Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Dr Minhajuddin Khurram
Al-Ameen Medical College
Bijapur (Karnataka)
India
Peripheral areterial occlusive disease
(PAOD/PAD/PVD) refers to the obstruction or
detoriation of ateries other than those...
 Impairment of circulation
 Incidence increases with age
 0.3%/yr (40 to 55yrs) to 1%/yr (after 75yrs)
 Quality of lif...
 Black (hispanic)
 Increasing age
 Smoking
 Hypertension
 Dyslipidemia
 Hypercoaguble states
 Renal insufficiency
...
 Family history of vascular disease or stroke/
heart attack
 In study
 C-reactive protein
 Homocysteine
 Intima
 Internal elastic membrane
 Media
 Composed of smooth m/s, collagen, elastin and
preteoglycans
 Blood suply:
...
 Acute
 Sudden occlusion of an artery
 No time for collateral openings
 Poikilothermia, Pain, Pulseless, Pallor, Paras...
 Atherosclerosis {lower limb}
 TAO (Buerger’s Disease) {lower limb}
 Infective
 Vasculitis syndromes
 Atherosclerosis =
Athero + sclerois
 Plaque composed of
smooth m/s, lipids,
connective tissue and
macrophages
 Brief pathophysiology
 Lipid deposition calcification erosive
areas and ulceration prothrombotic cell
activity plaque l...
 Ischemia may be due to
 Narrowing of the lumen
 Rupture leading to fibrous cap
 Embolization
 More shearing stress/
increased turbulence
 Infra renal aorta
 Iliac bifurcation
 Carotid bifircation
 Superficaial ...
 Inflammatory reaction of the arterial wall with
involvement of neighboring vein and nerves
 2nd to 4th decade of life; ...
 Pathology
smoking (nicotine)
Increased % carboxy hb
vasospasm damage to the vessel wall
TAO fibrosis
 Involves medium and small sized vessels;
those distal to the popliteal artery
 Very rare upper limb involvement
 Acute...
 Chronic Lesion
 Arteries and veins bound together by fibrosis
 Nerve involvement
 Fibroblastic activity and endotheli...
 Pain (Intermittent claudication)
 “Claudio”= I limp
 Cramp like pain
 Brought on by exercise
 Not present on walking...
 Pain (Intermittent claudication)
 Clinical Classification
a) Boyd’s Classification
Grade Pain
I Pain relieved on contin...
 Claudication distance : distance at which the
pain first appears
b) Fontaine Classification
c) Rutherford Classification
 Pain (Intermittent claudication)
 Occlusion and site of claudication
Site of Occlusion Claudication site/ other symptom...
 Pain (Intermittent claudication)
 Rest pain
 Grade IV Boyd’s classification
 Felt in the foot (most distal parts)
 D...
 Pain (Intermittent claudication)
 Rest pain – “Hen-holding”
 Pain (Intermittent claudication)
 Critical limb ischemia
 Persistently recurring ischemic rest pain requiring
regular,...
 Pain (Intermittent claudication)
 Differential Diagnosis
1. Nerve root compression (eg: herniated disc)
Sharp lacinatin...
 Pain (Intermittent claudication)
 Differential Diagnosis
3. Arthritic/ inflammatory
Aching pain
Variable pain
Not relie...
 Pain (Intermittent claudication)
 Differential Diagnosis
5. Venous claudication
Bursting type of pain
Relief speeded by...
 Other symptoms
 Ulceration
 Gangrene
 Loss of senstion
 Loss of movements
 History
 Can identify the location and severity of the disease
 Pain:
 Location
 Precipitating and aggravating facto...
 History
 Vascular review of symptoms
 TIA
 Difficulty in speech or swallowing
 Dizziness/ drop attacks
 Blurry visi...
 Physical examination
 Inspection
 Change in colour
 Signs of ischemia
 Bueger’s test
 Capillary filling test
 Veno...
 Physical examination
 Palpation
 Skin temperature
 Venous refilling
 Perpheral pulses
 Disapperaing pulse
 Joint m...
 Physical examination
 Dry vs Wet Gangrene
Dry gangrene Wet gangrene
Dry, shriveled, mummified Odematous, putrified and
...
 Physical examination
 Dry vs Wet Gangrene
 ABPI
 ABPI
 Physiological testing
SBP of PT/PT/PA (higher)
--------------------------------- = ABPI
Higher of the two brachia...
 ABPI
 Note:
 Normal value doesn’t rule out ischemia
 Retest after exercise, ABPI may fall
 Post exercise ABPI consid...
 Segmental pressure
Difference of 20-30 mmHg is indicative of significant lesion
 Photo-Plethysmography
 Investigation for segmental flow
 Infra-red light emitting source + a photosensor
 Light decre...
 Doppler Ultrasound
(DU)
 Continous wave DU with
segmental waveforms
 Doppler shift converted to
audio signal
 Normal ...
 Doppler Ultrasound (DU)
 Obstructive disease
 Initial Loss of reversal flow in early diastole (Bi-phasic)
 Severe  ...
