Arterial diseases

ARTERIAL
DISEASES
M O D E R AT O R : D R . B . G M A N J U N AT H
P R E S E N T E R : D R I N D U M AT H I . B

OVERVIEW
• INTRODUCTION - AV FISTULA
• ARTERIES OF LOWER LIMB - ANEURYSM
• PALPATION OF BLOOD VESSELS - ANOMALIES
• FEATURES OF ARTERIAL STENOSIS -UL-ARTERIAL
INSUFFICIENCY
• LEVELS OF ARTERIALOBSTRUCTION -CERVICAL RIB
• INVESTIGATIONS FOR ARTERIAL DISEASES
• CLINICAL TESTS
• TREATMENT PLAN
• BUERGERS DISEASE
• RAYNAUD’S PHENOMENON
• RAYNAUD’S DISEASE

INTRODUCTION
• Arterial disorders represent the most common cause of
morbidity and death in Western societies.
• It is due to the effects of atheroma on the arteries supplying
the heart muscle (coronary thrombosis and myocardial
infarction) and brain (stroke)& also common at other sites.
• Arterial stenosis or occlusion is commonly caused by
atherosclerosis , acutely as a result of emboli or trauma.
• Stenosis produces symptoms and signs that are related to the
organ supplied by the artery

ARTERIES OF LOWER LIMB
• Abdominal aorta bifurcates -at L4 into
two common iliac arteries.
• Common iliac artery - 5 cm in length
passes downward and laterally.
• At lumbosacral intervertebral disc-
anterior to sacroiliac joint, divides into
external & internal iliac arteries.
• External iliac artery common
femoral artery at the level of inguinal
ligament.
• About 5 cm below the inguinal
ligament common femoral divides into
superficial femoral and deep femoral
(Profunda femoris) arteries.

• Deep femoral artery -collateral
circulation around the knee joint.
• It also communicates above with
gluteal vessels to maintain
collateral circulation around the
gluteal region.
• Superficial femoral artery at the
hiatus in the adductor magnus,
as popliteal artery .
• At the inferior angle of the
popliteal fossa it divides into
anterior and posterior tibial
arteries.

• Anterior tibial artery
continues as dorsalis pedis
artery which forms dorsal
arterial arch of the foot.
• Posterior tibial artery ends as
medial and lateral plantar
arteries which forms plantar
arterial arch of the foot.
• Posterior tibial artery gives
peroneal artery which runs
close to fibula supplying calf
muscles.

ARTERIES OF UPPER LIMB
• Right subclavian artery begins from
brachiocephalic trunk (innominate
artery)
• Left subclavian artery arises
directly from the arch of aorta.
• From underneath the
sternoclavicular joint artery arches
over the pleura and apex of lung
about 2.5 cm above the clavicle
and then reaches the lateral border
of first rib to continue as axillary
artery.
• Subclavian artery is divided into
three parts by scalenus anterior

ARTERIES OF UPPER LIMB
• Axillary artery is -three parts -pectoralis
minor muscle.
• At the lower border of teres major muscle
it enters the arm and continues as brachial
artery.
• About 2.5 cm below the crease of the
elbow joint, it bifurcates into radial and
ulnar arteries which run in the forearm.
• Ulnar artery -superficial palmar arch which
is completed by superficial palmar branch
of radial artery.
• Radial artery enters the dorsum of hand
and first intermetacarpal space to form
deep palmar arch .

PALPATION OF BLOOD VESSELS
• Dorsalis pedis artery is felt
lateral to the extensor hallucis
longus tendon.
• The posterior tibial artery — is
felt just behind the medial
malleolus midway between it and
the tendo Achillis.

• The anterior tibial artery — is
felt in the midway anteriorly
between the two malleoli against
the lower end of tibia just above
the ankle joint and just lateral to
the tendon of the extensor
hallucis longus which is made
prominent by asking the patient to
extend his great toe .

• Popliteal artery is difficult to feel.
• It is palpated with knee flexed about
40-50°, to relax the popliteal fascia.
• It is felt in the lower part of the fossa
the fingers are moved sideways to
feel the pulsation of the popliteal
artery against the posterior aspect
of. the tibial condyles.

• The femoral artery — is felt at the groin
just below the inguinal ligament midway
between the anterior superior iliac spine
and the symphysis pubis.
• The radial and ulnar arteries — are felt
at the wrist on the lateral and on the
medial sides of its volar aspect
respectively.
• The brachial artery — is felt in front of the
elbow just medial to the tendon of biceps.
• The subclavian artery — is felt just above
the middle of the clavicle.

• Common carotid artery — is
felt in the carotid triangle just
in front of sternomastoid
muscle against the carotid
tubercle of the sixth cervical
vertebra.
• The superficial temporal
artery — is felt just in front of
the tragus of the ear.

CAUSE AND EFFECT
• Arterial stenosis or occlusion is commonly caused by
atheroma, but can occur acutely as a result of emboli
or trauma.
• Stenosis or occlusion produces symptoms and signs
that are related to the organ supplied by the artery.
• severity of the symptoms is related to the size of the
vessel occluded.

CAUSE AND EFFECT
• Lower limb (claudication, rest pain and gangrene)
• Brain (transient ischaemic attacks and stroke)
• Myocardium (angina and myocardial infarction)
• Kidney (hypertension and renal failure)
• Intestine (abdominal pain and infarction).

