MK
Uploaded byMinhajuddin khurram
PPTX, PDF28,967 views

Chronic lower limb ischemia

1. The document discusses peripheral arterial occlusive disease (PAOD), also known as peripheral artery disease (PAD), which refers to obstruction of arteries outside the heart and brain. 2. Risk factors for PAOD include smoking, diabetes, hypertension, hyperlipidemia, older age, male sex, family history of vascular disease, and certain ethnicities. 3. Symptoms range from intermittent claudication to critical limb ischemia with rest pain and tissue loss. Physical exam findings and tests like the ankle-brachial pressure index can help in diagnosis. 4. Management options discussed include conservative treatment for mild cases as well as endovascular and surgical revascularization procedures for more severe cases.

Embed presentation

Downloaded 2,080 times
1 / 123
2 / 123
Most read
3 / 123
Most read
4 / 123
5 / 123
6 / 123
7 / 123
8 / 123
9 / 123
10 / 123
11 / 123
12 / 123
13 / 123
14 / 123
15 / 123
16 / 123
17 / 123
18 / 123
19 / 123
20 / 123
21 / 123
22 / 123
23 / 123
24 / 123
25 / 123
26 / 123
27 / 123
28 / 123
29 / 123
30 / 123
31 / 123
32 / 123
33 / 123
34 / 123
35 / 123
36 / 123
37 / 123
38 / 123
39 / 123
40 / 123
41 / 123
42 / 123
43 / 123
44 / 123
45 / 123
46 / 123
47 / 123
48 / 123
49 / 123
50 / 123
51 / 123
52 / 123
53 / 123
54 / 123
55 / 123
56 / 123
57 / 123
58 / 123
59 / 123
60 / 123
61 / 123
62 / 123
63 / 123
64 / 123
65 / 123
66 / 123
67 / 123
68 / 123
69 / 123
70 / 123
71 / 123
72 / 123
73 / 123
74 / 123
75 / 123
76 / 123
77 / 123
78 / 123
79 / 123
80 / 123
81 / 123
82 / 123
83 / 123
84 / 123
85 / 123
86 / 123
87 / 123
88 / 123
89 / 123
90 / 123
91 / 123
92 / 123
93 / 123
94 / 123
95 / 123
96 / 123
97 / 123
98 / 123
99 / 123
100 / 123
101 / 123
102 / 123
103 / 123
104 / 123
105 / 123
106 / 123
107 / 123
108 / 123
109 / 123
110 / 123
111 / 123
112 / 123
113 / 123
114 / 123
115 / 123
116 / 123
117 / 123
118 / 123
Most read
119 / 123
120 / 123
121 / 123
122 / 123
123 / 123
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 supplying the heart and within the brain
 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
 Black (hispanic)  Increasing age  Smoking  Hypertension  Dyslipidemia  Hypercoaguble states  Renal insufficiency  DM  Younger>aged
 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:  Internal half: Direct diffusion  External half: vasa vasorum  External elastic membrane  Adventitia • Fibroblasts and collagen
 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
 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 lipid core becomes necrotic covered by FIBROUS CAP rupture, perceived as injury laying down of platelets and formation of a clot.
 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 femoral arteries  Ostia or renal, coronary and mesenteric arteries.
 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
 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 Lesion:  Arteritis, periarteritis, acute phlebitis (migratory in 30%) and periphlebitis.  Invasion of wall by polymorphs and giant cells.  Thrombus, with microabscesses
 Chronic Lesion  Arteries and veins bound together by fibrosis  Nerve involvement  Fibroblastic activity and endothelial proliferation in the thrombus  Thrombus organized as fibrous tissue
 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
 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
 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 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
 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
 Pain (Intermittent claudication)  Rest pain – “Hen-holding”
 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
 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
 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
 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
 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 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
 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
 Physical examination  Inspection  Change in colour  Signs of ischemia  Bueger’s test  Capillary filling test  Venous refilling  Pregangrenous/ gangrenous part examination
 Physical examination  Palpation  Skin temperature  Venous refilling  Perpheral pulses  Disapperaing pulse  Joint movements / muscle strength  Sensations  Auscultation:  Bruits
 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
 Physical examination  Dry vs Wet Gangrene
 ABPI
 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
 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
 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 decreases when flow increases  Generates a pressure and waveform of different arteries  A difference of 20-30 mmHg is significant.
 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.
 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
 Doppler Ultrasound (DU)
 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.
 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)
 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
 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
 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
 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 dissection e) Contrast nephropathy f) Contrast allergy
 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
 Digital subtraction angiography (DSA)  Angiographic images being digitilised by a computer  With substraction of extrenous background (bone, soft tissues)
 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)
 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
 General Investigations  ECG  ECHO  Lipid profile  COPD  Blood tests to exclude  Anemia  DM  Deranged RFT  High blood viscosity (polycythemia and thrombocythemia)
 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
 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
 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)
 Conservative management  Stop smoking  Keep walking  Reduce weight (obese individuals)  Exercise  Diabestes and hypertension  Care of feet  Buerger’s position  Buerger’s exercise
 Conservative management  Drugs  Analgesics- Aspirin  Vasodialtors  Cilostazol (phosphodiasterase inhibitors)  Pentoxyphylline (phosphodiasterase inhibitors)  Prostacycline  Platelet aggregation inhibitors  Clopidrogel  Aspirin  Prostacycline
 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
 Indirect surgeries  Sympathectomy  Chemical  Surgical  Indications:  Rest pain  Skin ulcerations  TAO  Elderly patient (senile gangrene)
 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
 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
 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.
 Surgical Management  Surgical Revascularization Procedures  Open  Endo-vascular  Amputation
 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”
 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 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%
 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
 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
 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
 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
 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
 Aorto-bifemoral bypass
 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
 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
 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
 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
 Open Surgical Management  Endarterectomy  Balloon  Artery is exposed after clamping  Proximal arteriotomy is made  Fogarty ballon catheter is passed
 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)
 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
 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
 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
 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
 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”
 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
 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
 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
 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
 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
 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
 Endovascular management  Subintimal angioplasty
 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
 Endovascular management  Stenting
 Endovascular management  Stenting
 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
 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
 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
 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
 Endovascular management  Endovascular atherectomy Rotational cutter Laser tipped
 Amputation  Indication for amputation  Dead Limb  Gangrene  Deadly Limb  Wet gangrene  Spreading cellulitis  Dead Loss Limb  Severe rest pain with  Ischemia  Paralysis  Contracture
 Amputation  Choice of amputation  Below knee amp[utation (BKA)  Above knee amputation (AKA  Ray amputation  Transmetatarsal amputation  Miscellaneous  Syme’s  Chopart’s  Lisfranc’s
 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
 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
 Amputation  Ray amputation
 Amputation A. Syme’s B. Chopart’s C. Lisfranc’s D. Transmetatarsal
Chronic lower limb ischemia

