arterial disease indetail

1. ARTERIAL DISORDERS
Dr.V.Prithvinathan. MBBS., M.S.(Gen. Surgery)
Department Of General Surgery

3. Arterial disorders
Arterial stenosis and occlusion.
Aneursym.
Arteritis and vasospastic conditions
TAO(Buergur’s disease)
Gangrene

4. Arterial stenosis and occlusion
Cause and effect
Atherosclerosis – Degenerative condition large and medium Artery ,intima - plaque
Thromboembolism
Traumatic
Chronic-collateral circulation
Stenosis or occlusion produces symptoms and signs that are related to the organ supplied by the artery:
e.g. 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.

5. Features of Arterial Occlusion
 Dependent rubor or sunset foot

6. Colour change with elevation and
dependency

7. Features of arterial occlusion of lower limbs
Intermittent claudication
It is a cramp-like pain felt in the muscles that is:
brought on by walking.
not present on taking the first step (unlike osteoarthrosis).
relieved by standing still (unlike lumbar intervertebral disc nerve
`compression)

11. Rest pain.
Coldness, numbness, paraesthesia and colour changes.
Ulceration and gangrene.
Temperature, sensation and movement. Gangrene
Colour changes

12. Arterial pulsation
Pulsation distal to an arterial occlusion is usually absent.
Stenosis, or occlusion with a highly developed collateral circulation, may allow
distal pulses to be normal to palpation. In this case, the sign of the ‘disappearing
pulse’ may prove useful. After exercise to the point of claudication a previously
palpable pulse disappears, reappearing after rest. The explanation is that exercise
produces vasodilatation below the obstructing lesion and the arterial inflow cannot
keep pace with the increasing vascular space; pressure falls and the pulse
disappears.

13. LOCAL EXAMINATION
INSPECTION
1)CHANGE IN COLOUR is the most noticeable feature of an ischaemic limb.
• To detect minor change in the colour the clinician should put the affected limb and its
fellow side by side.
• Marked pallor is a remarkable feature of sudden arterial obstruction as seen in case of
embolism or in spasm of the arterioles in Raynaud's disease.
• Congestion and purple-blue cyanosed appearance are the characteristic features of severe
ischaemia and pregangrenous stage.
• As soon as the limb is elevated it becomes pallor.

14. 2)SIGNS OF ISCHEMIA While examining a case of arterial
insufficiency, one must know the signs of ischaemia.
These are :
• 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 and
• Minor ulceration in the pressure areas such as heel, malleoli, ball of
the foot, tips of the toes etc.

16. 3)BUERGERS POSTURAL TEST.
• In a normal person legs can be kept elevated at 90 degrees angle without appearance of any
pallor.
• Depending on the degree of ischemia pallor may appear on elevation of the limb to different
angles.
• This test is not very helpful in dark skinned individual as pallor is difficult to appreciate in dark
skin individual.
• Raise legs gradually and keep at 30° angle to the bed for 2 minutes and look for pallor.
• • If no pallor, raise limb to 45°/60°/90° and look for pallor
• • Mention at what level pallor appears. This angle is called Buerger’s angle of circulatory
insufficiency

18. 4- CAPILLARY FILLING TIME .
• After elevating the legs, the patient is asked to sit up and
hang his legs down by the side of the table.
• But an ischaemic leg will first become pallor when
elevated and gradually become pink in horizontal
position.
• This change of colour takes place slowly and is called 'the
capillary filling time’ .
• In severe ischaemia it takes about 20 to 30 seconds to
become pink.

19. 5)Venous refilling.
• Keep the limb elevated for a while and then laid flat on the bed, there
will be normal refilling of the veins within 5 seconds.
• In ischaemic limb it will be delayed.
• A normal limb is raised to about 90° there will be gradual collapse or
'guttering of the veins’.
• In ischaemic limb the veins are seen collapsed either in the horizontal
position or as soon as it is lifted to even 10° above the horizontal level.