RISK FACTORS
• Smokers
• Hypertension,
• Dyslipidemia,
• Hypercoagulable states
• Renal insufficiency
• Diabetes mellitus
• Older than 50 years,
• Male,
• Obese
• Family history of vascular
disease, heart attack, or
stroke

FEATURES OF ARTERIAL STENOSIS
• Intermittent claudication, rest pain.
• Cold periphery, numbness, paraesthesia.
• Colour changes, ulceration, gangrene.
• Altered sensation and decreased function/movements.
• Diminished/absent arterial pulsation l Thrill/bruit over the
stenosed artery
• Altered venous filling-normally it is in few seconds,it is
delayed in arterial stenosis & it is rapid in AV fistula.

• Intermittent claudication
• Intermittent claudication is a cramp-like pain felt in the muscles
.
• Due to arterial occlusion, metabolites like lactic acid and
substance P accumulate in the muscle and cause pain.
• The site of pain depends on site of arterial occlusion.

INTERMITTENT CLAUDICATION
• BOYD”S CLASSIFICATION:
• Grade I: Patient complains of pain after walking, and distance
in which pain develops is called as 'claudication distance'. If
patient continues to walk, due to increased blood flow in
muscle and opening of collaterals metabolites causing pain
are washed away and pain subsides.
• Grade II: Pain still persists on continuing walk, but can walk
with effort.
• Grade 111: Patient has to take rest to relieve the pain.

• The distance that a patient is able to walk without stopping
varies only slightly from day to day.
• It is altered by walking uphill, the speed of walking, carrying
heavy weights and changes in general health, such as
anaemia or heart failure.
• The pain of claudication is usually felt in the calf because the
superficial femoral artery is the most commonly affected (70
per cent of cases).

• Aortoiliac disease
(30 per cent of
cases) may
causethigh or
buttock
claudication.
• Buttock claudication
in association with
sexual impotence
resulting from
arterial insufficiency
is called Leriche’s
syndrome.

• Rest pain
This pain is continuous and aching in nature.
Rest pain occurs with the limb at rest .
Exacerbated by lying down or elevation of the foot.
 Pain is worse at night .
 It may be lessened by hanging the foot out of bed or by sleeping
in a chair.
• Anaerobic muscle metabolism occurs even at rest mainly
affecting the foot and leg.

• Ulceration and gangrene
• occurs with severe arterial
insufficiency.
• present as a painful erosion between
the toes or as shallow, non healing
ulcers on the dorsum of the feet, on
the shins and especially around the
malleoli.
• The blackened mummified tissues of
frank gangrene are unmistakable and
superadded infection often makes the
gangrene wet.

• Colour, temperature, sensation and
movement
• Acutely ischaemic foot -cold, white,
paralysed and insensate.
• Chronically ischaemic limb - equilibrate
with the temperature of its surroundings
and may feel quite warm .
• Chronic ischaemia does not produce
paralysis and sensation is usually
intact.
• Elevation of the limb produces pallor
which changes to a red/purple colour
when the limb is allowed to hang down
(dependent rubor or the sunset foot
sign).

• The capillary refill time:
• The tip of the nail or the pulp of a
toe or a finger is pressed for a
seconds and the pressure is
released.
• The time taken for the blanched
area to turn pink after the
pressure has been released is a
crude indication of capillary blood
flow.
• may be prolonged to 10 seconds
in severe ischaemia.

• Delayed venous refilling: Two fingers are placed over
the vein. Finger nearest to heart is moved away so as to
empty the vein. Distal finger is released to observe the
venous refilling.
• normal refilling of the veins- within 5 seconds.
• In ischaemic limb - delayed.
• If a normal limb is raised to about 90° there will be
gradual collapse or guttering of the veins.
• But in ischaemic limb the veins are seen collapsed -
horizontal position or as soon as it is lifted to even 10°
above the horizontal level.

SIGNS OF ISCHAEMIA
• Thinning of the skin
• Diminished growth of hair
• Loss of subcutaneous fat
• Shininess
• Trophic changes in the nails
which become brittle and show
transverse ridges
• Minor ulceration in the
pressure areas such as heel,
malleoli, ball of the foot, tips of
the toes etc.

INVESTIGATIONS
• Blood Investigations:
• Low Hb- delays healing due to poor oxygenation
• Raised WBC count –infection
• Raised platelet count -thrombosis
• Blood sugar and glycosylated haemoglobin (HbA 1 C)
• Lipid profile
• Peripheral smear
• Renal function tests

INVESTIGATIONS
• ECG - coronary ischaemia, left ventricular hypertrophy or
rhythm abnormalities.
• Normal ECG does not rule out these conditions.
• Cardiac echo or exercise testing can also be done.
• Arterial blood gases & pulmonary function test -severe lung
disease.

INVESTIGATIONS
1. Doppler ultrasound
2. Ankle brachial pressure index (ABPI)
3. Duplex imaging
4. Arteriography
5. DSA
6. Magnetic resonance angiogram (MRA)
7. Plethysmography
8. Photoplethysmography
9. Transcutaneous oximetry.

