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VASCULAR SURGERY

VASCULAR SURGERY. Assessment of arterial circulation in limp. Inspect: Color : marble white, blue hue, cyanosed Vascular angle- Burger's angle : lift leg to white look at what angle the leg is.

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VASCULAR SURGERY

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  1. VASCULAR SURGERY

  2. Assessment of arterial circulation in limp. • Inspect: • Color: marble white, blue hue, cyanosed • Vascular angle- Burger's angle: lift leg to white look at what angle the leg is. • Capillary filling time: after lifting the leg but it over the bed and see how long it takes for skin to turn pink. • Venous filling: look for guttering, and angle of venous loss. • Pressure areas: look particularly closely at these, as changes will be first apparent here, trophic, ulceration, gangrenous changes-heel, malleoli, head of 5th metatarsal, tips of toes, between toes, ball of foot.

  3. Assessment of arterial circulation in limp • Palpation: • Temperature: after 5 min exposure to ambiant temp. • Capillary refilling: press tip of toe. • Pulses: fem, dorsalis pedis, posterial tibial artery (medial malleoli), popliteal. • Test muscles/nerves- may be affected by ischaemia. • Auscultation: • over all major arteries • Blood pressure in both armes.

  4. ISCHEMIA It the condition of inadequate blood supply to an area of tissue producing harmful effect to its function &nutrition

  5. Acute Ischemia It the condition of inadequate blood supply to an area of tissue producing harmful effect to its function &nutrition of less than 2 weeks duration

  6. Acute Ischemia ( etiology) • Embolism • Thrombosis • Others • Acute arterial trauma • Dissecting aortic aneurysm • Compartmental syndrome • External compression • Poploteal entrapment • Cystic adventational disease

  7. Acute Ischemia

  8. Acute Ischemia

  9. Acute Ischemia

  10. Acute Ischemia

  11. Acute ischemia with Gangrene

  12. ARTERIAL EMBOLISM (Sever Ischemia)

  13. Less sever Ischemia

  14. Less sever Ischemia

  15. Less sever Ischemia

  16. Management of acute ischemia • Investigations • Urea, electrolytes, BSL • ECG, chest x ray • Initial treatment • Rehydration • I V analgesia • Heparinization

  17. Acute Ischemia

  18. Acute LL ischemia Less sever LL ischemia (previously ischemic limb) Sever LL ischemia (previously normal limb) Arterio-graphy must be done to determine site, size& extent of thrombus occlusion Fogarty embolectomy

  19. Sever LL ischemia (previously normal limb) Femoral embolectomy (assess degree of inflow) Poor inflow Good inflow Distal embolectomy Perform proximal Iliac embolectomy Perform intra-operative arteriogram To assess efficiency Poor inflow No occlusion Residual thrombus Proximal vascular reconstruction Close arteiotomy& Perform fasciotomy Thrombolysis

  20. Less sever LL ischemia (previously ischemic limb) Arterio-graphy Thrombolysis After the underlying Cause is detected If thrombo-lysis are contraindicated By pass procedure to site of occlusion or angioplasty

  21. Thrombo-lysis • This depend on per-cutaneous delivery of thrombo-lytic drugs within the thrombus • to dissolve it by intra-arterial catheter placed within the thrombus • Most centers in UK have limited the technique for thrombus less than 30 days

  22. Thrombo-lysis • Drugs • Streptokinase • Urokinase • Recombinant TPA • Technique • Local low dose • Pulse spray technique • High dose bolus technique • Check angio-graphy is done every 8-9 hous and catheter tip repositioned as necessary • Success is 60- 70 % with careful selection

  23. Thrombo-lysis • Complications • Mortality 1-2 % • Major bleeding 10 % • Minor bleeding 25 % • Stroke • Embolization • Contraindications • Bleeding diathesis • Long term anticoagulant • Stroke • Old age > 75 Y • Peptic ulcer

  24. Chronic LL ischemia (Risk factors) Sedentary life Obesity Age & sex Risk factors of LL ischemia Hyper- lipidaemia Diabetes Hypertension Smoking

  25. Chronic LL ischemia (Etiology) Age above 45 Y Age below 45 years Atherosclerosis is the commonest cause Diabetics Non Diabetics In males smokers In both In female Pre-senile atherosclerosis Raynaud’s disease Burger’s disease Arteritis

  26. Chronic LL ischemia (Clinically) Press & See How Color Fade (pre-gangrene) & (gangrene) Pain Sensation Hotness Color Function Pre-gangrene (Nutritional) Gangrene

  27. Chronic LL ischemia (DD) • Nerve compression (Sciatica) • Veins ( CVI and DVT) • Joints (arthropathy) • Muscle ( myopathy) • Bone pains • Superficial lesions in skin& Sc tissue

