective COX inhibitor

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CLOPIDOGREL Antiplatelet drug


CILOSTAZOL PDE-3 inhibitor

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?HYLLINE Reduces blood viscosity, improves RBC flexibility

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?OL NICOTINATE Vasodilator


PGE1 vasodilator

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SPECIFIC DRUGS


Low dose aspirin

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Nonselective COX inhibitor

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-Antithrombotic & analgesic


-May also be used after bypass surgery or angioplasty

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-Dose : 75 mg OD


-Side effects like nausea, vomiting, epigastric distress

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Clopidogrel

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Antiplatelet drug


P2Y12 receptor blocker

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Dose : 75 mg OD


Utilized for checking restenosis for stented coronaries

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Most important adverse effect : Bleeding

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Action lasts for 5 -7 days due to irreversible receptor blockade


Cilostazol

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PDE-3 inhibitor


Indicated for intermittent claudication in patients with no rest pain

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or heart failure

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Dose : 100 mg BD,30 min before or 2 hour after food


Most common side effect - Headache

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More effective than Pentoxiphylline


Pentoxiphylline

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Weak PDE inhibitor

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Reduces blood viscosity, improves RBC flexibility


Dose : 400 mg BD-TDS

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Mainly used in intermittent claudication


Available as TRENTAL-400

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Side effects like nausea, vomiting but well tolerated

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Xanthinol nicotinate


Compound of xanthine & nicotinic acid

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Vasodilator


Dose : 300-600 mg TDS oral

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Available as COMPLAMINA tab

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PGE1


Potent vasodilator, inhibitor of platelet aggregation

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Dose: 5-30 ng/kg/min


Administration : IV infusion: 100 mcg/500 ml NS

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Infused slowly for 10 hours per day for 5 days

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Eg:alprostadil


SURGICAL MANAGEMENT OF POVD

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DEEPAK ROY


Roll no.48

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Approach to surgical management-

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TransAtlantic Inter-Society Consensus


(TASC) Classification

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Based on TASC

• Type A lesions - Endovascular treatment



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• Type B lesions - Endovascular treatment


• Type C lesions – Surgery


• Type D lesions - Surgery

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ENDOVASCULAR PROCEDURES

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PERCUTANEOUS TRANSLUMINAL


BALLOON ANGIOPLASTY (PTA)

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• Done when Stenosis <5cm

INDICATIONS

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• Incapacitating Claudication


• Rest pain


• Limb salvage in limb threatening
  

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  ischemia


• Vasculogenic Impotence

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STEPS

• Angiogram

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• Introduce guidewire & balloon
  
  
  catheter

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• Balloon inflated


• Plaque ruptures



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• Satisfactory dilation confirmed by
  
  
  angiogram



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TYPES OF PTA

• Conventional: balloon is inflated along the lumen to break the
  
  

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  plaque circumferentially


• Sub intimal: balloon is inflated after passing sub intimal plane to
  
  

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  break the plaque

COMPLICATIONS

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ADVANTAGES:

• Faster Recovery

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• No general anasthesia


• Saphenous veins are preserved



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• May be combined with surgery

• Re-stenosis

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• Haematoma


• Haemorrhage & Pseudoaneurysm



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• Thrombosis and distal embolism

STENTING

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Expandable device at the site of occlusion


To prevent re-stenosis

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(elastic recoil, constrictive remodeling and intimal

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hyperplasia)


IDEAL INTRAVASCULAR STENT

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• High radiopacity


• Minimal or no foreshortening



This download link is referred from the post: MBBS Lecture Notes for all subjects (updated for 2021 syllabus) - All universities

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