DOPPLER ULTRASOUND BLOOD FLOW
DETECTION
• The Doppler signal indicates moving
blood.
• It does not indicate that the blood flow
detected is sufficient to prevent limb
loss.
• A continuous wave of ultrasound signal
is transmitted from the probe at an
artery.
• The reflected beam is picked up by a
receiver within the probe itself in a case

DETECTION
• The change in frequency in the reflected beam compared with
that of the transmitted beam is due to the Doppler shift,
resulting from the reflection of the beam by moving blood
cells.
• The frequency change may be converted into an audio signal
that is typically pulsatile.
• The Doppler ultrasound equipment can be used as a
sensitive stethoscope in conjunction with sphygmomanometer
to assess the systolic pressure in small vessels.

DETECTION

DETECTION
• It can be used to assess the
difference in arterial blood pressure
between segments of the limb and
hence can identify the site of
stenosis.
• In the leg the cuff is commonly
placed above the ankle, mid calf,
and
mid thigh to provide segmental

ANKLE–BRACHIAL PRESSURE INDEX
(ABPI)
• The ankle–brachial pressure index (ABPI) is the ratio of
systolic pressure at the ankle to that in the arm.
• A blood pressure cuff is applied above the ankle and the
systolic pressure is determined using a Doppler probe at the
dorsalis pedis or posterior tibial artery region.
• Similarly systolic pressure is recorded in the brachial artery
using Doppler probe.
• The higher systolic BP at the ankle is divided by the brachial
pressure to give the ABPI.

(ABPI)
• Normally the ankle systolic blood pressure is greater than the
brachial (arm) systolic blood pressure by 5 to 15 mm Hg.
• So, the ratio of the ankle blood pressure and arm blood pressure
will also be greater than one and is known as 'pressure index'.
• Normally it is more than 1 or about 1 (100%).
• Vascular disease is confirmed if it is less than 0.9.
• The test may be repeated after exercise.
• Normally ABPI will rise after exercise.
• In occlusive arterial disease it will fall.

(ABPI)
• >0.9 is normal
• 0.70-0.89 is mild ischaemia
• 0.50 - 0.69 is moderate ischaemia
• <0.5 is severe (rest pain)
• <0.3 critical ischaemia (tissue necrosis)
• Wall calcification should be suspected when ABPI is more
than 1.2 .

DUPLEX SCANNING
• The duplex imaging is a combination of B
mode ultrasound and Doppler.
• The B mode ultrasound will image the
vessels.
• The Doppler is then used to insonate the
imaged vessels and the Doppler shift is
obtained.
• The blood flow and turbulence.
• Indicates the direction of flow.
• High flow in a segment suggest stenosis.

DUPLEX SCANNING
• Duplex scanning is as
accurate as angiography .
• Advantages -cost-
effectiveness & safety.

ANGIOGRAPHY
• This is the most reliable method of determining the state of
the main arterial tree.
• Site of the occlusion
• Extent of the occlusion
• Nature of occlusion
• Run in—patency of the vessel proximal to the occlusion
• Distal run off—patency of the vessel distal to the occlusion
• State of collateral circulation.

RETROGRADE PERCUTANEOUS
CATHETERIZATION
• It is commonly done angiogram.
• It is done only when femorals are felt.
• Femoral artery is used because it can be easily felt and
cannulated to pass an arterial catheter.
• Water soluble iodine dye (Sodium diatrizoate) is injected.
• X-rays are taken to see the block, its extent in the affected
limb.

SELDINGER TECHNIQUE (STEPS)
Arterial cannula is passed into the artery.
Needle is removed and guidewire is passed through the
cannula
Cannula is removed
Dilator is passed over the guidewire
Dilator is removed & arterial catheter (5 French sized) is

CATHETERIZATION

CATHETERIZATION
• When vessels like superior
mesenteric or inferior mesenteric
vessels are selectively cannulated
and dye is injected, it is called
selective arteriography.
• Through the radial artery or brachial
artery the coronary arteries can be
cannulated and angiograms
obtained to search for coronary
artery blocks.

ANGIOGRAPHY
• Complications
• Groin hematoma
• Retroperitoneal bleeding
• Pseudoaneurysm,
• Arteriovenous fistula
• Arterial dissection.
• Even a small amount of bleeding after brachial artery
symptomatic brachial sheath hematoma and neural
compromise

ANGIOGRAPHY
Dyes used for arteriography:
• 1. Meglumine diatrozoate
• 2. Ionohexal
• 3. Carbon dioxide
• 4. Gadolinium.

ANGIOGRAPHY
• DIRECT ARTERIAL PUNCTURE.— carotid angiogram.
• Abdominal aorta (translumbar route) may be chosen for
aortoiliac and femoropopliteal arteriography.

DIGITAL
SUBTRACTION ANGIOGRAPHY (DSA)
• A computer system is used to digitize the angiographic
images.
• The extraneous background (bone, soft tissues, etc.) is
removed to provide clearer images.
• It can be carried out by injecting the contrast intra-arterially or
intravenously.
• Intravenous injection of the contrast avoids arterial puncture.
• large volumes of contrast agent is required for the
investigation.

DIGITAL
SUBTRACTION ANGIOGRAPHY (DSA)
• Complications: Anaphylaxis,
bleeding, thrombosis.
• Advantages:Small lesion, its
location and details are better
observed with greater clarity.
• Disadvantages: Cost factor and
availability.