 Doppler Ultrasound
(DU)
 Duplex Ultrasound
 Provides with B mode settings (gray settings)
 Pulsed Doppler spectral waveforms
 Can even detect ...
 Duplex Ultrasound
 Change in waveforms
 Triphasic  biphasic  Monophasic
 Ratio of PSV proximal and distal to occlus...
 Angiography
 Invasive techique of visualising the arterial tree
 Hypaque 45 (Sodium Diatrazoate) is used as a dye (75 ...
 Angiography
 Done in 4 stages
i. Dye released at the level of diaphragm in the aorta
 Abdominal aorta
 Celiac artery
...
 Angiography
 Done in 4 stages
iii. Contralateral common femoral artery
 Contralateral Sup Femoral artery
 Profunda fe...
 Angiography
 Site of block in
Atherosclerosis
 Angiography
 Cork-screw pattern of
vessels in TAO
 Block at multiple sites
in small and medium
sized arteries
 Angiography
 Risk / Complications:
a) Groin hematoma
b) Retroperitoneal bleeding
c) Pseudo-anuerysm
d) Arterial dissect...
 CT angiography
 IV contrast followed by Ct imaging
 Thin slices of 0.625mm
 Allows 3-D reconstruction
 Improved spee...
 Digital subtraction angiography (DSA)
 Angiographic images being digitilised by a computer
 With substraction of extre...
 MR angiography
 Uses Godalinium as contrast
 Better sensitivity and specificity
 Disadvantages:
 longer study durati...
 Carbon Dioxide angiography
 CO2 as contrast agent
 In cases of renal insuffieciency
 CO2 temporarily displaces blood ...
 General Investigations
 ECG
 ECHO
 Lipid profile
 COPD
 Blood tests to exclude
 Anemia
 DM
 Deranged RFT
 High ...
 Intravascular
ultrasound (IVUS)
 Catheter based
intravascular
ultrasound
 Provides transverse and
360 degree image of ...
 Brown’s vasomotor index
 For Buerger’s disease
 Test of vasospasm
 Block the nerves with Local anesthesia to predict
...
 Conservative management
 Indications:
 Ankle pressure >60mmHg
 Femoral pulse +
 No rest pain
 No tissue loss
 Cont...
 Conservative management
 Stop smoking
 Keep walking
 Reduce weight (obese individuals)
 Exercise
 Diabestes and hyp...
 Conservative management
 Drugs
 Analgesics- Aspirin
 Vasodialtors
 Cilostazol (phosphodiasterase inhibitors)
 Pento...
 Conservative management
 Drugs
 To Control
 Diabetes
 Hypertension
 Dyslipidemia
 Atherosclerosis
 Infection
 No...
 Indirect surgeries
 Sympathectomy
 Chemical
 Surgical
 Indications:
 Rest pain
 Skin ulcerations
 TAO
 Elderly p...
 Indirect surgeries
 Sympathectomy
 Chemical
 Produces cutaneous vasodilatation
 Injection in front of the lumbar fas...
 Indirect surgeries
 Sympathectomy
 Surgical (pre-ganglionic sympathectomy)
 Abdomen opened with oblique incision unde...
 Indirect surgeries
 Sympathectomy
 Surgical
 Sympathectomy from 1 to 4th lumbar ganglion
 Closed the site in layers
...
 Surgical Management
 Surgical Revascularization Procedures
 Open
 Endo-vascular
 Amputation
 Surgical Revascularization Procedures
 Open vs endo-vascular
 Trans-Atlantic Inter Society Documentation Management
of...
 TASC –II (Aorto-iliac)
 TASC –II (Aorto-iliac)
 TASC –II (Aorto-iliac)
 TASC –II (Aorto-iliac)
 TASC –II (Femoro-popliteal)
 TASC –II (Femoro-popliteal)
 TASC –II (Femoro-popliteal)
 TASC –II (Femoro-popliteal)
 Open Surgical Management (Aorto-iliac disease)
 Aorto-bifemoral bypass with a prosthetic graft via
transabdominal or re...
 Open Surgical Management
 Choice of Graft (Conduits)
 Great Sephanous vein
 Preferred for lower limbs with better pat...
 Open Surgical Management
 Choice of Graft (Conduits)
 PTFE (Polytetrafluoroethylene)
 Can be used as a replacement of...
 Open Surgical Management
 Choice of Graft (Conduits)
 Small sephanous vein
 Basillic vein
 Cephalic vein
 All these...
 Open Surgical Management (Aorto-iliac disease)
 Aorto-bifemoral bypass
 Midline or transverse abdominal incision
 CFA...
 Open Surgical Management (Aorto-iliac disease)
 Aorto-bifemoral bypass
 Vertical incision on anterior aspect of Aorta
...
 Aorto-bifemoral bypass
 Open Surgical Management (femoro-popliteal)
 Open groin surgery
 CFA endarectomy + profundoplasty/ iliofemoral bypass
...
 Open Surgical Management
 Endarterectomy
 Open:
 When it involves short segment of big arteries
 Also called “dis-ob...