More Related Content

PPT
Chronic limb ischemia
byKundan Singh
 
PDF
Critical Limb Ischemia
bySteve Henao MD FACS FACC
 
PPT
Acute limb ischemia
bymohammed Assuit)
 
PPT
Peripheral Vascular disease / Chronic limb ischemia / CLI / Acute limb Ischemia
byDr Sushil Gyawali
 
PPTX
Surgical Management of Lower Limb Occlusive Arterial Disease
byrajendra meena
 
PPTX
Critical limb ischemia. povd . dr mnr
bySREE GOKULAM MEDICAL COLLEGE AND RESEARCH FOUNDATION
 
PPTX
Chronic limb ischemia
byDr Slayer
 
PPT
Acute limb ischemia
byAbino David
 
Chronic limb ischemia
byKundan Singh
 
Critical Limb Ischemia
bySteve Henao MD FACS FACC
 
Acute limb ischemia
bymohammed Assuit)
 
Peripheral Vascular disease / Chronic limb ischemia / CLI / Acute limb Ischemia
byDr Sushil Gyawali
 
Surgical Management of Lower Limb Occlusive Arterial Disease
byrajendra meena
 
Critical limb ischemia. povd . dr mnr
bySREE GOKULAM MEDICAL COLLEGE AND RESEARCH FOUNDATION
 
Chronic limb ischemia
byDr Slayer
 
Acute limb ischemia
byAbino David
 

What's hot

PDF
Acute Limb Ischemia
bySun Yai-Cheng
 
PPTX
Acute limb ischemia
byTapish Sahu
 
PPT
occlusive arterial disease
byJoel Arudchelvam MBBS, MD, MRCS, FCSSL
 
PPTX
Peripheral arterial disease
byDr Virbhan Balai
 
PPTX
Anorectal disorders
byVikas V
 
PPTX
Acute limb ischemia
byShahid Mohammed
 
PPTX
SPLENIC INJURY.pptx
bySelvaraj Balasubramani
 
PPT
peripherial arterial disease
byNote Noteenote
 
PPTX
mesenteric cyst
byVeeru Reddy
 
PPTX
Approach to Management of Upper Gastrointestinal (GI) Bleeding
byArun Vasireddy
 