COMPUTED TOMOGRAPHY
ANGIOGRAPHY
• Advantage of CTA :
• Depiction of the entire vessel, with the
ability to appreciate thrombus and
calcification
• Thin slices of 0.625 mm allow three-
dimensional reconstructions and
multiplanar reformatting that is not
routinely achieved with conventional
arteriography.

COMPUTED TOMOGRAPHY
ANGIOGRAPHY
• CTA scan with
volume rendering
demonstrates normal
common iliac,
external iliac,
common femoral,
deep and superficial
femoral, popliteal,
and proximal tibial
arteries.

MAGNETIC RESONANCE
ANGIOGRAPHY
• It is a multiplanar imaging without arterial puncture, catheters,
or ionizing radiation.
• The principle is rearrangements of hydrogen atoms in a
strong magnetic field.
• The vascular tree and the soft tissue surrounding the vessel
can be seen.
• The dye used is called gadolinium (non-iodine containing).

MAGNETIC RESONANCE
ANGIOGRAPHY
• MRA scan -
distal tibial
disease

MAGNETIC RESONANCE
ANGIOGRAPHY
• ADVANTAGES:
• Degreeof stenosis and lesion length and even superiority in
identifying distal target vessels compared with conventional
arteriography.
• DISADVANTAGES:
• Need cooperation of the patient
• Discomfort of the patient
• Longer studies,
• Expense,

MAGNETIC RESONANCE
ANGIOGRAPHY
• Contraindications with certain metallic implants.
• Nephrogenic systemic fibrosis is a rare complication
associated with the administration of gadolinium-based
agents to patients with renal failure or renal insufficiency
having a GFR -30 mL/min or lower.
• Patients develop fibrosed nodules of the skin, eyes, and
joints.

CARBON DIOXIDE ANGIOGRAPHY.
• Angiography using carbon
dioxide as a contrast
medium -severe chronic
renal insufficiency.
• Carbon dioxide
temporarilydisplaces the
blood in the artery being
imaged.
• Carbon dioxide rapidly
dissolves, but 3 to 5 minutes
must be allowed to pass
between injections.

CARBON DIOXIDE ANGIOGRAPHY.
• The limitations of this contrast
agent include poor detail,
especially for small distal
vessels.
• The bolus may cause significant
discomfort for the patient.
• Complications-carbon dioxide
embolus, with gas trapping
mesenteric
ischemia,
• Carbon dioxide is not used for
arch or cerebral arteriography.

INTRAVASCULAR ULTRASOUND
• The use of catheter-based intravascular ultrasound has been
increased with improvements in highfrequency smaller
transducers.
• It provides a transverse, 360-degree image of the lumen of
the vessel throughout its length & about the wall anatomy.
• It has been used in peripheral interventions for opening
chronic total occlusions and in the endovascular treatment of
aortic dissection.

INTRAVASCULAR ULTRASOUND
DISADVANTAGE:
• Increases the length of procedures.
• Expensive.

PLETHYSMOGRAPHY
• Method of measuring blood flow in limbs.
• Venous outflow from a limb is briefly arrested while
allowing arterial inflow to measure the volume change in
the limb which is proportional to the arterial inflow.
• The pulse volume recording, i.e. the change in the volume
of an extremity between systole and diastole is a reflection
of the pulsatile blood flow.

PLETHYSMOGRAPHY
• Three systems-
• 1.Water-filled volume recorder,
• 2. Air-filled volume recorder
• 3. Mercury in a silastic strain gauze.
• Segmental plethysmography has
been introduced by placing venous
occlusion cuffs around the thigh, calf
and ankle.
• The cuffs are inflated to 65 mm Hg and
the pulsation is the quantitative measure
of the arterial diseases.

PHOTOPLETHYSMOGRAPHY
• It is a measurement of
the blood in the
cutaneous
microcirculation by
detecting the reflection
of infra-red light.

TRANSCUTANEOUS OXIMETRY
• It is the measurement of
intracutaneous oxygen
tension (PO2) by placing the
probe over the skin surface.
• Normal- 40–70 mmHg.
• Less than 40 mmHg -
inadequate wound healing.
• Level below 1O mmHg -
critical ischaemia with
complete failure of wound
healing.

INVESTIGATIONS
• Ultrasound abdomen –aneurysm & aorta and its anatomical
changes,other vessels in the abdomenother organs.
• Treadmill test/ECG/echocradiography to assess
cardiac&coronary status.
• Brown's vasomotor index:It is to assess the degree of
vasospasm.
• Rise of skin temp - Rise of mouth temp
Rise of mouth temperature
.

CLINICAL TESTS
• Buerger’s vascular angle:
• The patient is asked to raise his legs
one after the other keeping the knees
straight.
• The legs of a normal individual
remain pink even if they are raised to
90°.
• In ischaemic limb- pallor & the veins
will be empty and 'guttered'.
• The angle at which such pallor
appears is called 'Buerger's angle' or
the 'Vascular angle'.
• Vascular angle of less than 30° -
severe ischaemia.

CLINICAL TESTS
• capillary filling time:
• After elevating the legs, the patient
is asked to sit up and hang his legs
down
• A normal leg -pink (as it was during
elevated position)
• An ischaemic leg -pallor when
elevated and gradually become
pink in horizontal position.