 Open Surgical
Management
 Endarterectomy
 Open:
 Plane created between
plaque and media
 The plaque is removed
with ...
 Open Surgical Management
 Endarterectomy
 Closed
 Artery exposed and clamped
 Proximal and distal transverse incisio...
 Open Surgical Management
 Endarterectomy
 Balloon
 Artery is exposed after clamping
 Proximal arteriotomy is made
 ...
 Open Surgical
Management
 Endarterectomy
 Passed beyond the
obstruction
 Ballon is inflated
 Pulling the catheter
re...
 Open Surgical Management
 Profundoplasty
 Repairing of profunda femoris
 Arises posterior to CFA
 The vessel is diss...
 Open Surgical
Management
 Profundoplasty
 Defect is them closed by
a vein patch
 On table angiography is
then perform...
 Open Surgical Management
 Femoro-popliteal bypass
 In patients with SFA and popliteal artery occlusion with a distal
s...
 Femoro-popliteal
bypass
 Polpileat vein is held in
Silastic loops
 Graft is tunnelled and
placed at the
anastomotic si...
 Open Surgical Management
 Infrapopliteal bypass
 Disease involving popliteal artery and proximal tibial arteries.
 th...
 Open Surgical Management
 Infrapopliteal bypass
 Access to PTA with dissection and separation of Soleal muscle
attachm...
 Open Surgical Management
 Other bypasses
A. Axillofemoral graft
 Tunnelled subcutaneously between the axillary artery
...
 Endovascular management
 Basically involves gaining access into transmural space
via percutaneous femoral artery punctu...
 Endovascular management
 Balloon angioplasty
 Guide wire is negotiated through the stenosis or occlusion
 Then a ball...
 Endovascular management
 Balloon angioplasty
 Very good results for dilating the iliac and
femporopopliteal segments
...
 Endovascular management
 Subintimal angioplasty
 Creating an arterial dissection purposely begenning at the
proximal e...
 Endovascular management
 Subintimal angioplasty
 Endovascular management
 Stenting
 If the vessel fail to remain dilated use stents
 Stainless steel stents
 May be ...
 Endovascular management
 Stenting
 Endovascular management
 Stenting
 Endovascular management
 Stent garft
 Expanded PTFE (ePTFE) with external nitinol stent
 Inner surface bonded with he...
 Endovascular
management
 Cutting balloon
 Originally designed for
coronary arteries
 The balloon has three or
four at...
 Endovascular management
 Cryoplasty
 Apoptosis by cooling
 Designed by Polar Cath Peripheral Dilatation System
(Bosto...
 Endovascular management
 Endovascular atherectomy
 Excision atherectomy catheters remove and collect the atheroma
 Ab...
 Endovascular management
 Endovascular atherectomy
Rotational cutter Laser tipped
 Amputation
 Indication for amputation
 Dead Limb
 Gangrene
 Deadly Limb
 Wet gangrene
 Spreading cellulitis
 Dead...
 Amputation
 Choice of amputation
 Below knee amp[utation (BKA)
 Above knee amputation (AKA
 Ray amputation
 Transme...
 Amputation
 Level of amputation
 Skin perfusion pressure >=40 mmhg
 Transcuatneous oxygen pressure >= 30mmhg
 Predic...
 Amputation
Below Knee Amputation Above Knee Amputation
Poor Healing Better Healing
More chances of revision/
healing by ...
 Amputation
 Ray amputation
 Amputation
A. Syme’s
B. Chopart’s
C. Lisfranc’s
D. Transmetatarsal
Chronic lower limb ischemia
Chronic lower limb ischemia
Chronic lower limb ischemia
Chronic lower limb ischemia
Chronic lower limb ischemia
Chronic lower limb ischemia
Chronic lower limb ischemia
Chronic lower limb ischemia
Upcoming SlideShare
Loading in …5
×

Chronic lower limb ischemia

15,242 views

Published on

A complete seminar on chronic lower limb ischemia

Published in: Healthcare, Health & Medicine

Chronic lower limb ischemia

  1. 1. Dr Minhajuddin Khurram Al-Ameen Medical College Bijapur (Karnataka) India
  2. 2. Peripheral areterial occlusive disease (PAOD/PAD/PVD) refers to the obstruction or detoriation of ateries other than those supplying the heart and within the brain
  3. 3.  Impairment of circulation  Incidence increases with age  0.3%/yr (40 to 55yrs) to 1%/yr (after 75yrs)  Quality of life/cost of treatment  Non whites> whites  Male gender  Obesity
  4. 4.  Black (hispanic)  Increasing age  Smoking  Hypertension  Dyslipidemia  Hypercoaguble states  Renal insufficiency  DM  Younger>aged
  5. 5.  Family history of vascular disease or stroke/ heart attack  In study  C-reactive protein  Homocysteine
  6. 6.  Intima  Internal elastic membrane  Media  Composed of smooth m/s, collagen, elastin and preteoglycans  Blood suply:  Internal half: Direct diffusion  External half: vasa vasorum  External elastic membrane  Adventitia • Fibroblasts and collagen
  7. 7.  Acute  Sudden occlusion of an artery  No time for collateral openings  Poikilothermia, Pain, Pulseless, Pallor, Parasthesia and Paralysis  Chronic  No sudden obstruction  Gradual narrowing of lumen  Enough time for collaterals to develop  More tolerant to prolonged ischemia
  8. 8.  Atherosclerosis {lower limb}  TAO (Buerger’s Disease) {lower limb}  Infective  Vasculitis syndromes
  9. 9.  Atherosclerosis = Athero + sclerois  Plaque composed of smooth m/s, lipids, connective tissue and macrophages
  10. 10.  Brief pathophysiology  Lipid deposition calcification erosive areas and ulceration prothrombotic cell activity plaque lipid core becomes necrotic covered by FIBROUS CAP rupture, perceived as injury laying down of platelets and formation of a clot.
