Ischemic Vascular Disease by Proffessor A. Z. Sule

1. ISCHAEMIC VASCULAR
DISEASE
By
DR. A. Z. SULE

2. INTRODUCTION
• The commonest cause of peripheral arterial disease
is atherosclerosis which is usually generalized and
affects the limb, coronary, cerebral, renal and
mesenteric vessels; the aorta and its main
branches.
• Other diseases e.g. hypertension, DM may co-exist
or even contribute to the genesis of atherosclerosis.

3. SURGICAL ANATOMY
• The wall of the vessel is made up of three layers:
Intima, media and adventitia.
Intima
• A thin relatively acelular, non-wetable lining
separated from the media by the internal elastic
lamina.
• Platelets are deposited on it if it becomes damage;
thrombosis may then occur.

4. • It becomes thickened and ulcerated in
atherosclerosis.
Media
• Composed of fibro-elastic tissue and smooth
muscles; thick and responsible for the strength of
the arterial wall.
• In the big arteries, fibro-elastic tissue predominates
and in the small arteries and arterioles which
controls microcirculation muscle fibers under
sympathetic control predominates.

5. • Unlike the intima which gets its blood supply
directly from the blood flowing directly over it; the
media derives nourishment via the vasa-vasorum
which reach it through the adventitia.
Adventitia
• Consist of areolar tissue and contains the plexus of
nerves and vasa-vasorum for the media.

6. CHRONIC OCCLUSIVE VASCULAR
DISEASE
• This is caused most commonly by atherosclerosis,
thromboangitis obliterans (Buerger’s disease),
Raynauld’s phenomenon, a cervical rib or popliteal
artery entrapment syndrome.

7. SURGICAL PATHOLOGY
A.Atherosclerosis
• It is a disease that affects the intima primarily but
also the media.
• It affects the middle aged and above and is six
times more commoner in males.
• It is more of a generalized disorder involving
cardiac, cerebral, extra cerebral neck vessels and
other sites to a bewildering and varying degree.

8. • The intima becomes thickened thus narrowing the
vessel.
• Lipids deposited in the deeper layers of the intima
increased in size to form plagues.
• These plagues become calcified and ulcerate
through the endothelium.
• Platelets can then be deposited on the roughened
surface to form a thrombus which may be detached
to lodge in a distal narrower vessel or enlarged to
block the artery.

9. • The lesion is focal in distribution and commoner in
large arteries with great mechanical stresses and at
the sites of origin of branches.
• The internal elastic lamina also become disrupted
and attenuated and the muscle of the media is
replaced by fibrous tissue, thus weakening the
vessel wall and causing distension of the affected
part and the formation of aneurysm of the vessel.

10. • With decreasing blood flow through the main
vessel, collateral vessels and the branches above
and below the stenosed part enlarged to supply
blood to the part.
• Risk factors are: Hyperlipidaemia
(hypercholesterolaemia and hypertriglyceridaemia;
long or acquired), DM, hypertension, cigarette
smoking, old age and hyperhomocysteinaemia.
• Diabetic develop atherosclerosis at an earlier age
and males and females are equally affected.

11. - The popliteal, tibials and associated small arteries
are commonly affected (macroangiopathy).
- In addition, microangiopathy affects the arterioles.
- These in addition to peripheral neuropathy
predisposed the diabetic to injury.
- The hyperglycaemia in uncontrolled DM also
repairs neutrophil and immune function leading to
increased risk of infection.

12. B. Thromboangitis Obliteran (Buerger’s Disease)
• The condition is a combination of inflammation and
obliteration of arteries and their adjacent veins.
• It starts in the distal small vessels and spread relentlessly
proximally.
• A strong relationship with tobacco smoking is established.
• The disease is confined to young people and though rare it
continues to be seen in developing countries where raw
tobacco is widely used.