CLINICAL TESTS
• This change of colour takes place slowly and is called 'the
capillary filling time'.
• In severe ischaemia 20 to 30 seconds to become pink.
• Then the ischaemic limb again changes colour and becomes
purple-red quickly.
• This is due to the filling of the dilated skin capillaries with
deoxygenated blood.

CLINICAL TESTS
• Venous refilling:
• After keeping the limb elevated then
laid flat on the bed.
• Normal refilling of the veins- within 5
seconds.
• In ischaemic limb -delayed.
• If a normal limb is raised to about 90°
there will be gradual collapse or
guttering of the veins'.
• In ischaemic limb- the veins are
collapsed as soon as it is lifted to even
10° above the horizontal level.

CLINICAL TESTS
• Delayed capillary filling: Blanched nails or pulp of fingers,
on pressure, will show delay in refilling (to turn pink) after
release of pressure.
• Disappearing pulse:
• The patient is exercised to the point of claudication, which
may unmask the effect of an arterial obstruction by
disappearance of the pulse.
• The pulse will reappear after a minute or two after rest.
• The exercise produces vasodilatation below the obstructing
lesion and the arterial inflow cannot keep pace with the
increasing vascular space and the pulse disappears.

CLINICAL TESTS
• Crossed leg test (Fuchsig 's test):
• Done for the patency of the popliteal
artery.
• Oscillatory movements of the foot
which occur synchronously with the
pulse of the popliteal artery.
• If the popliteal artery is blocked, this
oscillatory movement will be absent.

CLINICAL TESTS
• Cold and warm water test:
• To provoke the arteriospasm in case of Raynaud's disease.
• Pt is asked to put hand into ice-cold water hand becomes
white.
• patient is asked to dip her hand in warm water hand will
become blue due to cyanotic congestion.

CLINICAL TESTS
• Elevated arms test: Thoracic outlet
syndrome.
• Fatigue and pain in forearm
muscles,
• Paraesthesia of the forearm
• Tingling and numbness sensation in
the fingers

CLINICAL TESTS
• Allen’s test:
• Patency of radial and ulnar
arteries.
• If the radial artery is blocked the
colour -remains white.
• If it is patent - palm assumes
normal colour.

CLINICAL TESTS
• Branham’s Sign or Nicoladonis
sign:
• Arteriovenous fistula
• Pressure on the artery proximal to
the fistula will cause:
• Reduction in size of swelling
• Disappearance of bruit
• Fall in pulse rate.

CLINICAL TESTS
• Costoclavicular compression manoeuvre
(Falconer test):
• When the patient throws shoulders backwards
and downwards as an exaggerated military
position.
compress the subclavian artery between the
clavicle and the first rib
leading to reduction or disappearance of the
radial pulse.

CLINICAL TESTS
• Hyperabduction
manoeuvre ( Wright
test):
• When affected arm is
hyperabducted, radial
pulse becomes absent
or feeble due to
compression of artery by
pectoralis minor tendon.

CLINICAL TESTS
• Adson’s test - cervical rib &
scalenus anticus syndrome
• Onsitting -the radial pulse is felt.
• Patient is then asked to take a
deep breath and turn the face to
same side.
• If the radial pulse disappears or
become feeble it signifies cervical
rib or scalenus anticus
syndrome.

CLINICAL TESTS
• Reactive hyperaemia test:
• severity of arterial ischaemia.
• Inflating a sphygmomanometer cuff
around the limb to 250 mm Hg for
5minutes.
• The cuff is deflated and the time of
appearance of red flush in the skin is
noticed.
• Normal limb - 1 to 2 seconds
• Arterial occlusive disease- delayed
• Severely ischaemic limb-it may never
appear.

LIMB ISCHAEMIA
• Functional ischaemia & Critical ischaemia
• Functional Limb lschaemia:
• Flow of blood is normal when limbs are at rest.
• It will not be increased during exercise.
• It presents as claudication.
• It is defined as, "Muscle discomfort in the limb
reproducibly produced by exercise and relieved by rest
within 10 minutes. "

LIMB ISCHAEMIA
• Critical Limb lschaemia:
• Two criteria:
• 1. Recurring rest pain -persists
>2 weeks, requiring regular
analgesics with ankle systolic
pressure of < 50 mmHg or toe
systolic pressure < 30 mmHg &
ABPI < 0.5.
• 2. Ulceration or gangrene of the
foot or toes with similar
hemodynamic parameters.

LIMB ISCHAEMIA
• Pre-gangrene: It is the changes in
tissue which indicates that blood
supply is inadequate to keep the
tissues alive.
• Rest pain,
• Colour changes,
• Oedema,
• Hyperaesthesia with or without
ischaemic ulceration.

LIMB ISCHAEMIA
• Gangrene: It is macroscopic death of
tissue in situ with putrefaction.
• SIGNS OF GANGRENE
• 1. Change of colour-pale, bluish
purple and finally black.
• 2. Loss of temperature
• 3. Loss of sensation
• 4. Loss of pulsation
• 5. Loss of function

LIMB ISCHAEMIA
• Dry gangrene- gradual
occlusion of arterial circulation
• Affected part -dry, shrivelled,
hard, mummified & discoloured
from disintegration of
haemoglobin.
• There is clear line of
demarcation and is localized.