  11. 11.  Ischemia may be due to  Narrowing of the lumen  Rupture leading to fibrous cap  Embolization
  12. 12.  More shearing stress/ increased turbulence  Infra renal aorta  Iliac bifurcation  Carotid bifircation  Superficaial femoral arteries  Ostia or renal, coronary and mesenteric arteries.
  13. 13.  Inflammatory reaction of the arterial wall with involvement of neighboring vein and nerves  2nd to 4th decade of life; male>females  Specifically linked to smoking  Low socio-economic groups  Recently, familial disposition and autoimmune mechanism has also been postulated
  14. 14.  Pathology smoking (nicotine) Increased % carboxy hb vasospasm damage to the vessel wall TAO fibrosis
  15. 15.  Involves medium and small sized vessels; those distal to the popliteal artery  Very rare upper limb involvement  Acute Lesion:  Arteritis, periarteritis, acute phlebitis (migratory in 30%) and periphlebitis.  Invasion of wall by polymorphs and giant cells.  Thrombus, with microabscesses
  16. 16.  Chronic Lesion  Arteries and veins bound together by fibrosis  Nerve involvement  Fibroblastic activity and endothelial proliferation in the thrombus  Thrombus organized as fibrous tissue
  17. 17.  Pain (Intermittent claudication)  “Claudio”= I limp  Cramp like pain  Brought on by exercise  Not present on walking the first step  Relieved by standing still  Slight variation each day  Due to accumulation of substance P  Site of Claudication:  Group of muscles distal to the site of obstruction
  18. 18.  Pain (Intermittent claudication)  Clinical Classification a) Boyd’s Classification Grade Pain I Pain relieved on continued walking II Walks in pain III Compelled to take rest IV Pain at rest
  19. 19.  Claudication distance : distance at which the pain first appears
  20. 20. b) Fontaine Classification
  21. 21. c) Rutherford Classification
  22. 22.  Pain (Intermittent claudication)  Occlusion and site of claudication Site of Occlusion Claudication site/ other symptoms Aorto-iliac obstruction • Claudication in in both buttocks, thighs and calf • Absent femoral, popliteal and DP pulses • Impotence (Leriche’s syndrome) Iliac obstruction • Unilateral claudication in thigh and calf • Unilateral absence of femoral and distal pulses Femoropopliteal obstruction • Unilateral claudication in the calf • Absent distal pulses Distal obstruction • Ankle pulses absent • Claudication in calf and foot
  23. 23.  Pain (Intermittent claudication)  Rest pain  Grade IV Boyd’s classification  Felt in the foot (most distal parts)  Due to ischemia of the somatic nerves (cry of the dying nerves)  Exacerbate on lying down or elevation of foot  Worse at night; patient sits in “hen-holding” position  Pressure of even bed clothes worsens the pain  Lessened by hanging the foot down or sleeping on a chair  Patient may commit suicide
  24. 24.  Pain (Intermittent claudication)  Rest pain – “Hen-holding”
  25. 25.  Pain (Intermittent claudication)  Critical limb ischemia  Persistently recurring ischemic rest pain requiring regular, adequate analgesia for more than 2 weeks or ulceration or gangrene of foot or toes with ankle pressure <50mmHg or toe pressure <30mmHg
  26. 26.  Pain (Intermittent claudication)  Differential Diagnosis 1. Nerve root compression (eg: herniated disc) Sharp lacinating pain Sudden onset on walking History of back problems 2. Spinal stenosis History of back problems Motor weakness more prominent Onset by standing also Relived by change in position
  27. 27.  Pain (Intermittent claudication)  Differential Diagnosis 3. Arthritic/ inflammatory Aching pain Variable pain Not relieved as quickly 4. Baker’s cyst Swelling, tenderness Rest pain Subsides slowly Not intermittent