13. • There is dense round cell infiltration of the
adventitia and media and endothelial proliferation
of the intima.
• The lumen may be occluded by a thrombus which
is later replaced by firm granulation tissue that
become partially canalized.
• Fibrous replacement of round cells result in
thickened artery or vein being enclosed in fibrous
tissue.

14. C.Raynauld’s Phenomenon
• This is characteristically attacks of pallor and pain
in digits (nearly always the hand) followed by
cyanosis and then rubor as the condition relents.
• The phenomenon is seen in:
1. Women without other cause when it can be styled
Raynauld’s disease.
2. Both sexes, as a manifestation of some other
disorder the most important of which are:

15. i. Scleroderma or systemic sclerosis.
ii. Prolonged use of vibrating tools.
iii. Cold hypersensitivity associated with a positive
Coomb’s test when the lesion is probably slugging
of red cells in the capillaries.

16. D.Popliteal artery entrapment syndrome
• It is an uncommon cause of peripheral vascular
disease in young, fit people.
• It is also seen later in life.
• It present as progressive claudication or sudden
limb ischaemia.
• It results from abnormal relationship between
popliteal artery and the medial head of the
gastrocremius.

17. • The vessels normally passes between the two
heads of the muscle but in this courses around or
through the medial head and so may be
compressed and traumatized when the knee is
extended.
• The repeated trauma leads to fibrous thickening
and stenosis.

18. E.Cervical Rib Syndrome
• A cervical rib is an extra rib arising from the 7th
cervical vertebra.
• It may articulate with the first rib or manubrium
anteriorly or be partially replaced by a fibrous band
which is connected to the first rib.
• It may be unilateral or bilateral.

19. • The first dorsal root of the branchial plexus and
subclavian vessels as they pass between the
cervical rib and the scaleneus anticus to reach the
arm may become compressed and angulated.
• The lumen of the vessel becomes narrowed and
the part distal to the constriction dilates (post
stenostic dilatation)
• Resulting thrombosis often give rise to recurrent
emboli which may lodge in the digital arteries and
cause ischaemia of the fingers.

20. • Extension of the thrombus proximally may involve
the vertebral artery and cerebrovascular embolism.

21. CLINICAL FEATURES OF OCCLUSIVE
VASCULAR DISEASE
CHRONIC ARTERIAL OCCLUSION IN THE
LOWER LIMB
Symptoms
• Pain. This is of two types:
1. Intermittent claudication
2. Continuous rest pain.

22. Intermittent Claudication
• It means literally limping (Latin-claudicareto limp).
• Refers to pain experienced in the limb on exercise
and which is relieved by rest.
• It is nearly always a lower limb symptoms though it
can occur in the arms as a result of subclavian or
innommate disease.
• It is caused by ischaemia of muscles in the region
and presumably due to liberation of pain inducing
metabolites.

23. • The resulting blood flow in both normal and a limb
with diseased vessels is usually about the same.
On exercise, the muscle bed dilates and blood flow
is usually increased up to ten fold.
–When there is arterial block, this cannot happen
beyond the obstruction.
• The pain is cramp-like and varies from an ache to
acute severe pain which arrest the patients
walking.

24. • The pain must be related to exercise to qualify for
the description and must be relieved by rest.
• Useful information that may be sought relates to:
–Duration
–Progression or regression
–Site: The distribution of the pain provides an
indication of the site of major vessel occlusion.
• Buttocks pain means internal iliac occlusion and
calf pain is usually caused by a block of the
superficial femoral artery in the thigh.

25. • Pain in the calves radiating up into the thighs is
often due to aorto-iliac or generalized iliac artery
disease.
• Type: Intermittent claudication can be classified into
three (3) types:
Type I:
• Patient is able to continue walking after the onset of
pain and provided he walks at the same speed, the
pain eases off.

26. Type II:
• The pain persist with walking and the patient stops
not because the pain is unbearable but because it
is unpleasant.
Type III:
• The pain steadily worsen with walking and the
patient is forced by the severity of the pain to stop.
Claudication distance:
• Distance travelled before pain occurs.