LIMB ISCHAEMIA
• Wet gangrene: It is due to both
arterial and venous block along with
superadded infection and
putrefaction.
• Affected part - oedematous with
blebs.
• It spreads proximally and there is no
clear line of demarcation.
• It spreads faster.

LIMB ISCHAEMIA
• Line of demarcation:
• It is a line between viable and
dying tissue indicated by a band
of hyperaemia.
• It also indicates that disease is
getting localised.
• Final separation between
healthy and gangrenous tissue
occurs by development of a
layer of granulation tissue in
between.
• It is hyperaesthetic due to
ischaemia and irritation of
exposed nerve endings.

TREATMENT PLAN
• General measures:
• Stopping smoking
• Supervised exercises
• Regular controlled walk,
• Diet
• Care of limbs.
• Control of hypertension&diabetes
• Diet-weight reduction in obese patients.

TREATMENT PLAN
• Pharmacological therapy:
• Antiplatelet agents-aspirin (75–300 mg)daily-Clopidogrel
• Pentoxifylline 400–800 mg tablet 3 times daily -alters the
blood viscosity (useful in intermittent claudication)
• Naftidrofuryl oxalate (Praxilene)—May alter the tissue
metabolism and increase the claudication distance
• Prostaglandin E1 (Alpostin)—Useful in critical limb ischemia
in doses of 100 mg daily (over 10 hrs) for five days monthly ×
6 months.

THE ROLE OF SURGERY IN PERIPHERAL
VASCULAR DISEASE
• Can be divided into 3 broad groups.
• Direct arterial surgery
• Percutaneous transluminal angioplasty and stenting
• Endarterectomy
• Bypass graft.
• Lumbar sympathectomy
• Amputations.

INDICATIONS FOR DIRECT ARTERIAL
SURGERY
• Critical limb ischemia
• Severe intermittent claudication
• To lower the level of the amputation.

TRANSLUMINAL ANGIOPLASTY AND
STENTING:
• By inserting a balloon catheter
into an artery and inflating it
within a narrowed or blocked
area.
• Suitable for patients with
claudication, rest pain or tissue
necrosis.
• Involves percutaneous femoral
artery puncture under local
anaesthetic followed by insertion
of a guidewire under
fluoroscopic control.

STENTING
• A balloon catheter is then inserted
over the guidewire and positioned
within the lesion.
• The balloon is then inflated at high
pressure for approximately 1
minute and deflated.
• Dilation of the lesion is confirmed
by performing an angiogram.
• It has proved very successful in
dilating the iliac and femoropopliteal
segments.

STENTING
• Long occlusions -subintimal
angioplasty where the
guidewire crosses the
lesion in the subintimal
space (in the arterial wall)
and a new lumen is created
by inflation of the balloon.
• Complications include
failure, haematoma,
bleeding,thrombosis and
distal embolisation

STENTING
• Metal stent hold the lumen if the
vessels fail to stay adequately
dilated.
• Introduced on a balloon catheter
& expanded by balloon inflation.
• Self-expanding stent may be
used.

STENTING

BYPASS GRAFT
• A native vein (usually saphenous vein) or a prosthetic
material is used for bypassing the obstruction in the vessel.
• The bypass procedures can be classified as:
• Anatomic -femoropopliteal bypass
• Extra anatomic-femoro-femoral crossover graft.
-iliofemoral crossover graft
- Axillobifemoral.

OPERATIONS FOR ARTERIAL STENOSIS
• Site of disease and type of
operation:
• Aortoiliac occlusion - aortofemoral
bypass using a Dacrongraft.
• In unfit patients -Axillofemoral
bypass is an alternative.
• If only one iliac system is occluded-
iliofemoral or femorofemoral
crossover graft .
• Superficial femoral artery disease –
femoropopliteal bypass.

• Bilateral renal
arteries& left renal vein
has been divided.

• Exposure of the
right common
femoral, profunda,
and superficial
femoral arteries

• End-to-side aortic
anastomosis using PTFE
bifurcated graft.

• End-to-side
profunda
anastomosis.

OPERATIONS FOR ARTERIAL
STENOSIS
• Long-term graft patency -the quality of inflow &outflow,
graft length and the conduit used for the bypass.
• Autogenous saphenous vein gives the best results & can
be used reversed after valve disruption.
• If the long saphenous vein is not available -short saphenous
or arm veins may be used.
• If no vein is available, - prosthetic polytetrafluoroethylene
(PTFE)

STENOSIS
• Lower anastomosis using a
small collar of vein (Miller cuff)
between the PTFE and the
recipient artery, -improve
patency.
• Isolated common femoral
artery or profunda disease -
endarterectomy and patch
(vein or prosthetic) or a short
bypass in the groin. Completion angiogram of femoropopliteal
bypass graft (with Miller cuff).

STENOSIS
• Critical leg ischaemia- the occlusion extends beyond the
popliteal artery into the tibial vessels.
• Limb salvage can be attempted with a femorodistal bypass .
• The risk of early graft failure with limb loss is high .
• These long bypasses are only appropriate for limb salvage.

STENOSIS
• Aortofemoral bypass-the aorta is approached through a
midline or transverse abdominal incision.
• The common femoral arteries and their branches are
exposed through vertical groin incisions.
• The small bowel is retracted to the right and the posterior
peritoneum opened.
• Retroperitoneal tunnels are made from the aorta to the
groins.