PPTX
Hydatid disease of liver
bySummu Thakur
 
PPTX
Abdiminal tuberculosis
byThorlikonda Sasidhar
 
PPT
varicose vein surgery
byYazhini Thamaraiselvan
 
PPTX
Sigmoid volvulus/ Generalised abdominal pain
bySelvaraj Balasubramani
 
PPT
Venous Insufficiency
bySteve Henao MD FACS FACC
 
PPTX
LOWER GI BLEEDING
byArkaprovo Roy
 
PPTX
Esophageal injury
byDENNIS MIRITI
 
PPTX
Gastric Outlet Obstruction (GOO)
byMuhammad saad iqbal
 
PPTX
Management of Appendicular Lump
byDhaval Mangukiya
 
PPTX
Liver abscess
byJibran Mohsin
 
Acute Limb Ischemia
bySun Yai-Cheng
 
Acute limb ischemia
byTapish Sahu
 
occlusive arterial disease
byJoel Arudchelvam MBBS, MD, MRCS, FCSSL
 
Peripheral arterial disease
byDr Virbhan Balai
 
Anorectal disorders
byVikas V
 
Acute limb ischemia
byShahid Mohammed
 
SPLENIC INJURY.pptx
bySelvaraj Balasubramani
 
peripherial arterial disease
byNote Noteenote
 
mesenteric cyst
byVeeru Reddy
 
Approach to Management of Upper Gastrointestinal (GI) Bleeding
byArun Vasireddy
 
Hydatid disease of liver
bySummu Thakur
 
Abdiminal tuberculosis
byThorlikonda Sasidhar
 
varicose vein surgery
byYazhini Thamaraiselvan
 
Sigmoid volvulus/ Generalised abdominal pain
bySelvaraj Balasubramani
 
Venous Insufficiency
bySteve Henao MD FACS FACC
 
LOWER GI BLEEDING
byArkaprovo Roy
 
Esophageal injury
byDENNIS MIRITI
 
Gastric Outlet Obstruction (GOO)
byMuhammad saad iqbal
 
Management of Appendicular Lump
byDhaval Mangukiya
 
Liver abscess
byJibran Mohsin
 

Similar to Chronic lower limb ischemia

PPTX
Peripheral vascular disease
byAndrewCrofton
 
PPTX
PERIPHERAL ARTERIAL/Vascular DISEASE.pptx
byDr. Bipin Chaudhary
 
PPTX
ARTEIAL DISEASE / PVD - This PPT done by me for undergraduate education - Dr...
byParan Jyothi
 
PPT
Amol gulhane -peripheral vascular disease
byAmol Gulhane
 
PPTX
Peripheral arteial diaease presentation slideshow
byvinaygarg833255
 
PPTX
CHRONIC LOWER LIMB ISCHEMIA new.pptxTypes , clinical features
byAlFahadShajahan
 
PPTX
Peripheral Arterial Diseases PAD-WPS Office.pptx
byjehangirsaleem70
 
PPTX
Tutorial ischaemia of lower limbs
byfreeburn simunchembu
 
PPT
Peripheral-Vascular-Disease-Surgical-Presentation.ppt
bymussahemed8
 
PPT
Pad presentasi yg baik untuk menjadi .ppt
byaileenhidayat
 
PPT
Occlusive arterial disease 2019
byJoel Arudchelvam MBBS, MD, MRCS, FCSSL
 
PDF
arterial diseases presentation ; pvd peripheral vascular disease
byMridulSharma215012
 
PPTX
THROMBO ANGITIS OBLITERENS2-1.pptx
byvigneshram986
 
PPTX
Peripheral Arterial Disease (seminar).pptx
byhtetmyat33
 
PDF
Peripheral arterial diseases
bySelvaraj Balasubramani
 
PPTX
Clinical examination peripheral vascular disease
bySankaranolla Anand
 
PPTX
CLNICAL MEDICINE, vascular disease, dr. fatima.pptx
byfatima132662
 
PPTX
PERIPHERAL ARTERY DISEASE.pptx
bysandeep754264
 
PPT
Peripheral vascular disease and Clinical features of acute and chronic arteri...
bySumer Yadav
 