21. Gangrene
• Site and extent of gangrene
• Type (dry or moist)
• Color of the gangrenous area
• Line of demarcation—note the level and
depth of demarcation—whether skin, muscle
or bone deep
• Observe the limb above the gangrenous area
—whether pale, congested or edematous
• Look at the areas of pressure points —heel,
malleoli, ball of the foot and tip of the toes.

22. PALPATION
1)Skin temperature.
• Start palpating from the foot and find at
what level temperature becomes normal
• Comparing with the normal skin
temperature of the patient.
2)Capillary refilling.
• Test for capillary refilling—press the
nail bed/or the pulp/and then
release.
• Look for the rapidity of capillary
refilling

23. 3)Venous refilling.
(Harvey's sign)
Empty a segment of
vein with two fingers
and the distal fingers
released
look for the timing of
venous refilling.

24. 4)Crossed leg test (Fuchsig’s
test).-
• Crossed leg test (Fuchsig’s test): This is an
indirect test for assessment of presence of
popliteal pulse.
• Method: Patient sits on a chair with the legs
crossed one knee resting on the other—divert
attention—look for oscillatory movement of
upper leg
• If oscillatory movement is seen then popliteal
pulse is present
• If oscillatory movement is absent then
popliteal pulse is absent

25. 5)Cold and warm water test.
• Done to provoke the
arteriospasm in case of
Raynaud's disease
• Patient is asked to put her
hand into ice-cold water.
• The hand becomes white.
• The patient is then asked to
dip her hand in warm water.
• The hand will become blue
due to cyanotic congestion.

26. Pulsations Area to be examined
• Dorsalis pedis artery Proximal
intermetatarsal space on the
dorsum of the foot, lateral to the
tendon of extensor hallucis longus
The pulse is felt against the
navicular bone and base of 1st
metatarsal. Absent in 10% of
populations
• Posterior tibial artery Pulsation is
felt against the medial aspect of
the calcaneum, or against the back
of the medialmalleolus Peroneal
artery 1cm medial to the lateral
malleolus
Dorsalis pedis artery
Posterior tibial artery

27. Anterior tibial artery
Anterior tibial artery Midway between the malleoli against the lower end of the tibia just
above the level of ankle at the head of the talus

28. • Popliteal artery
• Three methods:
• 1. Flex the knee to 135° with the heel resting on the couch. The thumb of the
examiner is on the tibial tuberosity and the fingers over the lower part of the
popliteal fossa. Press the neuro vascularbundle against the posterior surface of
the tibia (in the upper part of popliteal fossa it is difficult to palpate the artery
because it is deep between the condyles of the femur)
• 2. The most reliable method is perhaps the most inconvenient. Here the patient
is examined inthe prone position. Flex the knee to relax the popliteal fossa and
feel the artery with fingertips of both hands in the lower part of the fossa over
the posterior surface of the upper end of tibia(medial tibial condyle)
• 3. With the leg straight, place one hand of the examiner around the knee with
the fingertips on the midline of popliteal fossa and hyperextend the knee
against this hand and the couch with the other hand

29. Popliteal artery

30. Femoral artery
At the groin mid way between the symphysis pubis and the anterior
superior iliac spine against the neck of femur

31. Radial artery
It is felt at the wrist in front of the lower end of the radius laterally, lateral to the
flexor carpi radialis tendon

32. Brachial artery
Brachial artery Is felt against the lower part of humerus, medial to the
biceps brachii tendon

33. Axillary artery
Axillary artery Felt in the apex of the axilla against the neck
of the humerus

34. Subclavian artery
Subclavian artery Felt against the first rib in the middle of supraclavicular
fossa

35. Common carotid artery
Common carotid artery Felt medial to the sternomastoid muscle at the level of
the thyroid cartilage against the carotid tubercle (Chassaigne tubercle) of the 6th
cervical vertebra Facial artery Felt against the body of the mandible where the
masseter is attached

36. Superficial temporal artery
Superficial temporal artery Felt in front of the tragus of the ear against
the temporal bone.