STENOSIS

STENOSIS
• Profundaplasty
• Common femoral artery and its branches
are exposed.
• After giving heparin IV and clamping the
vessel
• An incision is made into the common
femoral artery and carried down into the
profunda dividing the stenotic profunda
origin.
• The arteriotomy is then closed with a
patch of vein to widen the narrowed

STENOSIS
• For femoropopliteal bypass,-
popliteal artery above or below
the knee is exposed through a
medial incision.
• The common femoral artery is
exposed at groin level.
• The long saphenous vein may be
used in two different ways.
• First, it may be excised, its
tributaries tied, and the vein used
in a reversed fashion so the
valves do not obstruct the flow of

STENOSIS
• Alternatively, it may be left in place (in situ)
and the valves disrupted with a
valvulotome.
• The graft is sutured to the femoral artery -
proximally &popliteal artery- distally.
• Femorodistal bypass -distal anastomosis
to a tibial vessel.
• Using long saphenous vein preferably in
situ.
• No suitable vein is available, prosthetic
material (usually PTFE) may be used, with
or without a small vein collar (Miller cuff) at

STENOSIS
• A femorofemoral crossover
graft - tunnelling a prosthetic
graft subcutaneously above
the pubis between the
groins.
• An axillofemoral graft -
tunnelled subcutaneously
between the axillary artery
proximally, to reach one or
both of the femoral arteries

RESULTS OF OPERATION
• Long-term results of aortoiliac reconstructive surgery are
good.
• Femoropopliteal surgery is less successful.
• Immediate postoperative success for vein bypass exceeds 90
per cent, the five-year patency - 60 per cent.
• PTFE bypass yields poorer results than vein bypass, with
five-year success rates of less than 50 per cent.
• Surgery can ensure limb salvage in patients who are
generally debilitated and whose expected lifespan is limited.
• long-term patency is less important.

LUMBAR SYMPATHECTOMY
• Done if there is no chance for direct arterial surgery or
angioplasty.
• It has no role in the treatment of intermittent claudication.
• The indications are:
• Nonhealing ischemic ulcers
• Ischemic rest pain
• Vasospastic conditions
• Hyperhidrosis
• Causalgia.

• In lumbar sympathectomy the 2nd, 3rd &
4th lumbar sympathetic ganglia are
removed.
• The removal of bilateral first lumbar
ganglia will result in retrograde
ejaculation.
• Done either by open or laparoscopic
method.
• Open method - extra-peritoneal approach
using a loin incision.
• The sympathetic trunk lies on the side of
the bodies of the lumbar vertebrae on the

• Care is taken not to mistake and remove small lymphnodes
and tendinous strip of psoas minor.
• It is also important to avoid the genitofemoral nerve.

CHEMICAL SYMPATHECTOMY
• Under radiographic fluoroscopic
control with the patient in the lateral
position.
• Under local anesthesia a long spinal
needle is inserted to seek the side of
vertebral body to reach the lumbar
sympathetic chain.
• 5 mL of phenol in water (1:16) is
injected besides body of 2nd & 4th
lumbar vertebrae after confirming
the needle position by injecting
contrast agent.

CHEMICAL SYMPATHECTOMY
• It is carried out in two sites beside the bodies of second to
fourth lumbar vertebrae.
• It is important to avoid aorta, IVC and ureters.
• It is contraindicated in patients taking anticoagulants.

ROLE OF AMPUTATION
• Amputation is inevitable when the arterial surgery and
conservative treatment fail.
• The commonly performed amputations are:
• 1. Ray amputations for gangrene of toes
• 2. Transmetatarsal for fore foot gangrene
• 3. Below knee (BK) amputation-the gangrene is limited to foot
• 4. AK (above knee) amputation-the gangrene is approaching
to the leg.

OTHER SITES OF ATHEROMATOUS
OCCLUSIVE DISEASE
• Carotid stenosis (at the carotid bifurcation in the neck) may
cause transient ischaemic attacks.
• Cause unilateral motor or sensory loss in the arm, leg or face,
transient blindness (amaurosis fugax) or speech impairment.
• Distal embolisation of platelet thrombi -atheromatous plaque
into cerebral circulation.
• Stenosis (>70 per cent) -carotid endarterectomy .

CAROTID ENDARTERECTOMY
• The occluded intima and a part of the media are removed by
coring them out through an artificial plane created in the media.
• Indications for carotid endarterectomy in symptomatic
patients:
• Ipsilateral amaurosis fugax
• Contralateral facial paralysis or paraesthesia
• Arm/leg paralysis or paraesthesia
• Hemianopia
• Dysphasia
• Sensory or visual inattention/neglect

CAROTID ENDARTERECTOMY
Involves clamping the vessels
An arteriotomy in the common carotid artery continued up into the
internal carotid artery through the diseased segment.
Removal of the occlusive disease (endarterectomy)
Closure of the arteriotomy, often with a patch.
Temporary shunt is used to maintain cerebral blood flow while the
carotid system is clamped.

OCCLUSIVE DISEASE
• Subclavian artery stenosis -cause claudication in the arm or
digital ischaemia from distal embolisation.
• Treated - angioplasty or surgical bypass.
• Subclavian artery lesions - a cervical rib which should be
removed during arterial repair.
• Subclavian steal syndrome - occur if the first part of the
subclavian artery is occluded.

