This topic is under the Chapter Arterial Disorders. The MBBS Students should know about TAO & RP mostly because they cause Upper Limb Ischemia.

1. Prof. U. Murali.
Arteritis
&
Vasospastic Conditions

2. Learning Objectives
◼ Enumerate the causes of limb ischemia.
◼ Mention the risk factors & pathogenesis of TAO.
◼ Write the Classification & Criteria of TAO.
◼ Describe the C/F & Management of TAO.
◼ Differentiate between R. phenomenon | disease & syndrome.
◼ Explain the Surgical anatomy of Thoracic outlet.
◼ Outline the causes, C/F & management of TOS.
◼ Discuss about – Takayasu & Temporal Arteritis.

3. A D - Include
Major arterial (occlusive) Diseases
Peripheral arterial (occlusive) Diseases
Aorta / Carotids / Iliac arteries
Limb & Distal vessels – LL / UL

4. Arterial Diseases – Types
ACUTE
◼ Trauma / Injury
◼ Spasm – Intra-arterial inj.
◼ Embolism / Thrombosis
CHRONIC
◼ Atherosclerosis
◼ TAO
◼ Raynaud’s Disease
◼ Arteritis / Vasculitis
◼ Radiation

5. Limb Ischemia - Causes
◼ Atherosclerosis
◼ Embolism
◼ Arteriopathies – TAO /
Raynaud’s & Takayasu’s D.
◼ Diabetes
◼ Scleroderma
◼ Physical agents – trauma /
tourniquet / radiation injury

6. T A O
Prof. U.Murali.

7. TAO – Buerger’s Disease
◼ It is progressive, inflammatory
segmental, occlusive, non –
atherosclerotic disease of
small & medium sized
vessels with superficial
thrombophlebitis often may
present as Raynaud’s
phenomenon with skip
lesions.

8. Causes / Risk factors
◼ Familial nature
◼ Hormonal influence
◼ Hypersensitivity – Cigarette
◼ Alteration of autonomic
function
◼ Common – Jewish
◼ Young middle-aged Males
◼ Low SE – Group
◼ Poor hygiene / Rec. feet injuries
◼ Mostly LL – Involved

9. Pathogenesis

10. TAO – Classification & Criteria

11. TAO – Clinical Features
◼ Common in male smokers between
the 20-40 years of age group. It is a
smoker’s disease.
◼ I C - in foot and calf progressing to
rest pain, ulceration, gangrene.
◼ Recurrent migratory superficial
thrombophlebitis.
◼ Absence / feeble pulses distal to
proximal; DP / PT / P & F arteries.
◼ May present as R P.

13. TAO – Investigations
◼ Hb%, Blood sugar, ABPI.
◼ Arterial Doppler, Duplex
scan.
◼ U/S – abdomen.
◼ CT – Angiogram.
◼ Vein, artery, nerve biopsy.
◼ Electromyography.

14. TAO - Treatment – Medical
General Measures Drugs
• Stop Smoking
• Lifestyle changes
• Regular walk
• Care of feet
• Buerger’s position
/ exercise
• Anti-platelet – LDA,
C.Grel / Cilostazole
• Vasodilators – PP / DP
• Analgesics / Sedatives
• Xanthine nicotinate

15. TAO – Surgical
Surgery
• Omentoplasty
• Profundaplasty
• Lumbar Sympathectomy
• Amputations – if gangrenous

16. Raynaud’s Phenomenon
Prof. U.Murali.

17. Raynaud’s Phenomenon
◼ It is an episodic, localised
vasospasm of small
vessels, i.e., arteriolar
spasm. It leads to
sequence of clinical
features called as
Raynaud’s syndrome.
◼ Common in UL – Observed
on exposure to cold &
under stress.

18. Raynaud’s Phenomenon
◼ Working – vibrating tools
◼ Collagen Vascular Diseases
◼ Others –
- Cervical rib
- TAO
- Scalene syndrome
◼ Primary Raynaud’s: [ Raynaud’s Disease ]
- Idiopathic vasospastic disorder. Usually there is no
significant pain in primary type.
- It is common in females and younger age group.
- Usually, it is bilateral involving all digits.
◼ Secondary Raynaud’s: [ Raynaud’s Syndrome ]
- Due to some underlying cause.
- Significant pain will be present especially during re-
warming stage.
- There are positive auto-antibodies.
- Equal in both sexes; occurs at any age group.
- Not bilateral.
TYPES
CAUSES

19. Raynaud’s Syndrome
Sequence of clinical features due to arteriolar spasm :
◼ Local syncope: Due to vasospasm – Pallor
& Cold + tingling & numbness.
◼ Local asphyxia: Due to accumulation of
deoxygenated blood – Dusky cyanosis of
palm and digits with burning sensation.
◼ Local recovery: Due to relief of spasm in the
arteriole – flushing & pain.

20. Raynaud’s Disease
◼ Commonly seen in females, usually
bilateral.
◼ Occurs in UL with normal peripheral
pulses.
◼ Due to UL arteriolar spasm as a
result of abnormal sensitivity to cold.
◼ Patient develops blanching, cyanosis
and later flushing as in RS. If spasm
persists it results in gangrene.
◼ Precipitated & observed by placing
hands in cold water.
◼ Repeated attacks – Common.

