Download MBBS Final Year Surgery POVD Notes Notes

Download MBBS (Bachelor of Medicine and Bachelor of Surgery) 4th Year (Final Year) Surgery POVD Notes Handwritten Notes





PERIPHERAL
PERIPHERAL
OCCLUSIVE
OCCLUSIVE
VASCULAR
DISEASE
VASCULAR
DISEASE



? Byabang Limli
? Chaithra Jayaprakash
? Chinky M
? Cristoss Gregory
? Darsana Raj
? Deepak Peter
? Deepak Roy
? Deepthi Roy S
? Deepu Krishnan M





A Clinical disorder characterised by stenosis or
occlusion of the arteries of periphery especially those
supplying limbs.



Why are we so much concerned about POVD?
Peripheral artery disease has been
estimated to affect about 20%
individuals aged 55 to 75 years
The prevalence of POVD among Indians
(3.79%) is considerably lower as compared
Only 25% present with symptoms,most common
to Western counterparts (29%).
of which is Intermittent Claudication.
1-2% of pts with IC progress to point where

amputation or revascularisation is required.
? Mortality rate of people with IC is 2-3 times higher than general population.
? Death-- due to MI or stroke? means- IC nearly always occur in association with
widespread atherosclerosis.
Refrnce: Davidson's principles and practice of medicine
In 2010 about 202 million people suffered from POVD
worldwide.




? ANATOMY OF ARTERIAL SYSTEM
? ETIOPATHOGENESIS
? CLINICAL FEATURES
? CLINICAL EXAMINATION
? INVESTIGATIONS
? MEDICAL THERAPY
? SURGICAL MANAGEMENT
? ACUTE LIMB ISCHEMIA






ANATOMY OF
ARTERIAL SYSTEM
BYABANG LIMLI
Rol No.42


ARTERIES OF UPPER LIMB


SUBCLAVIAN ARTERY


AXILLARY ARTERY


BRACHIAL ARTERY

ARTERIES OF FOREARM


PALMAR ARCHES


ARTERIES OF LOWER LIMB











ETIOPATHOGENESIS
CHAITHRA JAYAPRAKASH
Rol No.43


CAUSES OF POVD
? ATHEROSCLEROSIS
? NON ATHEROSCLEROTIC CAUSES


ATHEROSCLEROSIS
? Leading cause of occlusive arterial disease
? Usually localized in large and medium-sized vessels.
? Characterized by intimal lesions called atheroma
? Lesions occurs preferentially at
?Arterial branch points
?Sites of increased turbulence
?Sites of intimal injury








RISK FACTORS
FIRMLY ESTABLISHED:
RELATIVE FACTORS:
? Dyslipidemia
? Age
? Cigarette smoking
? Gender
? Hypertension
? Family history
? Diabetes mellitus
? Hypothyroidism
? Sedentary lifestyle
? Homocysteinemia


PATHOGENESIS OF ATHEROSCLEROSIS
RESPONSE TO INJURY
ENDOTHELIAL DYSFUNCTION
Endothelium
intima
Media
Adventetia

INITIATION OF FATTY STREAK
FATTY STREAK


FIBRO-FATTY ATHEROMA






COMPLICATIONS
? Narrowing of lumen ISCHEMIA
? Weakening of wal ANEURYSMS
? Thrombosis ATHEROEMBOLISM
? Loss of elasticity
ELEVATION OF DIASTOLIC BP
LATE CHANGES
? Calcification
? Rupture, Ulceration
? Thrombus formation
? Haemorrhage

NON ATHEROSCLEROTIC CONDITIONS
CAUSING LIMB ISCHEMIA
v THROMBOANGITIS OBLITERANS (BUERGER DISEASE) PRESSURE NECROSIS
v RAYNAUDS SYNDROME EMBOLISM
v TAKAYASU'S DISEASE SCLERODERMA
v CYSTIC MYXOMATOUS DEGENERATION TRAUMA
v POPLITEAL ARTERY ENTRAPMENT SYNDROME RADIATION
v FIBROMUSCULAR DYSPLASIA DIABETES MELLITUS

THROMBOANGITIS OBLITERANS
(BUERGER' S DISEASE)
vIt is a segmental inflammatory disease that most often affects small
and medium-sized arteries, veins, and nerves of the upper and lower
extremities.
vCaused by idiosyncratic endothelial cell toxicity due to some
components of tobacco
vSeen in men of age group 20-40 years who smokes

PATHOGENESIS:
Smoke contains carbon monoxide and nicotinic acid
carboxyhaemoglobin
vasospasm and intimal hyperplasia
Thrombosis and obliteration of vessels
Panarteritis

Artery ,vein ,nerve together involved
Rest pain and ischaemia features
collaterals develop depending on site of blockage compensatory
smoking peripheral vascular disease
collaterals block up decompensatory peripheral vascular disease
(rest pain, ulceration,gangrene)

SHIANOYA'S CRITERIA FOR BUERGER'S
DISEASE:
? Tobacco use : only in males
? Starts before 45 years
? Distal extremity first involved without embolic or atherosclerotic
features
? Absence of diabetes mellitus or hyperlipidemia
? With or without thrombophlebitis


RAYNAUD'S DISEASE
? Idiopathic condition
? Characterized by recurrent, episodic vasospasm
of small arteries and arterioles of digits due to cold
exposure or emotional stress, tobacco.
? Young women < 30 yrs.
? Due to abnormal sensitivity of arterioles to cold.