  28. 28.  Pain (Intermittent claudication)  Differential Diagnosis 5. Venous claudication Bursting type of pain Relief speeded by elevation h/o DVT Signs of venous congestion 6. Chronic compartment syndrome Bursting pain Heavily muscled legs Relief speeded by elevation
  29. 29.  Other symptoms  Ulceration  Gangrene  Loss of senstion  Loss of movements
  30. 30.  History  Can identify the location and severity of the disease  Pain:  Location  Precipitating and aggravating factors  Frequency, duration and evolution  Rule out other causes of pain in the lower limbs  Patients with co- morbid conditions who cannot walk present late with gangrene and rest pain  Drug/Medical history  Surgical history  Family history : first degree with abdominal aortic aneurysm
  31. 31.  History  Vascular review of symptoms  TIA  Difficulty in speech or swallowing  Dizziness/ drop attacks  Blurry vision  Arm fatigue  Pain in abdomen after eating  Renal insufficiency (poorly controlled hypertension)  Impotence  Claudication  Rest pain or tissue loss
  32. 32.  Physical examination  Inspection  Change in colour  Signs of ischemia  Bueger’s test  Capillary filling test  Venous refilling  Pregangrenous/ gangrenous part examination
  33. 33.  Physical examination  Palpation  Skin temperature  Venous refilling  Perpheral pulses  Disapperaing pulse  Joint movements / muscle strength  Sensations  Auscultation:  Bruits
  34. 34.  Physical examination  Dry vs Wet Gangrene Dry gangrene Wet gangrene Dry, shriveled, mummified Odematous, putrified and discoloured Occurs due to slow and gradual loss of blood supply Occurs due to sudden loss of blood supply Clear line of demarcation is present Vague/ No line of demarcation No proximal extention Proximal extension Limited amputation High amputation
  35. 35.  Physical examination  Dry vs Wet Gangrene
  36. 36.  ABPI
  37. 37.  ABPI  Physiological testing SBP of PT/PT/PA (higher) --------------------------------- = ABPI Higher of the two brachial SBPs  Normal value =>1  Claudication <0.9  Rest pain <0.5  Imminent necrosis <0.3  Note:  Normal value doesn’t rule out ischemia  Retest after exercise, ABPI may fall  Wrong high readings in calcified arteries, e.g. seen in diabetics &ESRD
  38. 38.  ABPI  Note:  Normal value doesn’t rule out ischemia  Retest after exercise, ABPI may fall  Post exercise ABPI considered POSITIVE when  ABPI fall => 0.2 and/or  Failure to return to baseline in 3 minutes  Wrong high readings in calcified arteries, e.g. seen in diabetics &ESRD
  39. 39.  Segmental pressure Difference of 20-30 mmHg is indicative of significant lesion
  40. 40.  Photo-Plethysmography  Investigation for segmental flow  Infra-red light emitting source + a photosensor  Light decreases when flow increases  Generates a pressure and waveform of different arteries  A difference of 20-30 mmHg is significant.
  41. 41.  Doppler Ultrasound (DU)  Continous wave DU with segmental waveforms  Doppler shift converted to audio signal  Normal  Triphasic Signal  Sharp systolic upstroke  Reversal of flow in early diastole  Low amplitude forward flow throughout diastole.
  42. 42.  Doppler Ultrasound (DU)  Obstructive disease  Initial Loss of reversal flow in early diastole (Bi-phasic)  Severe  blunting of arterial waveform with decreased amplitude  Worsening  only diastolic flow (Mono-phasic )  In case of a proximal obstruction/ stenosis  Assessment downstream is less accurate  Shows moving blood but it may/ may not be sufficient
  43. 43.  Doppler Ultrasound (DU)
  44. 44.  Duplex Ultrasound  Provides with B mode settings (gray settings)  Pulsed Doppler spectral waveforms  Can even detect very low flow states  Color flow data and waveforms for analysis by a computer.  Shows blood flow and turbulence  Peak systolic velocities (PSV) and End diastolic velocities are recorded.
