Vascular Emergencies (Not including ruptured aneurysms)

1. Vascular Emergencies(Not includingruptured aneurysms) Adrian P. Ireland BA(mod) MB MCh BAO FRCS(I) RCSI final meds 12 Jan 2004

2. Outline • What are the Vascular Emergencies? • Review of the circulation • Pathogenesis of blocked arteries • Manifestations of blocked arteries • Monitoring the circulation • Occlusive peripheral vascular disease • Acute and Chronic Ischemia

3. Vascular Emergencies(not aneurysms) • Arterial • Acute ischaemia • Bleeding due to trauma (incl. iatrogenic) • Venous • Deep Venous Thrombosis (Phlegmesia Caeurlia Dolens) • Pulmonary Embolism • Lymphatic • Cellulititis • Compartment Syndrome

4. Occlusive Peripheral Vascular Disease • Peripheral vascular disease • Includes any disease affecting the peripheral vascular system • Occlusive – essentially blocked arteries

5. 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

6. William Harvey (1578-1657) On the Motion of the Heart and Blood in Animals (1628)

7. 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)

8. Pathogenesis Of Blocked Arteries • Atherosclerosis • Genes, hyperlipidemias • Lifestyle • Smoking • High fat diet • Lack of exercise • Co-morbidities • Diabetes, hypertension, hypothyroidism, homocysteine

10. 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

11. Principal causes of death in Ireland (males) Report on Vital Statistics Central Statistics Office Ireland, 1995

12. Annual Deaths Due toCerebrovascular Disease andIschemic Heart Disease Report on Vital Statistics Central Statistics Office Ireland, 1995

13. 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

14. Monitoring Circulation • Mottling, colour, temperature, movements, sensation • Palpable pulses, doppler signals • Non invasive pressure studies (Doppler) • Duplex imaging • Angiography (IAA, DSA, MRA)

15. Non Invasive Pressure Studies(NIPS)

17. Duplex of carotid stenosis

18. Angiography(DSA)

19. MRA

20. Occlusive Peripheral Vascular Disease • Classification based upon clinical presentation • Acute ischemia • Chronic ischemia • Anatomic classifcation based upon site(s) of disease

21. OPVD Anatomic Classification • Aorto-iliac • Le-Riche • Femero-popliteal • Tibio-peroneal

22. Acute Ischemia

23. Effects Of Acute Ischemia • Reduced blood flow • Pulseless, pallor, perishing cold • Nerve ischemia • Pain, paralysis, Paresthesia • Muscle ischemia • Rhabdomyolysis • Compartment syndrome • Ischemia reperfusion syndrome

24. Compartment Syndrome • Pathophysiology • Diagnosis • Management

25. 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

26. 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

27. Compartment SyndromeManagement • Fasciotomy

28. Acute Ischemia • Causes • Thrombosis • Embolism • The P’s • Thrombosis or embolism? • Clinical assessment of severity • Clinical algorithm

29. Causes of Acute Ischemia • Trauma • Thrombosis • Embolism • Small print • Aneurysm • Thrombophilia • Paradoxial embolism • Anatomic variation • Csytic adventitial disease

30. Thrombosis • Occlusive atherosclerosis • Aneurysm • Malignancy • Thrombophilia

32. Embolism • Macro-embolism • arterial side • venous side (patent foramen ovale) • Micro-embolism • ulcerated atherosclerotic plaques • aneurysm

33. The P ’s • No flow in artery • Pallor • Pulse absent • Perishing cold • Nerve becomes ischemic • Pain • Paresthesia / anesthesia • Paralysis

34. Thrombosis or Embolism?

35. Clinical Assessment of Severity • Viable no immediate threat • Threatened • Marginally ok if treated promptly • Immediately ok if treated immediately • Irreversible dead leg

36. Irreversible Ischemia • Sensory loss Profound,anaesthetic • Muscle weaknessProfound, paralysis • Arterial doppler Inaudible • Venous doppler Inaudible Amputation

37. Viable no immediate threat • Sensory loss None • Muscle weakness None • Arterial doppler Audible • Venous doppler Audible • Restore perfusion

38. Clinical Assessment of Severity • Viable No immediate threat • Threatened • marginally Ok if treated promptly • immediately Ok if treated immediately • Irreversible Dead leg

39. Threatened Marginally • Sensory loss Minimal (toes) to none • Muscle weakness None • Arterial doppler Inaudible • Venous doppler Audible • Restore perfusion

40. Threatened Immediately • Sensory loss More than toes, Pain • Muscle weakness Mild to moderate • Arterial doppler Inaudible • Venous doppler Audible Restore perfusion

41. 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?

42. acute non traumatic ischemia Irreversible Threatened Viable Clear embolus ?Thrombosis Duplex Adequate Inadequate Angiogram Treat Amputation Embolectomy Thrombolyse +/- PTA Reconstruct

43. 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

44. Chronic Ischemia

45. LaFontaine Classification Stage 1 claudication Stage 2 rest pain Stage 3 necrosis/ulceration

46. Definition Of Critical Ischemia • Presence of tissue loss OR • Rest pain with ankle pressure less than 50 mm Hg FOR • More than 2 weeks

47. Acute on Chronic Bypass

48. J.C. 68 year old male • Emergency admission 24.3.2000 to vascular service SVUH, via A/E • Ischemic right foot

49. 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

50. Past History • 1996 angina, failed angioplasty (aspirin) • 1996 hypertension (atenalol) • 1996 Hypercholesterolemia (diet) • June 1999 dizzyness ? cause • Carotid duplex showed non critical stenosis