Triphasic colour response
? White: arteriolar vasospasm &
reduced blood flow
? Blue: accumulation of
deoxyhemoglobin
? Red: return of blood flow after
release of Vasospasm


TAKAYASU'S DISEASE
? "Aortic arch syndrome"or the "pulseless
disease".
? A form of idiopathic large vessel
granulomatous vasculitis with massive
intimal fibrosis and vascular narrowing.
? Usually affecting aorta & it's branches


POPLITEAL ARTERY ENTRAPMENT
SYNDROME
Symptomatic Compression /
occlusion of popliteal artery due
to developmentally abnormal
relationship with medial head of
gastrocnemius / popliteus
muscle


CYSTIC MYXOMATOUS DEGENERATION
? Idiopathic accumulation of clear jelly like substances in the
outer layers of main artery (like a synovial ganglion)
? More common in popliteal artery.


FIBROMUSCULAR DYSPLASIA
? Developmental anomaly characterized by
irregular thickening in medium and large
arteries
? Due to Medial and intimal hyperplasia & fibrosis

CLINICAL FEATURES

CHINKY M

Rol No. 44

A CLINICAL SCENARIO
? A 60 year old man comes to OPD with history of cramp like pain in the
left leg during walking for the past 5yrs, which used to relieve on
taking rest, now presented with continuous severe aching type of
pain even at rest on the same limb. There is also blackish
discolouration of left big toe.


Patient may present with...
? Claudication pain
? Rest pain
? Ischemic ulcer
? Pre gangrene
? gangrene


INTERMITTENT CLAUDICATION
CRAMP LIKE PAIN FELT IN THE MUSCLE THAT IS ;
? brought on by walking
? not present on taking the first step
? relieved by standing still
? reproducible
CLAUDICATION DISTANCE
The distance at which patient complains of pain after walking

MAXIMUM WALKING DISTANCE
SUBSTANCE
P
Distance the patient can walk maximally with pain


BOYD'S CLASSIFICATION OF CLAUDICATION PAIN
Patient experiences pain after walking some
GRADE 1
distance. The person continues to walk and
pain disappears
GRADE 2
Pain persists and stil continues to walk with
effort.
GRADE 3
Pain compels the patient to take rest.


CLAUDICATION SITE ACCORDING TO THE
LEVEL OF OBSTRUCTION



REST PAIN
? Continuous aching type of pain in foot at rest
cry of dying nerves
? Aggravated by elevation of leg above level of heart, lying
down
? Reduced on hanging down
? worse at night


ISCHEMIC ULCER
? Inadequate blood supply
? Tender; punched out edge;
? Deep-Base rests on bone/ligament/tendon
? Surrounding skin ? cold, blue grey


PRE GANGRENE
Changes in tissue which indicates that blood supply is
inadequate to keep the tissue alive
? Rest pain
? Colour changes
? Oedema
? Hyperaesthesia
With or without ischaemic ulceration



GANGRENE
? Macroscopic death of tissue with superadded putrefaction
? Common site is distal part of limb
? Others:
? Appendix
? Loop of intestine
? Testis
? Gall bladder



CLINICAL FEATURES
? Colour changes
? Absence of pulsation
? Loss of sensation
? Loss of function
? Line of demarcation
? Lack of venous return



CLINICAL TYPES OF GANGRENE
? DRY GANGRENE
? WET GANGRENE



WET GANGRENE


DRY GANGRENE
? Gradual slowing of blood stream as in
atheromatous occlusion
? Affected part becomes dry, desiccated and
mummified
? Discoloration of affected part



SEPARATION OF GANGRENE
? Line of demarcation between viable and dying tissues
? Band of hyperaemia or hyperaesthesia
? Development of a layer of granulation tissue
? Ulceration follows & final line of demarcation develops

FONTAINE CLASSIFICATION OF LIMB
ISCHAEMIA
STAGE
FEATURES
Stage I
Asymptomatic
Intermittent claudication
Stage II
IIa- Well compensated > 200m
IIb- Poorly compensated < 200m
Stage III
Rest pain
Stage IV
Ulceration or gangrene