PDF
pvd-190130172505.pdf
bySreedharNaik6
 
Peripheral vascular disease
byAndrewCrofton
 
PERIPHERAL ARTERIAL/Vascular DISEASE.pptx
byDr. Bipin Chaudhary
 
ARTEIAL DISEASE / PVD - This PPT done by me for undergraduate education - Dr...
byParan Jyothi
 
Amol gulhane -peripheral vascular disease
byAmol Gulhane
 
Peripheral arteial diaease presentation slideshow
byvinaygarg833255
 
CHRONIC LOWER LIMB ISCHEMIA new.pptxTypes , clinical features
byAlFahadShajahan
 
Peripheral Arterial Diseases PAD-WPS Office.pptx
byjehangirsaleem70
 
Tutorial ischaemia of lower limbs
byfreeburn simunchembu
 
Peripheral-Vascular-Disease-Surgical-Presentation.ppt
bymussahemed8
 
Pad presentasi yg baik untuk menjadi .ppt
byaileenhidayat
 
Occlusive arterial disease 2019
byJoel Arudchelvam MBBS, MD, MRCS, FCSSL
 
arterial diseases presentation ; pvd peripheral vascular disease
byMridulSharma215012
 
THROMBO ANGITIS OBLITERENS2-1.pptx
byvigneshram986
 
Peripheral Arterial Disease (seminar).pptx
byhtetmyat33
 
Peripheral arterial diseases
bySelvaraj Balasubramani
 
Clinical examination peripheral vascular disease
bySankaranolla Anand
 
CLNICAL MEDICINE, vascular disease, dr. fatima.pptx
byfatima132662
 
PERIPHERAL ARTERY DISEASE.pptx
bysandeep754264
 
Peripheral vascular disease and Clinical features of acute and chronic arteri...
bySumer Yadav
 
pvd-190130172505.pdf
bySreedharNaik6
 

Recently uploaded

PPTX
Vitamin A deficiency, Vitamin A deficiency.pptx
byMeghna Verma
 
PDF
The Role of Mid Day Meal Schemes in Reducing Classroom Hunger
byAkshaya Patra Foundation USA
 
PPTX
MNS Care for FLW- CMD & SMD for public health
byHarsha Wakodkar
 
PPTX
DM2-Hypertension 2026. For health care professionals
bydunnibrahim
 
PPTX
Best-Dental-Insurance-Eligibility-Verification-Services.pptx
byTrans Dental
 
PPTX
HYPOTHYROIDISM IN PREGNANCY PowerPoint presentation
bypavatharani98
 
PDF
Raman Bhaumik - A Healthcare Executive
byRaman Bhaumik
 
PPTX
Muscle Insufficiency Tone Power Endurance Fit ,Rigidity
byHome
 
PDF
Medical Billing Audit Checklist for Practice Owners and Managers
byCHB Medical Billing
 
PDF
Unit 4; Concept of medical and surgical asepsis
byrobinam733
 
PDF
Raman Bhaumik - A Licensed Pharmacist
byRaman Bhaumik
 
PDF
X-Ray Positioning & Errors Radiographer-Focused Practical Guide By Durjay Lah...
byDurjay Laha
 
PPTX
World Cancer Day Powerpoint Presentation
by0001aditibasu
 
PPTX
1. cardio system.pptx anatomy & physiology
byPooja Rani
 
PPTX
FUNDAMENTALS-OF-NURSING-NCM103-LEC-2ND-SEM-2025-2026.pptx
byMarkDomingo15
 
PPTX
Child abuse child health nursing ppt Document from Mahi.pptx
bymahirav305
 
PPTX
YogicWave Official PPT| Know everything about YogicWave Yoga Institute.
byprathambisht77
 
PDF
NABH Entry Level Certification – Complete Implementation & Assessment Manual.pdf
byDr Jitu Lal Meena
 
PPTX
unit 6-cognitive process.pptx for bsc nursing 1st yr
bySulekhaDeshmukh
 
PDF
Raman Bhaumik - The Culture And Transformation
byRaman Bhaumik
 
Vitamin A deficiency, Vitamin A deficiency.pptx
byMeghna Verma
 
The Role of Mid Day Meal Schemes in Reducing Classroom Hunger
byAkshaya Patra Foundation USA
 