OCCLUSIVE DISEASE
• Arm exercise causes syncope because of reversed flow in the
vertebral artery leading to cerebral ischaemia.
• Treatment-Angioplasty.
• Mesenteric artery occlusive disease -pain after eating
(intestinal angina) &weight loss.
• Two of the three enteric vessels (coeliac axis, superior
mesenteric artery, inferior mesenteric artery) must be
occluded to produce symptoms

OCCLUSIVE DISEASE
• Renal artery stenosis -hypertension and eventual renal
failure.
• To improve renal blood flow with PTA or surgery.
• The mainstay of treatment is drugs to control hypertension,
diabetes, etc.

NON ATHEROSCLEROTIC
ARTERIOPATHIES
• Raynaud Syndrome
• Buerger Disease
• Vasculitis-
• Large-Vessel Vasculitis-Giant cell arteritis (temporal
arteritis), Takayasu disease.
• Medium-Vessel Vasculitis-Polyarterits nodosa, Kawasaki
disease. Behçet disease, Cogan syndrome.
• Small-Vessel Vasculitis-Wegener granulomatosis,
microscopic polyangiitis, and Churg-Strauss syndrome

THROMBOANGIITIS OBLITERANS
(BUERGER’S DISEASE)
• Middle-aged males- in smokers & tobacco users.
• Nonatherosclerotic inflammatory disorder involving medium
sized and distal vessels with cell mediated sensitivity to type I
and type 111 collagen.

• Smoke contains carbon monoxide and nicotinic acid
Carboxyhaemoglobin
• Causes initially vasospasm and hyperplasia of intima
• Thrombosis and so obliteration of vessels occur,commonly
medium-sized vessels are involved.

Panarteritis is common involvement is segmental
Eventually artery, vein and nerve are together involved
Nerve involvement causes rest pain
Patient presents with features of ischaemia in the limb

Once blockage occurs, plenty of collaterals open up - on the
site of blockage either around knee joint or around buttock
Once collaterals open up, through blood supply is -maintained
to the ischaemic area
compensatory peripheral vascular disease

If patient continues to smoke, disease progresses into the
collaterals, blocking them eventually, leading to severe
ischaemia
decompensatory peripheral vascular disease.
• It is presently called as critical limb ischaemia.
• It causes restpain, ulceration, gangrene.

• Shianoya's criteria Buerger's disease
• Tobacco use,Only in males
• Disease starts before 45 years
• Distal extremity involved first without embolic or
atherosclerotic features
• Absence of diabetes mellitus or hyperlipidaemia
• With or without thrombophlebitis

• Classification of TAO
• Type I: Upper limb TAO- rare.
• Type II: Involving legs& feet-crural/infrapopliteal.
• Type 111: Femoropopliteal.
• Type IV: Aortoiliofemoral.
• Type V: Generalised.

• Investigations:
• Hb, Blood sugar, ABPI.
• Arterial Doppler and Duplex scan (Doppler+ B mode US).
• CT angiogram - intervention is planned.
• Transfemoral retrograde angiogram-Shows blockage-sites,
extent, and severity.

• Cork screw appearance of the vessel due to dilatation of vasa
vasorum.
• Inverted tree/spider leg collaterals.
• Severe vasospasm causing corrugated/rippled artery.
• Distal run of/is amount of dye filling in the main vessel distal
to the obstruction through collaterals.
• If distal run off is good - ischaemia is compensated.
• If distal run off is poor - ischaemia is decompensated.

• Transbrachial angiogram:
• If femorals are not felt- transbrachial angiogram (through left
side brachial artery-left subclavian artery-and so to
descending aorta) should be done.
• Ultrasound abdomen to see abdominal aorta for block or
aneurysm.
• Vein, artery, nerve biopsy.

TREATMENT
• Stop smoking
• Drugs:Low dose of aspirin 75 mg once a day-antithrombin
activity.
• Prostacyclins, ticlopidine, praxilene, carnitine.
• Clopidogrel 75 mg; atorvastatin 10 mg; parvostatin 40 mg;
cilostazole100 mg bid- is a phosphodiesterase inhibitor -
improves circulation .

TREATMENT
• Analgesics, often sedatives, antilipid drugs like atorvastatin may
be needed.
• Injection of xanthine nocotinate 3000 mg from day 1 to 9000 mg
on day 5 - promote ulcer healing- to increase claudication
distance.
• Low molecular dextran may be also used.
• Naftidofuryl is useful in intermittent claudication-alters the tissue
metabolism.
• Gene Therapy: Intramuscular injection of vascular endothelial
growth factor (VEGF) - endothelial cell mitogen
angiogenesis.

REFERENCES
• The effect of valvulotomy on the flow rate through the saphenous vein graft: Clinical
implications Presented at the Third Annual Meeting of the Western Vascular Society,
Monterey, Calif., Jan. 28-31, 1988. Author links open overlay panelAlbert
K.ChinMDDavid N.MayerBARobert K.GoldmanBA *Joel
A.LermanBA **CorneliusOlcottIVMDThomas J.FogartyMD
• Surgical Intervention for Peripheral Arterial Disease :Shant M. Vartanian, Michael
S. Conte

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