CRITICAL LIMB ISCHEMIA
qPersistent ischemic rest pain
q requiring regular analgesics for >2 weeks
qwith or without ulceration or gangrene of the feet or toes
q Ankle systolic pressure < 50mm Hg or Toe systolic pressure < 30mm Hg and
q Ankle brachial pressure index < 0.3
q


HISTORY
? Age and gender
? Superficial phlebitis
? Limbs affected
? Involvement of other arteries
? Bilateral or unilateral
? Chest pain, transient blurring of vision,
weakness of body, abdominal pain, decreased
? Mode of onset
urine output
? Pain
? Diabetes ,hypertension, dyslipidemia
? Effects of warmth and cold
? Smoking
? Impotence
? Family history of atherosclerosis
? Paresthesia

CLINICAL EXAMINATION
CRISTOSS GREGORY
Roll No. 45



INSPECTION
SIGNS OF CHRONIC ISCHAEMIA
? THINNING OF SKIN
? DIMINISHED GROWTH OF HAIR
? LOSS OF SUBCUTANEOUS FAT,SHININESS
? TROPHIC CHANGES IN NAILS
? MINOR ULCERATIONS
? MUSCLE ATROPHY


BUERGER'S POSTURAL TEST

The patient is asked to raise his legs one after the other keeping the
knees straight
Ischemic limb ? certain degree will cause marked pallor
BUERGER'S ANGLE- angle
between limb and horizontal
plane at which pal or appears
<30 - SEVERE ISCHAEMIA


CAPILLARY FILLING TIME
? After elevating the legs,patient is asked
to situp and hang his legs
? Time taken for the foot to become pink
? >20-30 sec indicate severe ischaemia



VENOUS REFILLING
? After keeping the leg elevated for 30 sec then
laid flat on bed
? Normal refil ing-<5 seconds
? Ischaemia-veins col apse & guttered at 10-15


FUCHSIG'S CROSSED LEG TEST
? Sits with the legs crossed one above the other
? The crossed leg- show oscillatory movements of the foot
? Synchronous to popliteal pulse
? If popliteal artery blocked-movements absent

PALPATION
? Skin Temperature
palpated with back of fingers
temp is cold at ischemic site


CAPILLARY REFILLING TIME
? Tip of the nail pressed for few seconds and the pressure
released
? Time taken blanched area become pink
? Normal -2-3 seconds
? Longer in case of ischemic limb


VENOUS REFILLING/HARVEYS SIGN
? Two index finger- side by side on a vein-pressed firmly
? the finger nearer to the heart is moved proximally so as to empty
? Distal pressure released
? Refilling observed
? POOR- ISCHAEMIA




PALPATION OF
BLOOD VESSELS



LOCATION OF RADIAL PULSE
Felt at the wrist on lateral
Felt at the wrist in front of the lower end
aspect against lower end
of the radius lateral y, lateral to the
of front of radius
flexor carpi radialis tendon


LOCATION
OF ULNAR
PULSE
Felt at the wrist on medial
aspect against lower end of
front of ulna



LOCATION
OF
BRACHIAL
PULSE
Felt in front of elbow, just
medial to the biceps brachi
tendon




AXILLARY
PULSATION
Felt in the apex of the axil a
against shaft of the humerus



SUBCLAVIAN
PULSATION
Felt against the first rib just
above the middle of clavicle



SUPERFICIAL
TEMPORAL
ARTERY
PULSATION
Felt in front of the tragus of the ear
against the zygomatic bone.


DORSALIS
PEDIS ARTERY
PULSATION
Felt just lateral to tendon of extensor
hal uces longus at the proximal end of
first web space, felt against navicular
and middle cuneiform bones.




ANTERIOR
TIBIAL
ARTERY
PULSATION
Felt anteriorly in midway between
the mal eoli against the lower end
of the tibia just above the ankle
joint,lateral to extensor hal ucis
longus tendon


POSTERIOR
TIBIAL ARTERY
Pulsation is felt against calcaneum just
behind medial mal eolus midway between it
and tendo-achil es




POPLITEAL
ARTERY
1. Knee flexed to 40 degrees with
heel resting on couch.
Examiner's thumb placed over
tibial tuberosity and fingers
placed over lower part of
popliteal fossa.
2. Patient is prone. Examiner
feels along the line of artery
with fingertips after flexing the
knee passively with another
hand



FEMORAL
PULSATION
At the groin just below ingunal
ligament midway between the
symphysis pubis and the anterior
superior iliac spine against the neck
of femur


COLD AND WARM WATER TEST
? Raynaud's disease
? Asked to put hand in ice cold water-
Hands become white
? Then hands put in hot water-Hands
become blue due to cyanotic
congestion