MNS Care for FLW- CMD & SMD for public health
byHarsha Wakodkar
 
DM2-Hypertension 2026. For health care professionals
bydunnibrahim
 
Best-Dental-Insurance-Eligibility-Verification-Services.pptx
byTrans Dental
 
HYPOTHYROIDISM IN PREGNANCY PowerPoint presentation
bypavatharani98
 
Raman Bhaumik - A Healthcare Executive
byRaman Bhaumik
 
Muscle Insufficiency Tone Power Endurance Fit ,Rigidity
byHome
 
Medical Billing Audit Checklist for Practice Owners and Managers
byCHB Medical Billing
 
Unit 4; Concept of medical and surgical asepsis
byrobinam733
 
Raman Bhaumik - A Licensed Pharmacist
byRaman Bhaumik
 
X-Ray Positioning & Errors Radiographer-Focused Practical Guide By Durjay Lah...
byDurjay Laha
 
World Cancer Day Powerpoint Presentation
by0001aditibasu
 
1. cardio system.pptx anatomy & physiology
byPooja Rani
 
FUNDAMENTALS-OF-NURSING-NCM103-LEC-2ND-SEM-2025-2026.pptx
byMarkDomingo15
 
Child abuse child health nursing ppt Document from Mahi.pptx
bymahirav305
 
YogicWave Official PPT| Know everything about YogicWave Yoga Institute.
byprathambisht77
 
NABH Entry Level Certification – Complete Implementation & Assessment Manual.pdf
byDr Jitu Lal Meena
 