21. R P – Investigations
◼ X – Ray – involved part
◼ DSA / MR Angiogram
◼ Doppler / Duplex scan
◼ ANA – assay
◼ FTT – Cold recovery time
(N - < 10 mt / RP - > 30 mt)
◼ Other Routine – RBS / LP

22. R P – Treatment
◼ Treat the cause.
◼ To avoid precipitating factors.
◼ Drugs – Vasodilators / LDA /
Nifedipine, nitrates – topical,
Steroids – in Sec. RP.
◼ Prostaglandin derivatives –
can be given.
◼ Amputation – severe cases.

23. T O S
Prof. U.Murali.

24. TOS – Thoracic Outlet Syndrome
◼ It is a collection of symptoms
brought about by abnormal
compression of the neurovascular
bundle by bony, ligamentous or
muscular structures in the narrow
space between clavicle and first
rib – the thoracic outlet.
◼ Boundaries of TO –
 Ant – Manubrium sterni
 Lat – First rib
 Post – T1 vertebra

25. TO – Spaces
TO has got 2 main spaces:
◼ Costoclavicular space –
 Sup – Clavicle, subclavius
 Inf – First rib
 Ant med – Costoclavicular Lig.
 Post lat – Sc. anterior
 Contains – SCV
◼ Scalene triangle –
 Ant – Sc. anterior
 Inf – First rib
 Post – Sc. medius
 Contains – SCA & BP

26. TOS – Causes
◼ Bony Abnormalities –
 Cervical rib
 Long C7 transverse process
 # Clavicle / First rib
 Exostosis
◼ Soft Tissue Abnormalities –
 Muscle – Insertion /
Hypertrophy
 Fibrous bands & ligaments
◼ Tumour
◼ Trauma – Brachial plexus injury
◼ Poor Posture
◼ Obesity

27. TOS - Classification
➢ Accounts for more than
90% of cases.
➢ More common – Women
➢ It is secondary to
compression of the BP –
nerves passes between
the anterior & middle
scalene muscles.
➢ Accounts for 3 – 4% of
cases.
➢ Categorized – Into
primary & secondary.
➢ Primary venous TOS is
also called Paget –
Schroetter syndrome.
➢ Accounts for 1 – 2% of
cases.
➢ Associated with most
serious complication –
Limb ischemia (which may
result in the loss of the
affected upper extremity).
Neurogenic Venous Arterial

28. TOS – Features
◼ Neurological symptoms
- Pain / Paraesthesia in affected
shoulder, arm & hand.
- Numbness & Weakness in
forearm, hand.
- Occipital headaches.
◼ Vascular symptoms
- Easily Fatigue.
- Coldness.
- Upper limb claudication.
- Swelling - Oedema.
- Ulcers / Gangrene.
SYMPTOMS
◼ Tenderness over trigger
points
◼ Pulsatile swelling
◼ Thrill & Bruit
◼ Examine the pulse
◼ Cyanosis / Collateral
veins
◼ Reduced sensation
SIGNS

30. TOS – Investigations
◼ Basic Blood tests.
◼ X-ray chest & cervical spine.
◼ Doppler study – UL / Neck.
◼ Vascular Imaging – Angiogram.
◼ CT / MRI – Neck.
◼ Nerve conduction studies.
◼ Electromyography.

31. TOS – Treatment

32. Arteritis
Prof. U.Murali.

37. To Summarize
◼ Types of Arterial diseases | Causes of Limb ischemia.
◼ Risk factors & Pathogenesis of TAO.
◼ Classification, Criteria, C/F & management of TAO.
◼ To distinguish between RD, RP and RS.
◼ Causes, C/F & management of TOS.
◼ Differences between Takayasu & Temporal arteritis.

38. References

39. Question Time
◼ List 5 causes of upper limb ischaemia.
◼ State the name and components of the criteria for TAO.
◼ Define TAO. Explain its pathogenesis.
◼ Outline the medical & surgical treatment aspects of TAO.
◼ Distinguish {5} between Raynaud's disease & Raynaud's syndrome.
◼ Classify thoracic outlet syndrome.
◼ Identify the clinical tests to diagnose TOS.
◼ Mention 5 differences between Takayasu & Temporal arteritis.

40. The following are the clinical features of
thromboangitis obliterans, except –
◼ a) Raynaud’s phenomenon.
◼ b) Claudication of extremities.
◼ c) Absence of popliteal pulse.
◼ d) Migratory superficial thrombophlebitis.

41. Which is not true about thoracic outlet
syndrome? –
◼ a) Radial nerve is commonly affected.
◼ b) Neurological features are most common.
◼ c) Resection of 1st rib relieves symptom.
◼ d) Positive Adson’s test.

42. Sequence of colour changes observed
in Raynaud’s Syndrome include –
◼ a) Red, blue and white.
◼ b) White, blue and red.
◼ c) Blue, red and white.
◼ d) White, red ad blue.

43. In Takayasu arteritis the most common artery involved
is –
◼ a) Common carotid artery.
◼ b) Renal artery.
◼ c) Inferior mesenteric artery.
◼ d) Subclavian artery.

44. Thoracic outlet syndrome is primarily diagnosed by –
◼ a) CT scan.
◼ b) Clinical evaluation.
◼ c) M R I.
◼ d) Angiography.