ELEVATED ARMS TEST
? Thoracic outlet syndrome suspected
? Shoulder is abducted to 90 degree, arms
externally rotated , hands opened and
closed for 5 min
? Fatigue, pain, numbness, paresthesia,
tingling sensation in forearms and
fingers


ALLENS TEST
? To test the patency of radial and ulnar arteries
? Clench the fist tightly,radial and ulnar arteries obliterated for 1 min
now the fist is openened and hand appears white
? Relieving the preassure on either of the arteries if artery is patent the
hand will regain normal colour


COSTOCLAVICULAR COMPRESSIVE
MANOEUVRE
? Radial pulse is felt shoulders moved backwards and downwards
? This compresses the subclavian artery leading to reduction or
disappearance of radial pulse


ADSONS TEST
? Positive in case of cervical rib and scalenus anticus
syndrome
? Patient asked to take a deep breath and turn head to
the affected side radial pulse is diminished due to
compression of subclavian artery


AUSCULTATION
Arterial bruit
? Due to turbulent blood flow through a stenotic arterial
segment.
? Transmitted distally along artery





DARSANA RAJ
Rol No.45


NON INVASIVE
INVESTIGATIONS



GENERAL INVESTIGATIONS
vBLOOD ROUTINE ? Hemoglobin, TC, DC, Platelet count, ESR
vRISK FACTORS
DM - FBS,PPBS, HbA1C
ATHEROSCLEROSIS - Lipid profile
vCHEST X RAY
vPULMONARY FUNCTION TESTS
vBASELINE ECG, EXERCISE ECG
vECHOCARDIOGRAM
vRENAL FUNCTION TEST


ANKLE BRACHIAL PRESSURE
INDEX(ABPI)
? ABPI = Ankle systolic pressure
Brachial systolic pressure


> 1 - NORMAL
< 0.9 ? CLAUDICATION
< 0.5 ? REST PAIN

< 0.3 ? IMMINENT NECROSIS
> 1.4 ? CALCIFIED VESSEL



DOPPLER ULTRASOUND
CHRISTIAN DOPPLER
? Indicates moving blood
?Can assess systolic pressure in small
vessels
?Measure segmental difference in BP in
limb





PRINCIPLE :DOPPLER SHIFT
1.Sharp systolic upstroke
TRANSDUCER
3.Low amplitude forward
flow throughout the diastole

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

RECEIVER
DOPPLER WAVEFORM




DOPPLER WAVEFORM
1.Sharp systolic upstroke
3.Low amplitude forward flow throughout the
diastole
2. Reversal of flow in early diastole due to vessel compliance








PROGRESSIVE
SEVERE DISEASE
BIPHASIC PATTERN/
MONOPHASIC PATTERN
Blunting of arterial waveform
MULTIPHASIC PATTERN
&Increased diastolic flow
Diastolic reversal lost


DUPLEX SCANNING
? Doppler + B mode ultrasound(images vessels)
? Second beam insonates imaged vessel
? Doppler shift is assessed
Colour doppler: colours indicate change in direction and velocity of flow.
? MORE COST EFFECTIVE AND SAFE COMPARED TO ANGIOGRAPHY





?Blue-flow away from the
transducer
?Red-flow towards
transducer
Brighter the
colour,faster the
velocity


USES OF DUPLEX
a) Precise anatomical localisation of lesions
b)Quantitative severity of disease
c)Assess plaque morphology


SEGMENTAL PLETHYSMOGRAPHY
? Non invasive
? Detect changes in blood
volume between systole and diastole
? Photoplethysmography
cutaneous microcirculation

INVASIVE INVESTIGATIONS


DIAGNOSTIC ARTERIOGRAPHY
? Gold standard investigation prior to intervention
? Involves injection of radiopaque solution into
arterial tree
? Retrograde percutaneous catheterization
(Seldinger technique) commonly used
? Usually involves femoral artery


CONTRASTS USED
Sodium diatrizoate
(Hypaque45)
Meglumine diatrizoate
Ionohexal


SELDINGER TECHNIQUE


ARTERIOGRAPHIC INFORMATION
vSite of occlusion
vExtent & Nature of occlusion
vPatency of vessel proximal/distal to
occlusion
vState of collateral circulation




COMPLICATIONS
Puncture site or Catheter related
Contrast agent related
? Hemorrhage
? Anaphylactoid
? Pseudoaneurysm
? Allergic reactions
? AV fistula
? Vasodilation
? Thrombosis&
? Nephrotoxicity
Embolism
? Neurological
complications


DIGITAL SUBTRACTION ANGIOGRAPHY
vEmploys computer system to digitise angiographic image
vPrecontrast images subtracted from contrast image
vRemove extraneous background clarity
vIntra- arterial y or intravenously(multilevel occlusion)
vDisadvantages : cost factor and availability
vComplications : anaphylaxis, bleeding, thrombosis