unit 6-cognitive process.pptx for bsc nursing 1st yr
bySulekhaDeshmukh
 
Raman Bhaumik - The Culture And Transformation
byRaman Bhaumik
 

Chronic lower limb ischemia

  • 1.
    Dr Minhajuddin Khurram Al-AmeenMedical College Bijapur (Karnataka) India
  • 2.
    Peripheral areterial occlusivedisease (PAOD/PAD/PVD) refers to the obstruction or detoriation of ateries other than those supplying the heart and within the brain
  • 3.
     Impairment ofcirculation  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.
     Black (hispanic) Increasing age  Smoking  Hypertension  Dyslipidemia  Hypercoaguble states  Renal insufficiency  DM  Younger>aged
  • 5.
     Family historyof vascular disease or stroke/ heart attack  In study  C-reactive protein  Homocysteine
  • 7.
     Intima  Internalelastic 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
  • 9.
     Acute  Suddenocclusion 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
  • 10.
     Atherosclerosis {lowerlimb}  TAO (Buerger’s Disease) {lower limb}  Infective  Vasculitis syndromes
  • 12.
     Atherosclerosis = Athero+ sclerois  Plaque composed of smooth m/s, lipids, connective tissue and macrophages
  • 13.
     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.
  • 15.
     Ischemia maybe due to  Narrowing of the lumen  Rupture leading to fibrous cap  Embolization
  • 16.
     More shearingstress/ increased turbulence  Infra renal aorta  Iliac bifurcation  Carotid bifircation  Superficaial femoral arteries  Ostia or renal, coronary and mesenteric arteries.
  • 17.
     Inflammatory reactionof 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
  • 19.
     Pathology smoking (nicotine) Increased% carboxy hb vasospasm damage to the vessel wall TAO fibrosis
  • 20.
     Involves mediumand 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
  • 21.
     Chronic Lesion Arteries and veins bound together by fibrosis  Nerve involvement  Fibroblastic activity and endothelial proliferation in the thrombus  Thrombus organized as fibrous tissue
  • 22.
     Pain (Intermittentclaudication)  “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
  • 23.
     Pain (Intermittentclaudication)  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
  • 24.
     Claudication distance: distance at which the pain first appears
  • 25.
  • 26.
  • 27.
     Pain (Intermittentclaudication)  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
  • 28.
     Pain (Intermittentclaudication)  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
  • 29.
     Pain (Intermittentclaudication)  Rest pain – “Hen-holding”
  • 30.
     Pain (Intermittentclaudication)  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
  • 31.
     Pain (Intermittentclaudication)  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
  • 32.
     Pain (Intermittentclaudication)  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
  • 33.
     Pain (Intermittentclaudication)  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
  • 34.
     Other symptoms Ulceration  Gangrene  Loss of senstion  Loss of movements
  • 35.
     History  Canidentify 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
  • 36.
     History  Vascularreview 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
  • 37.
     Physical examination Inspection  Change in colour  Signs of ischemia  Bueger’s test  Capillary filling test  Venous refilling  Pregangrenous/ gangrenous part examination
  • 38.
     Physical examination Palpation  Skin temperature  Venous refilling  Perpheral pulses  Disapperaing pulse  Joint movements / muscle strength  Sensations  Auscultation:  Bruits
  • 39.
     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
  • 40.
     Physical examination Dry vs Wet Gangrene
  • 41.
  • 42.
     ABPI  Physiologicaltesting 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
  • 43.
     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
  • 44.
     Segmental pressure Differenceof 20-30 mmHg is indicative of significant lesion
  • 45.
     Photo-Plethysmography  Investigationfor 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.
  • 46.
     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.
  • 47.
     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
  • 48.
  • 49.
     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.
  • 50.
     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)
  • 51.
     Angiography  Invasivetechique 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
  • 52.
     Angiography  Donein 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
  • 53.
     Angiography  Donein 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
  • 54.
     Angiography  Siteof block in Atherosclerosis
  • 55.
     Angiography  Cork-screwpattern of vessels in TAO  Block at multiple sites in small and medium sized arteries
  • 56.
     Angiography  Risk/ Complications: a) Groin hematoma b) Retroperitoneal bleeding c) Pseudo-anuerysm d) Arterial dissection e) Contrast nephropathy f) Contrast allergy
  • 57.
     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
  • 58.
     Digital subtractionangiography (DSA)  Angiographic images being digitilised by a computer  With substraction of extrenous background (bone, soft tissues)
  • 59.
     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)
  • 60.
     Carbon Dioxideangiography  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
  • 61.
     General Investigations ECG  ECHO  Lipid profile  COPD  Blood tests to exclude  Anemia  DM  Deranged RFT  High blood viscosity (polycythemia and thrombocythemia)
  • 62.
     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
  • 63.
     Brown’s vasomotorindex  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
  • 64.
     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)
  • 65.
     Conservative management Stop smoking  Keep walking  Reduce weight (obese individuals)  Exercise  Diabestes and hypertension  Care of feet  Buerger’s position  Buerger’s exercise
  • 66.
     Conservative management Drugs  Analgesics- Aspirin  Vasodialtors  Cilostazol (phosphodiasterase inhibitors)  Pentoxyphylline (phosphodiasterase inhibitors)  Prostacycline  Platelet aggregation inhibitors  Clopidrogel  Aspirin  Prostacycline
  • 67.
     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
  • 68.
     Indirect surgeries Sympathectomy  Chemical  Surgical  Indications:  Rest pain  Skin ulcerations  TAO  Elderly patient (senile gangrene)
  • 69.
     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
  • 70.
     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
  • 71.
     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.
  • 73.
     Surgical Management Surgical Revascularization Procedures  Open  Endo-vascular  Amputation
  • 74.
     Surgical RevascularizationProcedures  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”
  • 75.
     TASC –II(Aorto-iliac)
  • 76.
     TASC –II(Aorto-iliac)
  • 77.
     TASC –II(Aorto-iliac)
  • 78.
     TASC –II(Aorto-iliac)
  • 79.
     TASC –II(Femoro-popliteal)
  • 80.
     TASC –II(Femoro-popliteal)
  • 81.
     TASC –II(Femoro-popliteal)
  • 82.
     TASC –II(Femoro-popliteal)
  • 83.
     Open SurgicalManagement (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%
  • 84.
     Open SurgicalManagement  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
  • 85.
     Open SurgicalManagement  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
  • 86.
     Open SurgicalManagement  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
  • 87.
     Open SurgicalManagement (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
  • 88.
     Open SurgicalManagement (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
  • 89.
  • 90.
     Open SurgicalManagement (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
  • 91.
     Open SurgicalManagement  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
  • 92.
     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
  • 93.
     Open SurgicalManagement  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
  • 94.
     Open SurgicalManagement  Endarterectomy  Balloon  Artery is exposed after clamping  Proximal arteriotomy is made  Fogarty ballon catheter is passed
  • 95.
     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)
  • 96.
     Open SurgicalManagement  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
  • 97.
     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
  • 98.
     Open SurgicalManagement  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
  • 99.
     Femoro-popliteal bypass  Polpileatvein 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
  • 100.
     Open SurgicalManagement  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”
  • 101.
     Open SurgicalManagement  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
  • 102.
     Open SurgicalManagement  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
  • 104.
     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
  • 105.
     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
  • 106.
     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
  • 107.
     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
  • 108.
     Endovascular management Subintimal angioplasty
  • 109.
     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
  • 110.
  • 111.
  • 112.
     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
  • 113.
     Endovascular management  Cuttingballoon  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
  • 114.
     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
  • 115.
     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
  • 116.
     Endovascular management Endovascular atherectomy Rotational cutter Laser tipped
  • 117.
     Amputation  Indicationfor amputation  Dead Limb  Gangrene  Deadly Limb  Wet gangrene  Spreading cellulitis  Dead Loss Limb  Severe rest pain with  Ischemia  Paralysis  Contracture
  • 118.
     Amputation  Choiceof amputation  Below knee amp[utation (BKA)  Above knee amputation (AKA  Ray amputation  Transmetatarsal amputation  Miscellaneous  Syme’s  Chopart’s  Lisfranc’s
  • 119.
     Amputation  Levelof amputation  Skin perfusion pressure >=40 mmhg  Transcuatneous oxygen pressure >= 30mmhg  Predictors for Transmetatarsal amputation:  Toe Blood Pressure >=30 mmhg  Ankle Blood Pressure >= 80 mmHg
  • 120.
     Amputation Below KneeAmputation Above Knee Amputation Poor Healing Better Healing More chances of revision/ healing by secondary intention Less chances of revision Better ambualtion Poor ambulation
  • 121.
  • 122.
     Amputation A. Syme’s B.Chopart’s C. Lisfranc’s D. Transmetatarsal