27. Relief:
• When pain in the limb is due to occlusive vascular
disease, it will always be relieved by rest.
Continuous Rest Pain
• This pain is characteristically boring, gnawing and
severe, often worse at night and somewhat relieved
by hanging the foot over the edge of the bed.

28. LOSS OF FUNCTION
• A patient with occlusive disease at the bifurcation
of the aorta and some collateral circulation may
experience progressive weakness of his lower
limbs muscles and failure of erection (Leriche’s
syndrome).
• A limb totally deprived of circulation will be flaccid
and anaesthetic.

29. GENERAL SYMPTOMS
• General symptoms of arterial disease are present in
about 50% with intermittent claudication.
• Cardiovascular disease may cause angina,
shortness of breath and swelling of the ankles.
• Cerebral vascular disease may be associated with a
past history of stroke or transients visual
disturbances or limb weakness.

30. SIGNS
General
• It is important to search for pulse irregularities,
hypertension, evidence of cardiac failure, bronchitis
and emphysema.
• The carotid, subclavian and renal vessels should be
auscultated for bruit indicating stenotic disease.
• The abdominal aorta must be palpated for evidence
of aneurysmal dilatation.

31. LOCAL
Inspection:
• Dry pale skin
• Fissuring of nails, moist or infected inter digital
clefts, ulceration and gangrene.
• Elevation of the affected limb will often cause pallor
and blanching which may be accentuated by rapid
ankle and toe movement.

32. • When the limb is lowered below the heart level it
will regain its colour more slowly than on the
healthy side and after a few minutes it may become
blue and congested.
Palpation
• Palpation of the peripheral pulses is the most
valuable clinical observation and in many instances
the extent and position of the arterial disease can
be estimated.

33. • If a pulse is absent at any point there must be a
proximal block of the vessel concerned.
• Popliteal pulse is difficult to feel and the dorsalis
pedis and posterior tibial pulses will be absent in
normal person 10% and 5% respectively.
• Palpable collateral vessels may occasionally be
detected when major vessels are occluded.

34. • Palpation of the superficial veins of the legs may
reveal the presence of thrombosis which
accompany thrombo-angitis obliterans in 30% of
patients.
• Palpation for skin temperature change may show
marked variation close to the site of a complete
obstruction.

35. Auscultation:
• A systolic bruit over a main vessel indicates the
presence of a stenosis at that level or possibly
higher up.
Movement of Joints:
• Reduced power of hip movements may be present
with an aortic block.
• Weakened knee and ankle movement can occur
with femoral and popliteal block.

36. • The effect of exercise on the appearance of the
limb and distal pulses may be observed.
• In major vessel disease, pallor ensure and weak or
normal pulses can both disappear.

37. INVESTIGATION OF PERIPHERAL
ARTERIAL DISEASE
GENERAL INVESTIGATION
• The commonest cause of peripheral arterial
occlusive disease is atherosclerosis.
• Other diseases e.g. DM, hypertension may co-exist
and contribute to the genesis of atherosclerosis. For
these reasons, the following investigation must be
done:

38. 1. Full blood count/Hb genotype
- Raised platelet count
- Polycythemic states
2. E/U, urinalysis, serum creatinine – kidney function.
3. Serum cholesterol/Triglycerides – Hyperlipidaemia
4. Fasting blood sugar – DM
5. Chest – lung disease.
6. Plain abdominal x-ray – aortic aneurysm
7. ECG – cardiac abnormalities.

39. NON-INVASIVE INVESTIGATIONS
• These help to establish the diagnosis of arterial
disease and do not involve any physical injury or
radiation to the body.
• Not indicated in severe ischaemia, rest pain or
tissue loss where arteriography is clearly indicated.
1. Doppler Studies:
• The hand held doppler probe is used as adjunct to
palpation to establish the presence of blood flow in
peripheral vessels. The presence of an audible
signal in any vessel established its patency.