  45. 45.  Duplex Ultrasound  Change in waveforms  Triphasic  biphasic  Monophasic  Ratio of PSV proximal and distal to occlusion  >2.0 indicates a stenosis of 50% or more  Difficult in aoto-illiac segments, especially in obese individuals  (patient should fast overnight)
  46. 46.  Angiography  Invasive techique of visualising the arterial tree  Hypaque 45 (Sodium Diatrazoate) is used as a dye (75 to 100 ml)  Course of arteries, constrictions, and distal “Run off”  To plan interventions 1. Transfemoral 2. Trans-lumbar (established bi-lateral obstruction)  Seldinger technique is used
  47. 47.  Angiography  Done in 4 stages i. Dye released at the level of diaphragm in the aorta  Abdominal aorta  Celiac artery  Sup mesenteric artery  Inferior mesenteric artery ii. Dye released at aortic bifurcation  B/L common iliac arteries  Hypogastric arteries  External iiliac arteries  Common femoral arteries  Sup Femoral arteries  Profunda femoris
  48. 48.  Angiography  Done in 4 stages iii. Contralateral common femoral artery  Contralateral Sup Femoral artery  Profunda femoris  Popliteal artery  3 crural arteries  Pedal arteries iv. Ipsilateral common Femoral artery  Sup Femoral artery  Profunda femoris  Popliteal artery  3 crural arteries  Pedal arteries
  49. 49.  Angiography  Site of block in Atherosclerosis
  50. 50.  Angiography  Cork-screw pattern of vessels in TAO  Block at multiple sites in small and medium sized arteries
  51. 51.  Angiography  Risk / Complications: a) Groin hematoma b) Retroperitoneal bleeding c) Pseudo-anuerysm d) Arterial dissection e) Contrast nephropathy f) Contrast allergy
  52. 52.  CT angiography  IV contrast followed by Ct imaging  Thin slices of 0.625mm  Allows 3-D reconstruction  Improved speed  Lesser contrast material  Appreciation of thrombus, calcification, etc. better  Disadvantages similar to angiography
  53. 53.  Digital subtraction angiography (DSA)  Angiographic images being digitilised by a computer  With substraction of extrenous background (bone, soft tissues)
  54. 54.  MR angiography  Uses Godalinium as contrast  Better sensitivity and specificity  Disadvantages:  longer study duration  Costlier  Metallic implants contra-indication  Nephrotoxic contrast  Fibrosed nodules of skin, eyes and joints (rare complication)
  55. 55.  Carbon Dioxide angiography  CO2 as contrast agent  In cases of renal insuffieciency  CO2 temporarily displaces blood but dissolves in 3-5 minutes  Poor detail  Significant patient discomfort  Gas trapping mesenteric ischemia
  56. 56.  General Investigations  ECG  ECHO  Lipid profile  COPD  Blood tests to exclude  Anemia  DM  Deranged RFT  High blood viscosity (polycythemia and thrombocythemia)
  57. 57.  Intravascular ultrasound (IVUS)  Catheter based intravascular ultrasound  Provides transverse and 360 degree image of the lumen of the vessel  Qualitative data about the wall anatomy
  58. 58.  Brown’s vasomotor index  For Buerger’s disease  Test of vasospasm  Block the nerves with Local anesthesia to predict efficacy of Sympathectomy  Rise in skin temperature is recorded  Index = Rise in skin temperature – Rise of mouth temperature Rise of mouth temperature  Index =>3.5 is positive for sympethectomy
  59. 59.  Conservative management  Indications:  Ankle pressure >60mmHg  Femoral pulse +  No rest pain  No tissue loss  Controlled infection (eg diabetic patient)  Unfit for surgery  ABPI >0.5 (Relative indication)
  60. 60.  Conservative management  Stop smoking  Keep walking  Reduce weight (obese individuals)  Exercise  Diabestes and hypertension  Care of feet  Buerger’s position  Buerger’s exercise
  61. 61.  Conservative management  Drugs  Analgesics- Aspirin  Vasodialtors  Cilostazol (phosphodiasterase inhibitors)  Pentoxyphylline (phosphodiasterase inhibitors)  Prostacycline  Platelet aggregation inhibitors  Clopidrogel  Aspirin  Prostacycline
  62. 62.  Conservative management  Drugs  To Control  Diabetes  Hypertension  Dyslipidemia  Atherosclerosis  Infection  Note: Risk of limb Loss to be explained to the patient (Failure in 25% of patients)  Opening up of collaterals or change of gait with less usage of the affected muscle
  63. 63.  Indirect surgeries  Sympathectomy  Chemical  Surgical  Indications:  Rest pain  Skin ulcerations  TAO  Elderly patient (senile gangrene)
  64. 64.  Indirect surgeries  Sympathectomy  Chemical  Produces cutaneous vasodilatation  Injection in front of the lumbar fascia which contains sympathetic trunk; Under C-Arm  5ml phenol in water is inected in front of 2nd, 3rd and 4th lumbar vertebra
  65. 65.  Indirect surgeries  Sympathectomy  Surgical (pre-ganglionic sympathectomy)  Abdomen opened with oblique incision under genral anasthesia  Dissection through flat abdominal muscles, and peritoneum  The sympathic chain is situated medial to the medial margin of psoas muscle  Rt side  overlapped by IVC  Lt side  overlapped by aorta  Sympathetic chain identified by the presence of ganglia  First lumbar ganglia is as high as crus of the diaphragm
  66. 66.  Indirect surgeries  Sympathectomy  Surgical  Sympathectomy from 1 to 4th lumbar ganglion  Closed the site in layers  Note: in case of bilateral surgery; preserve L1 of atleast one side  causes retrograde ejaculation.