Editor's Notes

  • #4 Resulting into ischemiaMay be due to co-morbid conditions and poverty
  • #8 DESCRIBE EACHIntima, single layer of cells, longitudinal axis, in contact with bloodMedia: strengthProteoglycans: disachharide bound to proteins, act as cement
  • #10 I- limbs are viable and not immediately threatenedIIa – limbs are viable but salvagable if treatedIIb – limbs are salvagable if treated ungentlyIII- not salvagable
  • #11 Infective eg: syphilis
  • #14 Cap composed of smooth musclesandconnective tissuesIn this way an insignificant narrowing can result in major obstruction
  • #28 Occlusion one level above the site of claudication
  • #36 Evolution is important.. Decrease in claudication distance , finally rest painMedical history: prior stroke, diabetes, hypertension, dyslipidemia, tobocco abuseDrug history: anti platelet agents, beta blockers, statins, heparin, protamineSurgical history: previous surgeries, coronary artery bypass grafting, previous sephanous vein harvesting
  • #38 Theory Das
  • #39 Theory Das
  • #40 Theory Das
  • #41 Theory Das
  • #42 BP cuff and continous wave doppler
  • #43 BP cuff and continous wave doppler&lt;0.9 …6 folds of cardiovascular morbity
  • #44 BP cuff and continous wave doppler&lt;0.9 …6 folds of cardiovascular morbity
  • #47 A continous wave ultrasound is transmitted by the probe which is reflected by moving RBCsand picked up by the receiver within the probe and converted to audio signalsChange in frequency of the reflected beam gives Doppler shift
  • #49 A continous wave ultrasound is transmitted by the probe which is reflected by moving RBCsand picked up by the receiver within the probe and converted to audio signalsChange in frequency of the reflected beam gives Doppler shift
  • #52 Previously under LA , now under USG guidance
  • #57 Nephropathy:Increase hydration
  • #59 DSA with PA view
  • #62 High blood viscosity (polycythemia and thrombocythemia)  smoking, malignancy, renal dysfunction,
  • #71 From erecter spinae to medial border of rectus
  • #72 From erecter spinae to medial border of rectus
  • #73 From erecter spinae to medial border of rectus
  • #84 End to end : better flow dynamicsEnd to side : the blood supply to pelvis is intact
  • #99 Bypass can be performed even if one or more tibial arteries are occluded in the leg
  • #113 PTA : percuatneous transluminal angioplasty
  • #119 Emotional decision for the patientCause of depressionMore hospital stayMortality of 5-10% (BKA) and 15%(AKA)
  • #120 Predictors of wound healing