40. 2. Ankle Branchial Pressure Index:
• Using the ordinary sphygmomanometer and a hand
held doppler probe, the systolic blood pressure of
the posterior tibial or dorsalis pedis artery (ankle)
and the branchial artery are measured.
• The ankle systolic pressure is normally greater than
the branchial systolic pressure by 5-15mmHg.
• The ankle brachial pressure index i.e. Ankle BP or
arm BP is therefore greater than one, usually 1-1.2.

41. • In practical terms ABPI of 0.9-1 is regarded as
normal.
–ABPI 0.75-0.9: Mild occlusive disease.
–ABPI 0.5-0.75: Moderate occlusive disease
–ABPI <0.5: Severe occlusive disease.
Advantage:
• Simple, reproducible and can be done by the bed
side.

42. • Use to assess the severity of occlusive vascular
disease and the state of collaterals circulation.
Disadvantages:
• Inability to pinpoint site of occlusion, inaccurate
values in calcified vessels and in obese or big legs
results are not reliable.

43. 3. Doppler wave form analysis:
• It is an analysis of blood flow in a peripheral vessel.
It shows pulsatility – forward and reverse phases.
• It provides a very useful test to establish stenosis in
peripheral arteries.
4. Duplex USS Scan:
• This combines the B-mode ultrasound scanner with
a pulse doppler real time frequency analysis of
resulting wave-form.

44. 5. Pulse Oximetry:
• Measured oxygen saturation of arterial blood and
useful in determining peripheral perfusion and O2
delivery.

45. INVASIVE INVESTIGATIONS
• Involves the puncture of vessels to introduce contra
st material for imaging or the use of radiation or bot
h.
• It is indicated when surgery is contemplated or gang
rene imminent.
1. Angiography:
• It is the standard method for investigation of the site
, extent and severity of arterial disease and run offs
and collateral.

46. 2. Digital subtraction angiography.
3. CT scan with contrast.
4. Magnetic Resonance Angiography (MRA).
DIFFERENTIAL DIAGNOSIS (DD)
1. Prolapse Intervetebral Disc:
• Pain starts in the back and later radiates to the
legs.
• Pain is present at rest and made worse by
coughing.

47. • Knee jerk is diminished or absent.
• Myelogram establishes the disease.
2. O/A of the Hip or Knees:
• Pain is most marked in the joint which has limited
movement.
• X-ray establishes the disease.

48. MANAGEMENT OF OCCLUSIVE
VASCULAR DISEASE
• Goal – Relief of symptoms and prevent limb loss.
The Underlying Cause
1. Dietary manipulation:
• Only of use in patient with gross disturbances of
cholesterol or lipids and often very effective even
then.

49. • May be supplemented by agents (Statins – that
inhibit hydroxymethylglutary coenzyme A – HMG-
CoA) which is to lower serum cholesterol, LDL,
triglycerides to 2.6mmol/L.
• Weight reduction to reduce burden on the affected
lower limbs.
• Cessation of smoking: Highly desirable in
atheroma; mandatory in Buerger’s disease if the
condition is not to progress.
• Control of DM.
• Specific therapy for disease such as polyarteritis or
lupus erythromatosis.

50. MANAGEMENT OF THE LIMB
General
• Patients should be reminded that they have a limb
or limbs that are at risk and that minor injury or
infection may lead to gangrene, specifically:
i. The feet must be kept clean and dry.
ii. The feet must be kept warm and over heating and
possible blistering must be avoided.
iii.The toe-nails must be carefully trimmed.

51. iv. Corns, papilloma and fungal infection must be
properly treated.
v. Shoes should be soft and well fitting.
vi. Minor trauma such as having the toes trodden on
in a crowd must be avoided.