CT ANGIOGRAPHY
?Contrast dependant
?Rendered in 3D format, can be rotated and
viewed in different directions
?Disadvantage: Exposure to radiation
?Advantage: More rapid than MRA
It shows entire vessel


MAGNETIC RESONANCE ANGIOGRAPHY
? Principle: Rearrangement of protons in a strong
magnetic field & multiplanar imaging
? Dye used: Gadolinium
? Contraindications:Patients with pacemakers,
intracerebral shunts, cochlear implants
? Disadvantages:Poor visibility of peripheral
circulation& collateral circulation



INVESTIGATION FOR VASOSPASM
? Method : nerve block with local anaesthetic
? Nerve block relieves sympathetic vasospasm rise in skin temperature
? Rise in skin temperature recorded & compared with mouth temperature.
? Brown's vasomotor index =
Rise in skin temperature ? rise in mouth
temperature
Rise in mouth temperature
? Sympathectomy done only when index is 3.5 or more.

Medical MANAGEMENT
OF POVD

DEEPAK PETER
Roll No. 47

GENERAL MEASURES
? STOP SMOKING
Smoking Progression of atheroma Bypass graft failure
? CARE OF FOOT ( CHIROPODY )
-Well fitting footwear
-Heel raise
-Avoid exposure to more cold & warm temperature , trauma




? Control of diabetes and hypertension, hyperlipidemia
? Reduction of weight
? Regular exercise(Walking within limits of disability)

Buergers position and Exercise
Regular graded isometric exercises up to the point of
claudication improves the collateral circulation.
In buergers position head end of bed is raised foot
end of bed is lowered to improve circulation

SPECIFIC DRUGS
? ASPIRIN
Nonselective COX inhibitor

? CLOPIDOGREL
Antiplatelet drug

? CILOSTAZOL
PDE-3 inhibitor

? PENTOXIPHYLLINE
Reduces blood viscosity , improves RBC flexibility

? XANTHINOL NICOTINATE
Vasodilator
? PGE1
vasodilator





SPECIFIC DRUGS
?Low dose aspirin
Nonselective COX inhibitor
-Antithrombotic & analgesic
-May also be used after bypass surgery or angioplasty
-Dose : 75 mg OD
-Side effects like nausea , vomiting, epigastric distress




?Clopidogrel
Antiplatelet drug
P2Y12 receptor blocker
Dose : 75 mg OD
Utilized for checking restenosis for stented coronaries
Most important adverse effect : Bleeding
Action lasts for 5 -7 days due to irreversible receptor blockade




?Cilostazol
PDE-3 inhibitor
Indicated for intermittent claudication in patients with no rest pain
or heart failure
Dose : 100 mg BD,30 min before or 2 hour after food
Most common side effect ? Headache
More effective than Pentoxiphylline




? Pentoxiphylline
Weak PDE inhibitor
Reduces blood viscosity , improves RBC flexibility
Dose : 400 mg BD-TDS
Mainly used in intermittent claudication
Available as TRENTAL-400
Side effects like nausea , vomiting but well tolerated




? Xanthinol nicotinate
Compound of xanthine & nicotinic acid
Vasodilator
Dose : 300-600 mg TDS oral
Available as COMPLAMINA tab


PGE1
Potent vasodilator , inhibitor of platelet aggregation
Dose: 5-30 ng/kg/min
Administration : IV infusion: 100 mcg/500 ml NS
Infused slowly for 10 hours per day for 5 days
Eg:alprostadil

SURGICAL MANAGEMENT OF POVD
DEEPAK ROY
Roll no.48



Approach to surgical management-
TransAtlantic Inter-Society Consensus
(TASC) Classification





Based on TASC
? Type A lesions - Endovascular treatment
? Type B lesions - Endovascular treatment
? Type C lesions ? Surgery
? Type D lesions - Surgery

ENDOVASCULAR PROCEDURES
Percutaneous
Transluminal
Stenting
Angioplasty
Atherectomy
Cryoplasty





PERCUTANEOUS TRANSLUMINAL
BALLOON ANGIOPLASTY ( PTA )
? Done when Stenosis <5cm
INDICATIONS
? Incapacitating Claudication
? Rest pain
? Limb salvage in limb threatening
ischemia
? Vasculogenic Impotence




STEPS
DEFLATED
INFLATED
? Angiogram
? Introduce guidewire & balloon
catheter
? Balloon inflated
? Plaque ruptures
? Satisfactory dilation confirmed by
angiogram


TYPES OF PTA
? Conventional : balloon is inflated along the lumen to break the
plaque circumferentially
? Sub intimal : balloon is inflated after passing sub intimal plane to
break the plaque