  67. 67.  Surgical Management  Surgical Revascularization Procedures  Open  Endo-vascular  Amputation
  68. 68.  Surgical Revascularization Procedures  Open vs endo-vascular  Trans-Atlantic Inter Society Documentation Management of Peripheral Arterial Disease (TASC) 2000  TASC –II in 2007 “Endovascular therapy is the treatment of choice for Type A lesions and surgery is the treatment of choice for Type D lesions. Endovascular treatment is the preferred treatment for Type B lesions and surgery is the preferred treatment for good risk patients with Type C lesions”
  69. 69.  TASC –II (Aorto-iliac)
  70. 70.  TASC –II (Aorto-iliac)
  71. 71.  TASC –II (Aorto-iliac)
  72. 72.  TASC –II (Aorto-iliac)
  73. 73.  TASC –II (Femoro-popliteal)
  74. 74.  TASC –II (Femoro-popliteal)
  75. 75.  TASC –II (Femoro-popliteal)
  76. 76.  TASC –II (Femoro-popliteal)
  77. 77.  Open Surgical Management (Aorto-iliac disease)  Aorto-bifemoral bypass with a prosthetic graft via transabdominal or retroperitoneal approach.  End to end or end to side proximal anastomosis  Nervi erigentes should be taken care of (damage will lead to retrograde ejaculation) in the area of CIA  Mortality 5%
  78. 78.  Open Surgical Management  Choice of Graft (Conduits)  Great Sephanous vein  Preferred for lower limbs with better patency rates (90% First yr and 60% five yrs)  Should preferentially be used in all below knee by-passes  Can be used in situ  Better size match  Removal of valves with valvulotome  Reversed  No need of disruption of valves  May be harvested endoscopically  No added advantage of one over the other
  79. 79.  Open Surgical Management  Choice of Graft (Conduits)  PTFE (Polytetrafluoroethylene)  Can be used as a replacement of LSV  Poorer results compared to LSV (50% in five yrs)  New: with heparin coating  Dacron is a brand name of PTFE
  80. 80.  Open Surgical Management  Choice of Graft (Conduits)  Small sephanous vein  Basillic vein  Cephalic vein  All these three veins have very thin walls, hence no good results  veins when joined to increase the length gives poor results  Cryo-preserved arteries  Cadevaeric arteries preserved in cold  Bovine pericardial patches
  81. 81.  Open Surgical Management (Aorto-iliac disease)  Aorto-bifemoral bypass  Midline or transverse abdominal incision  CFA and branches exposed through groin incision  Small bowel retracted to right  Posterior peritoneum is open  Retroperitoneal tunnels are made to groin.  Heparin 5000U given iv bolus and vessels clamped
  82. 82.  Open Surgical Management (Aorto-iliac disease)  Aorto-bifemoral bypass  Vertical incision on anterior aspect of Aorta  Dacron sutured end to side (taking all the layers)  The Limbs fed to the groin sutured end to side to CFA  Posterior peritoneum closed over peritoneum
  83. 83.  Aorto-bifemoral bypass
  84. 84.  Open Surgical Management (femoro-popliteal)  Open groin surgery  CFA endarectomy + profundoplasty/ iliofemoral bypass  In case of added proximal (iliac) occlusion  CFA endarectomy + profundoplasty / iliofemoral bypass + iliac stenting  In case of added distal (SFA)occlusion  CFA endarectomy + profundoplasty +SFA stenting/ femoropopliteal bypass
  85. 85.  Open Surgical Management  Endarterectomy  Open:  When it involves short segment of big arteries  Also called “dis-obliteration/ reboring”  Heparin 5000U given pre-opeartively  Artery is exposed after placing clamps  Distal clamp applied first  Longitudinal incision taken oven the occlusion till the plaque is reached
  86. 86.  Open Surgical Management  Endarterectomy  Open:  Plane created between plaque and media  The plaque is removed with the diseased intima  In case of thrombus, it is removed  Closed with non absorbable fine sutures directly or a vein graft  Post op anticoagulant therapy with warfarin
  87. 87.  Open Surgical Management  Endarterectomy  Closed  Artery exposed and clamped  Proximal and distal transverse incisions taken  Plane created between plaque and tunica media  Wire loop passed from distal to lower arteriotomy insion, stripping the plaque  Can be used in relatively longer occlusions
  88. 88.  Open Surgical Management  Endarterectomy  Balloon  Artery is exposed after clamping  Proximal arteriotomy is made  Fogarty ballon catheter is passed
  89. 89.  Open Surgical Management  Endarterectomy  Passed beyond the obstruction  Ballon is inflated  Pulling the catheter removes the atheroma  More commonly used for emboli (as they are comparetively loosely adherant)
  90. 90.  Open Surgical Management  Profundoplasty  Repairing of profunda femoris  Arises posterior to CFA  The vessel is dissected out and clamps are applied  Arteriotomy extending from CFA to distal to occlusion  Atherectomy is then performed
  91. 91.  Open Surgical Management  Profundoplasty  Defect is them closed by a vein patch  On table angiography is then performed to check for patency  May be done in adjunct to bypass surgeries
  92. 92.  Open Surgical Management  Femoro-popliteal bypass  In patients with SFA and popliteal artery occlusion with a distal segment of patent popliteal artery.  In continuity with any crural artery  Longitudinal groin incision to access the CFA  Popliteal artery is exposed medially from thigh or the leg  In above knee bypass, incision proximal to the knee to access popliteal artery  In below knee bypass, popliteal fossa is opened