52. Vasodilators:
• Many have been tried and all are found wanting.
• When the problem is inflow, it is of little use dilating
the distal circulation.
Anti-platelet
• Aspirin: 75-350mg/day
• Phentoxifylline – lower fibrogen level and lowered
platelets aggregation.

53. • Glostazol (phosphodiesterose III inhibitor) –
antiplatelet, vasodilatation and anti-lipid activity.
Hypervolaemia
• In patients with Buerger’s disease who are having
a wave of extension of the process, dextran 70
transfusion may temporary increase perfusion and
is used by some.

54. SPECIFIC MANAGEMENT
Claudication:
• Many patients with claudication can live within their
distance.
• There is rarely any threat to the limb.
• In the circumstance where claudication is
incapacitating, direct surgery should be considered.

55. Major ischaemia from a proximal block with rest
pain and impending gangrene:
i. Remove any remediable cause such as embolus.
ii. Try to restore blood flow by direct surgery.
–In aorto-iliac disease, this is usually by either
thrombo-endarterectomy (disobliteration) in
which the clot and disease intima and media are
removed and the vessel reconstructed using
only adventitia.

56. –Below the inguinal ligament some form of by-
pass graft (reverse saphenous is the best) is
used.
–Direct surgery can only be done if there are
patent vessels distally as established by
arteriography; what the vascular surgeon call
runoff.

57. iii. In the absence of runoff, sympathectomy should
be done but it is unlikely to influence outcome.
iv. Amputate dead tissue or occasionally allow this to
separate.
– When the block is proximal and cannot be
relieved, major amputation is usual.

58. Ischaemia from distal block:
• By definition this is an end artery obstruction
therefore sympathectomy or direct surgery are
inapplicable.
• Conservatism should be practiced; provided the
dead tissue is dry; it can often be left to separate
spontaneously.

59. Local Treatment of Gangrene and Ulcers
• Relief of pain with analgesics. A little alcohol may
help as it has vasodilatory effect.
–Simple dressings are used.
–A dry gangrenous part should be exposed.
• Obviously loose slough may have to be removed
and pus drained.
• Antibiotics are prescribed if there is spreading
sepsis.

60. • Restoration of circulation as earlier stated.
• Establishment of skin closure by secondary
intension healing or skin graft.
Recent Innovations:
1. Percutaneous trans-luminal angioplasty may be
used as primary therapy or as adjunct to surgery.
2. Endovascular stents.

61. Raynauld’s Disease
• Opinion differs as to whether prolonged relief can
be achieved by degeneration of blood vessels.
• Opponents say that many patients relapse and that
this is because by degeneration the smooth muscle
in the blood vessel wall is rendered more sensitive
to whatever stimulus provokes a reaction.

62. Raynauld’s phenomenon
• This cause must be removed if this is possible,
otherwise the patient must be encouraged to avoid
cold stimulus.

63. CAROTID ARTERIAL VASCULAR
DISEASE
• Stroke could result from the occlusion of major extra
cranial vessels.
• Two forms exist:
a. Occlusion of the carotid bifurcation when circle of W
illis perfusion is adequate.
b. Emboli from an ulcerated plague at the common car
otid bifurcation.

64. • Both pathological situations may cause transient
ischaemic attack (TIAs) – sudden loss of vision
(amaurosis fugax), fleeting paraesthesiae in the
limbs, temporary paralysis and loss of cerebral
function such as speech.
• If there is a suspicion on clinical examination or
non-invasive investigation that carotid stenosis
exist, then angiography is necessary.

65. MANAGEMENT
• Opinion is divided amongst those who say:
• Anticoagulant therapy;
i. Prevent complete thrombotic occlusion
ii. Avoid recurrent emboli from an ulcerating
atheromatious plaque.
• And those who maintain that:

66. i. Complete stroke can be avoided by disobliteration
of the carotid bifurcation.
ii. Same operation will ‘rebore’ the vessel and so
prevent embolism.
• The answer rests on facilities.