  28. Where is the site of occlusion ? Aortoiliac pattern • Claudication gluteal region • Wasting of thigh muscles • Lost or weak femoral pulses • Impotence if bilateral Inguinal ligament Femoro popliteal pattern Adductor hiatus • Claudication calf • Lost or weak popliteal pulse • Beurger’s sign (pallor on elevation and rubor on dependency) Distal circulation pattern

  29. Chronic LL ischemia(thrombosis) Le Riche syndrome • Claudication in gluteal region • Wasting of thigh muscles • Lost or weak femoral pulses • Impotence

  30. Claudication foot • Lost or weak dorsalis pedis and or posterior tibial • Beuger’s sign • Nutritional changes (10 items) Aortoiliac pattern Inguinal ligament Femoropopliteal pattern • Skin, • skin appendages, • subcutaneous fat, • muscles, • ulcers, • gangrene, • delayed venous filling, • coldness, • motor and • sensory changes Adductor hiatus Distal circulation pattern

  31. Chronic LL ischemia

  32. Chronic LL ischemia

  33. Chronic LL ischemia

  34. Chronic LL ischemia

  35. Vascular lab • Segmental limb pressure • Ankle- Brachial Index • Normal > 1 • Intermittent claudication 0.5- 0.9 • No healing < 0.5 • Rest pain 0.4

  36. Vascular lab • Toe- brachial Index • Normal 0.8- 0.9 • Caludicate 0.35 • Rest pain 0.1 • Toe pressures • Normal 90 – 100 mmHg • CLI < 30 mmHg • Exercise tests

  37. Non Invasive • Doppler U/S • Duplex U/S • Plethysmography • Isotope blood flow • Trans-cutaneous oxygen tension

  38. Invasive (Arteriography) It is the gold stander of arterial tree Methods • Directly trans-femoral if pulse is palpable • Seldinger approach • Digital sub-straction angiography contrast material injected I.V in large volumes or IA. In small tiny volumes

  39. Invasive (Aorto-graphy) »Translumbar if both F pulses are not felt »Transfemoral aortography if one F pulse is felt »Transbrachial if the entire distal aorta is occluded »Digital sub-straction angiography

  40. Invasive (Arteriography) Potential complications include • Contrast-related • Anaphylactic reaction • Toxic reactions • Deterioration in renal function • Technique-related • Haematoma • Arterial spasm • Sub-intimal dissection • False aneurysm • Arteriovenous fistula • Embolisation • Infection

  41. New imaging modalites • MR angiography (is now providing the most sensitive test for identifying tibial vessels) • CT angiography which is articularly useful for the assessment of aneurysmal disease • Angioscopy • Intravascular ultrasonography

  42. Treatment of chronic LL ischemia I - Risk factor reduction • Stop smoking - arrests disease progression • Lipid-lowering drugs • Anti-platelet medication • Good diabetic control if appropriate II- Regular exercise • as part of supervised exercise program • Lose weight

  43. Treatment of chronic LL ischemia III – Pharmaco-therapy • Vasodilator drugs with small benefits • Naftidrofyl oxalate, Praxiline • Pentoxyifyllin, Trental 400 • Prostacyclin • Vasodilator drugs with minimal benefits • Antiplatlets ( aspirin) • Prostaglandins • Ca channel blockers

  44. Endo vascular surgery Basic principles • The symptoms should be life-style limiting • Co-management of underlying conditions likely to limit safety or success (smoking, heart failure etc) • Proximal disease should be managed before distal ones • Localized (<10 cm) non-ulcerating lesion is an ideal lesion

  45. Endo vascular surgery Basic techniques •Balloon dilatation •Stents • Atherectomy devices • Lasers • Vibrating and rotating wires

  46. Percutaneous transluminal angioplasty • Angioplasty of the aorto-iliac segment has a 90% 5 year patency • Angioplasty of the infra-inguinal vessels has a 70% 5 year patency • Best results seen with short segment stenoses less than 2 cm long Complications occur in less than 2% of patients • Wound haematoma • Acute thrombosis • Distal embolisation • Arterial wall rupture

  47. Percutaneous transluminal angioplasty with stents Use of stents • Most are used to correct inadequacies or complications of PTA • To avoid re-stenosis which occurs within 90 days of PTA • When there is significant residual gradient or stenosis following PTA • When there is acute occlusions during PTA • When there is dissection longer than PTA site

  48. Surgical treatment of claudication and rest pain • Indications for surgery: • claudication is a relative indication. • rest pain if fit for operation. • Ischaemic ulceration that does not respone to conservative management. • acute occlusion. • After decision on surgery is done do arteriography: site, type of operation and  if technically possible

  49. Surgical treatment Direct arterial surgery Indirect arterial surgery Sympathectomy Bypass Thromb endarterectomy Amputation

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