2. Learning Objectives
â—Ľ Enumerate the causes of limb ischemia.
â—Ľ Mention the risk factors & pathogenesis of TAO.
â—Ľ Write the Classification & Criteria of TAO.
â—Ľ Describe the C/F & Management of TAO.
â—Ľ Differentiate between R. phenomenon | disease & syndrome.
â—Ľ Explain the Surgical anatomy of Thoracic outlet.
â—Ľ 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
7. TAO – Buerger’s Disease
â—Ľ 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
â—Ľ Familial nature
â—Ľ Hormonal influence
◼ Hypersensitivity – Cigarette
â—Ľ Alteration of autonomic
function
◼ Common – Jewish
â—Ľ Young middle-aged Males
◼ Low SE – Group
â—Ľ Poor hygiene / Rec. feet injuries
◼ Mostly LL – Involved
11. TAO – Clinical Features
â—Ľ Common in male smokers between
the 20-40 years of age group. It is a
smoker’s disease.
â—Ľ I C - in foot and calf progressing to
rest pain, ulceration, gangrene.
â—Ľ Recurrent migratory superficial
thrombophlebitis.
â—Ľ Absence / feeble pulses distal to
proximal; DP / PT / P & F arteries.
â—Ľ May present as R P.
17. Raynaud’s Phenomenon
â—Ľ 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
â—Ľ 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.
â—Ľ Local asphyxia: Due to accumulation of
deoxygenated blood – Dusky cyanosis of
palm and digits with burning sensation.
â—Ľ Local recovery: Due to relief of spasm in the
arteriole – flushing & pain.
20. Raynaud’s Disease
â—Ľ Commonly seen in females, usually
bilateral.
â—Ľ Occurs in UL with normal peripheral
pulses.
â—Ľ Due to UL arteriolar spasm as a
result of abnormal sensitivity to cold.
â—Ľ Patient develops blanching, cyanosis
and later flushing as in RS. If spasm
persists it results in gangrene.
â—Ľ Precipitated & observed by placing
hands in cold water.
◼ Repeated attacks – Common.
21. R P – Investigations
◼ X – Ray – involved part
â—Ľ DSA / MR Angiogram
â—Ľ Doppler / Duplex scan
◼ ANA – assay
◼ FTT – Cold recovery time
(N - < 10 mt / RP - > 30 mt)
◼ Other Routine – RBS / LP
22. R P – Treatment
â—Ľ Treat the cause.
â—Ľ To avoid precipitating factors.
◼ Drugs – Vasodilators / LDA /
Nifedipine, nitrates – topical,
Steroids – in Sec. RP.
◼ Prostaglandin derivatives –
can be given.
◼ Amputation – severe cases.
24. TOS – Thoracic Outlet Syndrome
â—Ľ 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
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
37. To Summarize
â—Ľ Types of Arterial diseases | Causes of Limb ischemia.
â—Ľ Risk factors & Pathogenesis of TAO.
â—Ľ Classification, Criteria, C/F & management of TAO.
â—Ľ To distinguish between RD, RP and RS.
â—Ľ Causes, C/F & management of TOS.
â—Ľ Differences between Takayasu & Temporal arteritis.
39. Question Time
â—Ľ List 5 causes of upper limb ischaemia.
â—Ľ State the name and components of the criteria for TAO.
â—Ľ Define TAO. Explain its pathogenesis.
â—Ľ Outline the medical & surgical treatment aspects of TAO.
â—Ľ Distinguish {5} between Raynaud's disease & Raynaud's syndrome.
â—Ľ Classify thoracic outlet syndrome.
â—Ľ Identify the clinical tests to diagnose TOS.
â—Ľ Mention 5 differences between Takayasu & Temporal arteritis.
40. The following are the clinical features of
thromboangitis obliterans, except –
◼ a) Raynaud’s phenomenon.
â—Ľ b) Claudication of extremities.
â—Ľ c) Absence of popliteal pulse.
â—Ľ d) Migratory superficial thrombophlebitis.
41. Which is not true about thoracic outlet
syndrome? –
â—Ľ a) Radial nerve is commonly affected.
â—Ľ b) Neurological features are most common.
â—Ľ c) Resection of 1st rib relieves symptom.
◼ d) Positive Adson’s test.
42. Sequence of colour changes observed
in Raynaud’s Syndrome include –
â—Ľ a) Red, blue and white.
â—Ľ b) White, blue and red.
â—Ľ c) Blue, red and white.
â—Ľ d) White, red ad blue.
43. In Takayasu arteritis the most common artery involved
is –
â—Ľ a) Common carotid artery.
â—Ľ b) Renal artery.
â—Ľ c) Inferior mesenteric artery.
â—Ľ d) Subclavian artery.
44. Thoracic outlet syndrome is primarily diagnosed by –
â—Ľ a) CT scan.
â—Ľ b) Clinical evaluation.
â—Ľ c) M R I.
â—Ľ d) Angiography.