COMPLICATIONS
ADVANTAGES:
? Faster Recovery
? Re-stenosis
? No general anasthesia
? Saphenous veins are preserved
? Haematoma
? May be combined with surgery
? Haemorrhage & Pseudoaneurysm
? Thrombosis and distal embolism




STENTING
Expandable device at the site of occlusion
To prevent re-stenosis
(elastic recoil, constrictive remodeling and intimal
hyperplasia)


? IDEAL INTRAVASCULAR STENT
? High radiopacity
? Minimal or no foreshortening
? Longitudinal flexibility
? Radial elasticity
? Retrievability
? High expansion ratio






TYPES OF STENTS
1.Bal oon expandable stents
Stent has high tensile strength and crush resistance once inflated.
-E.g. : Palmaz stent , Strecker stent
2.Self expandable stent
It is made of stainless steel ( The Wallstent ) or Nitinol alloys.
3.Drug eluting stents





DRUG ELUTING STENTS
? DES releases drug to block cel proliferation
? Drugs like paclitaxel , sirolimus
? Superior to bare metal stents


COMPLICATIONS OF STENTING
- Al ergic reactions
- Bleeding
- Blockage of artery
- Stent thrombosis



ATHERECTOMY
? Physical removal of atheromatous plaque
? Through open surgery or percutaneous route
? The obstructing fibrous plaque is pulverized into micro
particles and washed away
? Typically a balloon or stent procedure follows


TYPES OF ATHERECTOMY


CRYOPLASTY
? Balloon angioplasty + cryotherapy.
? In Cryoplasty, Balloon catheter filled with liquid
nitrous oxide reaches the blockade
? Liquid N2O evaporates into a gas
? Balloon inflates & freezes surrounding tissues
? Induce apoptosis in smooth muscle cells






SURGICAL PROCEDURES
IN POVD

DEEPTHI ROY S
Rol No.49



INDICATIONS
Surgical operations are reserved for patients
with severe symptoms where angioplasty has
failed or is not possible
Type A lesions - Endovascular treatment
Type B lesions - Endovascular treatment
TASC
Type C lesions ? Surgery
Type D lesions - Surgery


SURGICAL METHODS:
? Bypass graft
? Endarterectomy
? Profundoplasty
? Sympathectomy
? Amputations

SURGICAL BYPASS GRAFTING
? What is bypass graft??
A native vein(mostly LSV) or a prosthetic material is
used for bypassing obstruction in the vessel
? This method is employed when there is segment of artery is
occluded with distal ends patent.

MATERIALS USED:
NATURAL GRAFT
SYNTHETIC GRAFT
? Long saphenous vein graft
? PTFE(polytetrafluroethylene)
? Short saphenous vein graft
? Dacron Graft
? human umbilical vein graft
gives best result
If LSV not available, short saphenous vein may be used



LONG SAPHENOUS VEIN
Can be used as:
Most useful
and successful
Insitu graft
Reverse graft
? Saphenous vein is dissected
? Saphenous vein intact in same
out, reversed & sutured above
position, sutured above and
and below to respective arterial
below blocked region after
segments
arterialisation.
? Why Reversed? to nul ify
? Arterialisation-venous Valves
action of valves
are removed with valvulotomy
instrument.
? Less patency
? Better long term patency





Reverse
SYNTHETIC GRAFT
In situ
? PTFE(polytetrafluroethylene)
Low risk of disintgratieon with
? Dacron Graft- woven/knitted
infection
Low thrombogenecity
Low tissue reactivity




BYPASS PROCEDURES
In LOWER LIMB, can be classified into:
Anatomical procedures
Extraanatomical procedures:
? Bypass procedure that preserves
? These are procedures that circumvents
normal anatomical pathways
"normal" anatomical pathways.
? Aortofemoral bypass
? Femorofemoral
? Femoropopliteal bypass
? Iliofemoral
? Axillofemoral
? Axillobifemoral


AORTOFEMORAL BYPASS
? Done in Aortoiliac occlusion
? surgical bypass is from the infra-renal
abdominal aorta to both femoral arteries.



FEMOROPOPLITEAL BYPASS
? Indication- disease in superficial femoral artery with profunda
femoris occlusion
? Bypass is from femoral to popliteal artery


FEMOROFEMORAL CROSSOVER
GRAFT
? Operation of choice in unilateral iliac occlusion.
? The graft is placed in a tunnel which can either be a
subcutaneous suprapubic tunnel or behind the
rectus muscle
? PTFE graft is usually used ,Anastomosed end to side




AXILLO FEMORAL &
AXILLOBIFEMORAL BYPASS
Axillofemoral-
? From axillary artery to femoral
artery
? in bilateral iliac occlusion with
pregangrenous limb on one side
Axillobifemoral bypass


Problem with graft:
? Leak
? Infection
? Thrombosis
? Cost is more
? Not easily available
? Reblock