37. Arterial bruit
A bruit indicates turbulence, suggesting stenosis, and is conducted
distally.
Venous refilling
The limb is elevated for 30 s and then laid flat. Normal venous
refilling occurs within seconds and slow refilling indicates arterial
insufficiency.
Fast refilling and varicose veins suggest an arteriovenous fistula

38. Relationship of clinical findings to site of disease
Aortoiliac obstruction Claudication in both buttocks, thighs and calves.
Femoral and distal pulses absent in both limbs
Bruit over aortoiliac region
Impotence common (Leriche)
Iliac obstruction Unilateral claudication in the thigh, calf and buttock
Bruit over the iliac region
Unilateral absence of femoral and distal pulses
Femoro popliteal obstruction Unilateral claudication in the calf
Femoral pulse palpable with absent
unilateral distal pulses
Distal obstruction Femoral and popliteal pulses palpable
Ankle pulses absent
Claudication in calf and foot

40. Trophic changes

41. Investigations
General investigations
Urine routine
Blood sugar
Blood urea and serum creatinie
Lipid profile
CBC
ECG
X-ray chest
Echocardiogram

42. • Doppler ultra sound
• Ankle brachial pressure index (ABPI)-(Cornerstone of
diagnosis)
• Duplex imaging
• Arteriography – if intervention is planned
• DSA
• Magnetic resonance angiogram (MRA)
• Plethysmography
• Transcutaneous oximetry

44. Doppler ultrasound blood flow detection
A hand-held Doppler ultrasound probe is most useful in the assessment of
occlusive arterial disease.
An ultrasound signal is transmitted from the probe at an artery and the reflected
beam is picked up by a receiver within the probe.
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 cells.
The frequency change may be converted to
an audible signal.
Hand-held Doppler probe and
sphygmomanometer used to determine
systolic pressure in the dorsalis pedis
artery, as part of assessing the ankle–
brachial pressure index.

45. Simple hand-held Doppler
ultrasound probe.
The ankle–brachial pressure index (ABPI) is the
ratio of systolic pressure at the ankle to that in
the arm.
Resting ABPI is normally about 1.0; values below
0.9 indicate some degree of arterial obstruction
and less than 0.3 suggests imminent necrosis
(Critical limb ischaemia).
Doppler ultrasound equipment can be used as a
very sensitive type of stethescope in conjunction
with a sphygmomanometer to assess systolic
blood pressure in small vessels.

46. Duplex imaging
This is a major investigative technique in vascular disease.
A duplex scanner uses B-mode ultrasound to provide an image of vessels.
A second type of ultrasound, namely Doppler ultrasound, is then used to insonate
the imaged vessels and the Doppler shift obtained is analysed by a computer in the
duplex scanner.
Such shifts can give detailed knowledge of vessel blood flow and turbulence.
Many scanners have colour coding, which allows visualisation of blood flow on the
image

47. Angiography (synonym: arteriography)
Angiography is only appropriate if intervention is being contemplated. Even then,
it is often advisable to have a duplex scan first.
Classical angiography involves the injection of a radio-opaque solution into the
arterial tree, generally by a retrograde percutaneous catheter method (Seldinger
technique) usually involving the femoral artery.
Hazards include thrombosis, arterial dissection, haematoma, renal dysfunction
and allergic reaction.
Arterial occlusion just above the knee
Good collateral circulation

48. ANGIOGRAPHIC INFORMATION
1. Site of the occlusion
2. Extent of the occlusion
3. Nature of occlusion
4. Run in – patency of the vessel proximal to the
occlusion
5. Distal run off – patency of the vessel distal to the
occlusion
6. State of collateral circulation.