67. GASTROINTESTINAL ISCHAEMIA
SYNDROMES
• The coeliac axis, the superior mesenteric artery and
the two internal iliac arteries are the principal source
of blood supply to the stomach and intestine.
• Chronic stenosis or occlusion of the coeliac and sup
erior mesenteric arteries is caused by atheroscleros
is in vast majority of cases.

68. CF
• Postprandial abdominal pain which has been
labeled abdominal or visceral angina.
• Pain appears 15-20 minutes after the beginning of
a meal and lasts for an hour or longer.
• Pain occurs as a deep-seated steady ache in the
epigastrium occasionally radiating to the right or left
upper quadrant.
• Weight loss from reluctance to rest.
• Upper abdominal bruit in 80% of patients.

69. • Angiography confirm disease, Duplex ultrasound
scan, MRA are used with increasing frequency as
less invasive methods.
• When the obstruction is atherosclerotic, surgical
revascularization of the superior mesenteric and
coeliac axis may be performed by either
endarterectomy or graft replacement.
• Percutaneous transluminal angioplastic and
stenting has gained acceptance as alternative form
of therapy.

70. ACUTE ARTERIAL OCCLUSION
• Sudden occlusion of a previously patent artery supp
ly to an extremity is a dramatic event characterized
by:
–Abrupt onset of severe ischaemia with pain, cold
ness, numbness, motor weakness and absent pu
lses.
• Tissue viability depends on the extend to which flow
is maintained by collaterals circuits or surgical interv
ention.

71. • The clinical manifestation are those of ischaemia of
nerves, muscle and skin.
• When ischaemia persists; motor and sensory,
paralysis; muscle infarction and cutaneous
gangrene become irreversible in a matter of hours.
• A line of demarcation develops between viable and
non-viable tissue.
• Acute major arterial occlusion may be caused by:

72. a. Embolus – Results from dislodgement of a blood
clot from the heart (fibrillating, heart valves,
infective endocarditis, atherosclerotic plaque
aneurysm sac, tumours).
b. Thrombosis.
c. Trauma – Contusion or laceration by a bone after
a fracture, arterial catheterization.
d. Dissection – Thoracic aorta.

73. CF
• Characterized by 5Ps: Pain, pallor, pulselessness,
paraesthesia and paralysis.
• Pain is present in 80% of patients and its onset
usually indicate the time of onset of vessel
occlusion.
• Pain is absent in some patients because of prompt
onset of anaesthesia and paralysis.

74. • If changes persist beyond 12 hours, limb salvage is
unlikely.
• Skin and S/C tissue have greater resistance to
hypoxia than nerves and muscles.
TREATMENT
• Embolism and thrombosis – Anti-coagulation by IV
heparin particularly the upper limb where collateral
are good.

75. • When the ischaemia persist or is profound; catheter
directed thrombolysis, percutaneous mechanical
thrombectomy, surgical embolectomy, ultrasound
accelerated thrombolysis.
Traumatic Arterial Occlusion
• Arterial injury must be corrected within a few hours
to avoid development of gangrene.
• Repair of arterial injury is usually performed in
conjunction with repair of other injuries.

76. ACUTE GASTROINTESTINAL
ISCHAEMIA SYNDROME
• This is a complex and serious disorder that commo
nly affect the superior mesenteric artery.
• The cause is either embolic or thrombotic.
• The diagnosis can be difficult and its recognition is
often delayed resulting in irreversible bowel ischae
mia that require extensive bowel resection.

77. • Patients classically presents with excruciating
diffuse abdominal pain with surprising absence of
physical findings such as abdominal tenderness or
distention; unless actual bowel perforation
produces a surgical abdomen.
• The mortality from acute mesenteric ischaemia
remains high and patients who have massive bowel
resection rarely survive or if they survive, they
develop incapacitating short gut syndrome.