  93. 93.  Femoro-popliteal bypass  Polpileat vein is held in Silastic loops  Graft is tunnelled and placed at the anastomotic site  Sephanous vein graft can be used  In situ (requires desruption of valves)  Reversed, can be accessed by a parallel skin incision
  94. 94.  Open Surgical Management  Infrapopliteal bypass  Disease involving popliteal artery and proximal tibial arteries.  the target artery must have luminal continuity with the foot  Stenosis upto 50% is accepted as patent for surgery  Calcification also not considered a contra-indiaction.  SFA or Popliteal artery is used for “inflow”
  95. 95.  Open Surgical Management  Infrapopliteal bypass  Access to PTA with dissection and separation of Soleal muscle attachment from tibea  access to PTA and PA  Access to ATA with anterolateral incision on legseparation of ant tibial muscle and external longus muscle ATA. Separation of interosseus membrane for tunneling of the graft.  Small veins can be used for anastomosis  Or PTFE graft can be used
  96. 96.  Open Surgical Management  Other bypasses A. Axillofemoral graft  Tunnelled subcutaneously between the axillary artery proximally, to reachone or both CFA  Low patency rates B. Femoro-femoral crossover bypass  Crossover graft by tunnelling a prosthetic graft subcutaneously above the pubis between the groins
  97. 97.  Endovascular management  Basically involves gaining access into transmural space via percutaneous femoral artery puncture  Balloon angioplasty  Subintimal angioplasty  Stenting  Stent graft  Variations of balloon angioplasty
  98. 98.  Endovascular management  Balloon angioplasty  Guide wire is negotiated through the stenosis or occlusion  Then a balloon is inflated to open the occlusion  It is kept inflated for approx 1 minutes with high pressure then deflated  May be combined with stenting
  99. 99.  Endovascular management  Balloon angioplasty  Very good results for dilating the iliac and femporopopliteal segments  Below knee procedures are less successful  98% success in CLI (extremely good results)  Limb salvage rate of 91% over 5 fyrs  Failure in TASC D patients
  100. 100.  Endovascular management  Subintimal angioplasty  Creating an arterial dissection purposely begenning at the proximal end of the oclusion  The guide wire is made to re-enter the lumen at the diastal end of occlusion  Use of balloon angioplasty to increase the diameter of the false lumen  Poor results  3 yrs patency rates being only 30%  But good for critical limb ischemia
  101. 101.  Endovascular management  Subintimal angioplasty
  102. 102.  Endovascular management  Stenting  If the vessel fail to remain dilated use stents  Stainless steel stents  May be introduced on a balloon catheter and placed in position  Self expanding stents (nitinol), which expand on withdrawing the sheath  Angioplasty (balloon) + stenting > primary stenting  But primary stenting > only angioplasty  Poor results in TASC D patients
  103. 103.  Endovascular management  Stenting
  104. 104.  Endovascular management  Stenting
  105. 105.  Endovascular management  Stent garft  Expanded PTFE (ePTFE) with external nitinol stent  Inner surface bonded with heparin  Extremely flexible  Can close conform to the shape of artery (esp: SFA)  Self expanding stents  Easier with better patency rates than atherectomy.  It is easier, with more better technical succes comapred t o PTA  Few studies show similar results comapred to bypass
  106. 106.  Endovascular management  Cutting balloon  Originally designed for coronary arteries  The balloon has three or four atherotomes or micro-surgical blades  These are mounted longitudinally on the balloon  The blades score the lesion and dilate the lesions
  107. 107.  Endovascular management  Cryoplasty  Apoptosis by cooling  Designed by Polar Cath Peripheral Dilatation System (Boston Scientific)  Balloon filled with nitrous oxide gas  To cool to -10 degrees C  Supposed to prevent restenosis
  108. 108.  Endovascular management  Endovascular atherectomy  Excision atherectomy catheters remove and collect the atheroma  Ablative atherectomy device fragment it  Rotational cutters turn at the speed of 8000rpm to shave the plaque and collect in a storage chamber  Laser atherectomy has a cold tipped laser that delivers burst of ultraviolet Xenon energy in short pulse durations  Results same as balloon angioplasty
  109. 109.  Endovascular management  Endovascular atherectomy Rotational cutter Laser tipped
  110. 110.  Amputation  Indication for amputation  Dead Limb  Gangrene  Deadly Limb  Wet gangrene  Spreading cellulitis  Dead Loss Limb  Severe rest pain with  Ischemia  Paralysis  Contracture
  111. 111.  Amputation  Choice of amputation  Below knee amp[utation (BKA)  Above knee amputation (AKA  Ray amputation  Transmetatarsal amputation  Miscellaneous  Syme’s  Chopart’s  Lisfranc’s
  112. 112.  Amputation  Level of amputation  Skin perfusion pressure >=40 mmhg  Transcuatneous oxygen pressure >= 30mmhg  Predictors for Transmetatarsal amputation:  Toe Blood Pressure >=30 mmhg  Ankle Blood Pressure >= 80 mmHg
  113. 113.  Amputation Below Knee Amputation Above Knee Amputation Poor Healing Better Healing More chances of revision/ healing by secondary intention Less chances of revision Better ambualtion Poor ambulation
  114. 114.  Amputation  Ray amputation
  115. 115.  Amputation A. Syme’s B. Chopart’s C. Lisfranc’s D. Transmetatarsal

×