49. Seldinger needle and guidewire
for introducing an arterial
catheter.

50. Magnetic resonace angiography is a noninvasive investigation. It
avoids arterial puncture and ionising radiation.
CT angiography is another recently introduced method.
MR angiogram showing a tight stenosis at the
midpoint of the left common iliac artery.

51. Non-surgical management of arterial stenosis or occlusion
General
1) Stopping smoking is essential.
2) Exercise in moderation (To improve the collateral circulation).
3) Low fat diet .
4) Weight reduction.
5) Care of the ischaemic foot (To keep the foot clean and dry and
careful pairing of the nails).

53. Drugs
1) To control diabetes and hypertension.
2) Pravastatin 40mg/day.
3) Clopidrogel 75mg/day.
4) Aspirin 75mg/day.

54. Transluminal angioplasty and stenting
A baloon catheter is inserted and inflated within a narrowed or
blocked area.
This is usually done percutaneously in the radiology department.
Narrowed superficial femoral artery before
and after PTA.

55. PTA has proved very successful in dilating the iliac arteries and to a
lesser extent, the arteries of the leg itself.
A stent is used to hold the lumen open.
Catheter balloon deflated
Balloon inflated

56. Operations for arterial stenosis or occlusion
Aortoiliac occlusion responds well to aortofemoral bypass
Today PTA is a better alternative

57. Superficial femoral artery occlusive disease
If the lesion is short PTA is a reasonable option.
If the lesion is not favourable for PTA a femoropopliteal bypass may be
considered

58. Prosthetic materials
Dacron is the favoured material for aortoiliac work.
For bypass in the femoropopliteal region, an autogenous vein or PTFE
is used.

59. Acute arterial occlusion
Embolic occlusion
An embolus is a body that is foreign to the blood stream and which
may become lodged in a vessel and cause obstruction.
It is often a thrombus that has become detached from the heart or a
more proximal vessel.

61. Emboli may lodge in any organ and cause ischaemic symptoms
Leg : Pain,pallor, paresis, pulselessness and paraesthesia.
Brain : The middle cerebral artery is commonly affected, resulting in
major or minor stroke.
Retina: Amaurosis fugax is fleeting blindness caused by embolus in the
central retinal artery.
Mesenteric vessels : Gangrene of the corresponding loop of intestine.

62. Clinical features
Embolic arterial occlusion is an emergency that requires immediate
treatment.
The leg is affected with pain, pallor, paresis, loss of pulsation and
paraesthesia.
The limb is cold and toes cannot be moved.
Pulses are absent distally.

63. Treatment
Immediate administration of 5000 U of heparin intravenously can
reduce extension of thrombus.
Analgesics to relieve pain.
Embolectomy.

64. Mesenteric artery occlusion
Acute mesenteric artery occlusion may be either thrombotic or
embolic.
Thrombotic occlusion follows progressive narrowing so the symptoms
also tend to be progressive with :
Weight loss
Abdominal pain
Leucocytosis
Diarrhoea
Hypovolaemia

65. Investigation
Arteriography
Abrupt cutoff of
proximal superior
mesenteric artery due to
embolus

66. Treatment
PTA or surgical bypass if the bowel has not already infarcted.
Embolic occlusion results in sudden severe abdominal pain with
bowel emptying (vomiting and diarrhoea).
Angiography and embolectomy usually of the superior mesenteric
artery or bypass surgery can reduce the high mortality rate in these
patients.

67. Air embolism
Air may accidentally injected into the venous circulation or sucked into
an open vein.
Venous air embolism is a rare complication of neck surgery if a large
vein is inadvertently opened.
If a large volume of air is allowed to reach the right side of the heart it
may form an air lock within the pulmonary artery and cause right
heart failure.

68. Treatment
Patient should be placed in Trendelenburg position to encourage the
air to enter the veins in the lower parts of the body.
Oxygen should be admistered.
In extreme cases air may be aspirated from the heart through a
needle introduced below the left costal margin