Aneurysms and ‘Peripheral Vascular Diseases’

1. Aneurysms and ‘Peripheral Vascular Diseases’ Department of Surgery Prince of Wales Hospital The Chinese University of Hong Kong

2. Aetiology • degenerative atherosclerosis • traumatic femoral pseudoaneurysm • inflammatory thromboangiitis obliterans • infective mycotic aneurysm • neoplastic carotid body tumour • congenital cerebral aneurysm • idiopathic Raynaud’s phenomenon

3. Vascular Disease • Major patterns of vascular disease • dilatation : aneurysm • narrowing : atherosclerosis • chronic obstruction • acute occlusion

4. Peripheral Vascular Disease (PVD) • Peripheral arterial occlusive disease • atherosclerosis • Buerger’s disease Chronic • Raynaud’s phenomena • Traumatic • Embolism Acute • Thrombosis

5. Chronic Limb Ischemia

6. Peripheral Vascular Disease (PVD) • Atherosclerosis • Male > Female • old > young • Commonly affects lower limbs • upper limbs relatively spared • shorter arteries • less exercise requirement • less turbulent flow

7. Risk Factors Smoking hyperlipidaemia hypertension diabetes mellitus Associated disease ischemic heart carotid stenosis (CVA / TIA) aortic aneurysm (abdominal / thoracic) PVD - Epidemiology

8. PVD - Clinical Presentation • Asymptomatic • Intermittent Claudication • Critical Limb Ischemia

9. Peripheral Vascular Disease • Fontaine Classification Stage I Asymptomatic Stage II Intermittent claudication Stage III Rest pain Stage IV gangrene / ulcer

10. PVD - Clinical Presentation • Asymptomatic • arterial insufficiency without symptoms of pain / ulcer / gangrene • ankle-brachial pressure index ABPI < 0.9

11. PVD - Clinical Presentation • Intermittent Claudication • limitation of walking by muscle pain (usually calf) • develop only when muscle is exercised • disappear on cessation of exercise Claudication distance • distance able to walk before having to stop to relieve the pain

12. PVD • critical limb ischemia severe rest pain requiring 2 weeks of analgesics / ulcer / gangrene + ankle systolic pressure < 50 mmHg / toe pressure < 30 mmHg (diabetes)

13. PVD Assessment Aims 1. Assess severity 2. Localization of disease segment 3. Associated disease

14. PVD Assessment - Investigation • Doppler ankle pressure • Ankle-Brachial Index (ABI) Ankle systolic pressure Brachial systolic pressure (normal ~ 0.9 - 1.0)

15. PVD Assessment - Investigation • Non-invasive Vascular Laboratory • segmental arterial pressure • waveform analysis

16. PVD - Vascular Lab

17. PVD Assessment - Investigation • digital subtraction arteriography • percutaneous arterial puncture • contrast injection - imaging • Potential risks: • allergic reaction • renal toxicity - acute renal failure • bleeding • arterial injury - embolism/ initimal tear

18. PVD Assessment - Investigation

23. PVD - Management Aims • Asymptomatic • control / reverse risk factors • Intermittent claudication • symptom control • Critical limb ischemia • limb salvage / pain control

24. PVD - Conservative Management • Risk factors modification • Stop smoking • control of underlying diseases • hypertension: ACE inhibitors • hyperlipidemia • diabetes

25. PVD - Conservative Management • Exercise • ‘supervised exercise program’ • possible mechanisms • improves O2 extraction • improves muscle metabolism • alteration in gait • encourage new vessel development?

26. PVD - Conservative Management • Drug Therapy: antiplatelet • aspirin: ‘low dose’ (e.g. 75-325mg) • ticlopidine, clopidogrel • inhibits platelet ADP receptors • thrombocytopenia

27. PVD - Conservative Management • Drug therapy • pentoxifylline • methylxanthine derivative • improves red cell deformability antiplatelet effect, lower fibrinogen level • cilostazol • phosphodiesterase 3 inhibitor • antiplatelet and vasodilatory effect

28. PVD - Conservative Management • Drug therapy • naftidrofuryl • serotonin receptor blocker • prostagladins

29. PVD - Conservative Management • Drug therapy • warfarin

30. PVD - Conservative Management • Foot care • avoid injury (poor healing) • toenail care • socking • Miscellaneous • Buerger’s position

31. PVD - Interventional Management • Angioplasty • Reconstruction Surgery • Amputation • Sympathectomy

32. PVD - Interventional Management • Angioplasty • interventional radiology • dilatation of stenosis • +/- endovascular stent

33. PVD - Interventional Management • Reconstruction Surgery • revascularization • symptom control • healing of ulcer • stop progression of gangrene • limit amputation level (e.g. AKA to BKA)

34. PVD - Surgical Management • Reconstruction Surgery • Surgical Bypass • Endarterectomy • Profundoplasty

35. PVD - Surgical Management • Surgical Bypass • anatomical Vs extra-anatomical bypass • saphenous vein graft Vs synthetic graft

36. PVD - Surgical bypass

37. PVD - Surgical Management • Endarterectomy • removal of atheromatous plaque

38. PVD - Surgical Management • Profundoplasty • widening of the narrowed segment of profundus femoris artery

39. aorto-bifemoral

40. femoro-popliteal above / below knee in-situ / reversed

41. axillo-femoral

42. axillo-bifemoral

43. femoro-femoral

44. PVD - Surgical Management • Amputation • control infection • control pain • level of amputation • Lumbar Sympathectomy • division of sympathetic nerve fibers • divert blood flow to skin

45. Acute Limb Ischemia

46. Aetiology • thrombosis • atherosclerosis • embolism • heart, aneurysm • spasm • compression • cervical rib • dissection

47. Thrombosis vs Embolism • Features of chronic ischemia • history of claudication • features of chronic ischemia in other leg • Presence of source of embolism

48. Clinical feature • 6 “p” • pain • paralysis • paraesthesia • pallor • pulseless • perishingly cold

49. Previous stable limb with sudden deterioration in arterial supply resulted in rest pain and/or severe ischemia of less than 2 weeks Acute limb ischemia

50. Management • Initial resuscitation • control underlying disease (AF / heart failure / dehydration) • rehydration • pain control (avoid IMI) • anti-coagulation (heparinization) • oxygen