ENDARTERECTOMY
? It is the removal of thrombus, along with diseased intima
through an arteriotomy
? Done mostly in carotid, aortoiliac obstruction
Disobliteration /
reboring



OPEN METHOD
Arteriotomy done along entire
diseased segment
Thrombus removed along with
diseased intima? endarterectomy
Arteriotomy closed with suture and
patient heparinised



SEMI CLOSE METHOD
two arteriotomies at either ends of
level of obstruction
Endarterectomy done with
endarterectomy stripper
closure of arteriotomies
Advantage of endarterectomy- it avoids prosthetic graft & its complications
Problem is- Reocclusion & stenosis




PROFUNDOPLASTY
? Done when there is localized block in the
opening of Profunda femoris artery.
? Incision in common femoral artery and
carried down into profunda femoris.
? Profunda femoris is opened, thrombus if
present, is removed.
? Opening is widened with vein or dacron
grafts.




? Importance--
Opens collaterals across knee joint
to open through profunda femoris,
so gives good blood supply below
knee level and may prevent above
knee amputation.
(if below knee amputation, better
outcome with prosthesis)

Different procedures :
SYMPATHECTOMY
? CERVICODORSAL SYMPATHECTOMY
? LUMBAR SYMPATHECTOMY
? CHEMICAL SYMPATHECTOMY
? Surgical cutting of sympathetic nerve trunk or removal of a ganglion
to relieve a condition affected by its stimulation.
? Principle- when sympathetic stimulation is removed, it
increases cutaneous blood supply thereby promoting healing
of ulcer and skin flaps in amputation.

INDICATIONS:
? This should be done if there is no chance for direct arterial surgery or
angioplasty. It has no role in treatment of intermittent claudication.
In Upper Limb
In Lower Limb
? Cervical rib with vascular
? Thromboangiitis obliterans
manifestation
? Promote healing of
? Raynaud's phenomenon
cutaneous ulcer
? Hyperhydrosis
? To change level of
? Upper Limb vasospasm
amputation and make flaps
? Causalgia
to heal better after
amputation



CERVICODORSAL SYMPATHECTOMY
? Removal of 2nd and 3rd thoracic ganglia which contains
cells of postganglionic fibers supplying upper limb
LUMBAR SYMPATHECTOMY
? L2,L3,L4 ganglia removed
? If L1 removed, it leads to failure of ejaculation


CHEMICAL SYMPATHECTOMY
?5ml phenol in water is injected lateral to vertebral
bodies of 2nd to 4th lumbar vertebrae.
?This procedure is contraindicated in patients taking
anticoagulants


AMPUTATION



AMPUTATION
? Amputation should be considered when part
of a limb is dead, deadly OR a dead loss
? Limb is dead when arterial occlusion is severe
enough to cause gangrene
Amputation is inevitable when arterial surgery and
conservative treatment fail


TYPES OF AMPUTATIONS
MAJOR AMPUTATION
? Below knee amputation
? Above knee amputation
MINOR AMPUTATION
SYME'S
LISFRANC'S GILLE'S
Amputation of a toe or part of foot
RAY
Eg: Ray Amputation
Gil ies' Amputation
Lisfranc's Amputation
CHOPART'S
Chopart's amputation
Syme's amputation



MAJOR AMPUTATION
BELOW KNEE AMPUTATION /
BURGESS AMPUTATION
? Preserves knee joint and gives best chance of
walking again with prosthesis.
? 2 types of skin flap are used-
? long posterior flap
? skew flap
? Stump length- 14-17cm from knee joint


ABOVE KNEE AMPUTATION
? Done in ischemia, sepsis, trauma, gangrene
which is spreading above
? Equal curved anterior and posterior flaps are
used
? Ideal femur stump length- 25cm from tip of
trochanter


GUILLOTINE AMPUTATION
? Done either in emergency conditions like severe sepsis,
gas gangrene, and machinery entrapment Or for the
control of infection before a second definitive higher
amputation
? Here all tissues are divided at same level
? Wound is left open at the end of the stump

PROSTHESIS
It is an artificial device that helps in replacement of whole
or a part of missing extremity.
COMMONLY USED PROSTHESES
? Above knee amputation ? suction type prosthesis
? Below- knee amputation ? PTB(patellar tendon bearing), SACH prosthesis
? Syme's amputation ? elephant boot, Canadian syme's prosthesis
? Partial foot amputation- shoe fillers


ADVANTAGES :
? Function of parts relatively retained
? Cosmetic

DISADVANTAGES

? Infection
? Pressure ulcers
? Joint disability

Well constructed stump and well fitted prosthesis are key to good functions


DEEPU KRISHNAN M
Roll No.50



DEFENITION
? Acute limb ischemia is any sudden decrease
or worsening in limb perfusion causing a
potential threat to viability of extremity.
? The term is applicable up to 2 weeks of an
initiating event.




PATHOPHYSIOLOGY
? Arterial narrowing Decreased blood flow Ischemia
? Acute ischemia causes endothelial injury with luminal
obliteration.
?Golden period is 6 hours beyond which irreversible
changes and loss of limb.

ETIOLOGY
? Embolism is the most common cause
? Other causes-
? Trauma
? Thrombosis of a native artery ? especially in
hypercoagulable states
? Thrombosis of a bypass graft- at the site of anastomosis


CLINICAL PRESENTATION OF
ACUTE LIMB ISCHEMIA
? PAIN
? PALLOR
? PARAESTHESIA ? anaesthesia
? PULSELESSNESS
? PARALYSIS
? POIKILOTHERMIA - cold limb



RUTHERFORD CLASSIFICATION OF
SEVERITY OF ACUTE LIMB ISCHAEMIA
CATEGORY
TISSUE
DESCRIPTION
SENSORY LOSS
MUSCLE WEAKNESS DOPPLER SIGNAL
I
viable
No pain.
_
_
audible
I a

Marginal y
Salvageable
Digital sensory
none
Arterial signal
threatened
loss +
inaudible
Salvageable with
IIb
Immediately
immediate
+
+
Arterial signal
threatened
revascularization
inaudible
I I
Both arterial and

Irreversible injury
Not salvageable
profound
profound
venous signals
inaudible



INVESTIGATIONS
?Coagulation Studies- PT, APTT, platelet count
?Angiography?Gold Standard
?ECG, Echocardiography
? Blood sugar
? Doppler arterial study










TREATMENT
General Measures
Simple measures to improve existing perfusion:
vReassure the patient
v Oxygen inhalation, IV infusion of fluid
vRelief of pain
v Avoid extremes of temperature
v Avoid pressure over heels
v Keep the foot dependent
v Correct hypotension
Heparin therapy -5000 U IV bolus given to reduce extension of
thrombus and maintain patency of surrounding vessels.


EARLY
LATE
Intra arterial thrombolysis
Surgery
AMPUTATION
Algorithm for diagnosis of acute limb ischemia







ENDOVASCULAR TREATMENT
? Thrombolysis is the first-line treatment in patients with
acute limb ischemia ? in Cat I and IIa
? Intra-arterial thrombolysis
? A narrow catheter is passed into the occluded vessel.
? Tissue plasminogen activator (TPA) is infused.
? Not done in limb threatened with gangrene



CONTRAINDICATIONS for thrombolysis
? Recent stroke, major surgery trauma
? Active blood diathesis
? History of GI bleeding/active peptic ulcer
? Pregnancy





SURGICAL T
REATMENT
Indications:
qImmediately limb-threatening ischemia is preferentially
treated surgically.
qCat IIb and early class II
? Embolectomy





EMBOLECTOMY
vThrombus is extracted by passing a Fogarty balloon
catheter.
vRepeat till back bleeding occurs.
vAngiogram at end to ensure
flow is restored
vPost op anticoagulation




COMPLICATIONS OF ARTERIAL
REPERFUSION
? REPERFUSION INJURY
? COMPARTMENT SYNDROME
? MUSCLE NECROSIS
? LOWER LEG SWELLING




COMPARTMENT SYNDROME
? Sudden ischemia followed by revascularization causes edema in the skeletal muscles
? Common in the anterior compartment of calf.
? Local muscle necrosis and nerve damage due to pressure, renal failure secondary to
liberation of muscle breakdown products.
? Muscle weakness, sensory changes, leg pain aggravated by dorsiflexion of toes.
? Management : Fasciotomy


SUMMARY
POVD - Clinical condition characterized by stenosis or occlusion in the
aorta or arteries of limbs.
Causes- Atherosclerosis,Non Atherosclerotic Causes- Buergers disease,
Raynauds syndrome
Clinical features ? Claudication, Rest Pain, Ulceration, Gangrene
Investigations-Duplex And Angiography

Management-General And Pharmacological Measure-control of risk
factors-drugs like aspirin, Clopidogrel
Endovascular Management- Percutaneous Transluminal Angioplasty,
atherectomy, stenting, cryoplasty
Open surgical procedures- bypass graft, endarterectomy, profundoplasty,
sympathectomy, amputation
Acute Limb Ischemia- sudden decrease in limb perfusion causing a
potential threat to viability of extremity




Arterial disorders are a cause of
morbidity, mortality and financial loss in
our societies(because mostly associated
with mi and stroke)
THANK
By eliciting a good clinical history and
YOU...
palpating for peripheral pulsations,
anatomic site of disease can be diagnosed
and effectively managed.


This post was last modified on 11 August 2021