A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs. Peripheral vascular disease is a sign of fatty deposits and calcium building up in the walls of the arteries (atherosclerosis). Risk factors include ageing, diabetes and smoking. Symptoms may include leg pain, particularly when walking. Tobacco cessation, exercise and a healthy diet are often successful treatments. When these changes aren't enough, medication or surgery can help.

1. PERIPHERAL VASCULAR
DISEASE
PRESENTER B M ARUN KUMAR
MODERATOR; DR YATHISH SIR.

2. PERIPHERAL ARTERIAL DISEASE
• Peripheral arterial disease results in compromised blood flow to the
extremities
• Chronic impairment of blood flow to the extremities is most often
due to atherosclerosis
• Acute arterial occlusion >>arterial embolism

4. Chronic Arterial Insufficiency
• Peripheral arterial insufficiency is defined an ankle-brachial index
(ABI) less than 0.9.
• The ABI is calculated as the ratio of the systolic blood pressure at the
ankle to the systolic blood pressure in the brachial artery

5. Risk Factors
• Older age
• Family history
• Smoking
• Diabetes mellitus,
• Hypertension
• Obesity
• Dyslipidemia
• Risk is doubled in smokers compared with nonsmokers.

6. Signs and Symptoms
• Intermittent claudication and rest pain
• Minor trauma to an ischemic foot produce a nonhealing skin lesion
• Decreased or absent arterial pulses
• Bruits auscultated in the abdomen, pelvis, or inguinal area
• Subcutaneous atrophy
• Hair loss,
• Coolness
• Pallor
• Cyanosis
• Dependent redness

7. Diagnosis
• Doppler ultrasonography.
• The ABI is a quantitative means of assessing the presence and
severity of peripheral arterial stenosis.
• Duplex ultrasonography—plaque formation and calcification
• Transcutaneous oximetry--severity of skin ischemia
• MRI and contrast angiography

8. Treatment
Medical therapy
• Exercise programs
• Modification of risk factors
• Stop smoking
• Lipid-lowering therapy
• Treatment of diabetes mellitus
• Treatment of hypertension
Surgical treatment
• Revascularization procedures are
indicated in patients with disabling
claudication, ischemic rest pain,
or impending limb loss.
• Percutaneous transluminal
angioplasty of iliac,Femoral and
popliteal artery
• Aortobifemoral bypass
• Axillobifemoral bypass
• Femorofemoral bypass
• Amputation

9. Anaesthetic Management
• Perioperative MI and cardiac death in patients with peripheral arterial
disease is due to the high prevalence of coronary artery disease .
• Due to claudication,unable to perform an exercise stress test,
pharmacologic stress testing ,echocardiography or nuclear imaging
is helpful to determine the presence and severity of ischemic heart
disease preoperatively.
• American College of Cardiology/American Heart Association
(ACC/AHA) guidelines, unstable angina is considered an active
cardiac condition requiring treatment or optimization before surgery

10. Anaesthetic Management
• Perioperative heart rate control (usually with carefully titrated β-
blockers) in vascular surgery patients at high risk reduces the
incidence of myocardial ischemia.
• The ACC/AHA guidelines on perioperative β-blocker therapy
recommend β-blockade for patients at intermediate and high
risk who are undergoing vascular surgery.
• Perioperative initiation of statins is also reasonable in patients
undergoing vascular surgery.

11. • The choice of anesthetic technique must be individualized for
each patient.
• Epidural or spinal anesthesia offers the advantages of
increasedgraft blood flow, postoperative analgesia, less
activation of the coagulation system, and fewer postoperative
respiratory complications.
• Intraoperative heparinization is not in itself a contraindication to
epidural anesthesia.
• epidural catheter placement is attempted, it should occur at least
1 hour before intraoperative heparinization.
• General anesthesia may be necessary when procedures are
expected to require long operative hours or when vein harvesting
from the upper extremities is needed.

12. • During aortoiliac or aortofemoral surgery, infrarenal aortic cross-
clamping is associated with fewer hemodynamic derangements than
higher aortic cross-clamping. Likewise the hemodynamic changes
associated with unclamping the abdominal aorta are less with infrarenal
aortic cross-clamping.
• Because of the comparatively benign effects of infrarenal clamping,
many practitioners place a central venous pressure catheter in lieu of a
pulmonary artery catheter in these patients, especially in the absence of
symptomatic left ventricular dysfunction.
• Heparin is commonly administered before application of a vascular
cross-clamp to decrease the risk of thromboembolic complications

13. Postoperative Management
• Adequate analgesia,
• Treatment of fluid and electrolyte derangements,
• Maintenance of oxygenation, ventilation,
• Heart rate, and blood pressure to reduce the incidence of
myocardial ischemia or infarction.

14. Subclavian Steal Syndrome
• Occlusion of the subclavian or innominate artery proximal to the
origin of the vertebral artery may result in reversal of flow
through the ipsilateral vertebral artery into the distal subclavian
artery.
• This reversal of flow diverts blood from the brain to supply the
arm (subclavian steal syndrome).
• Symptoms of CNS ischemia (syncope, vertigo,ataxia,
hemiplegia) and/or arm ischemia are usually present.
• Extreme neck movements or exercise of the ipsilateral arm may
accentuate these hemodynamic changes and cause neurologic
symptoms.

15. Subclavian Steal Syndrome
• There is often an absent or diminished pulse in the ipsilateral
arm, and systolic blood pressure is often found to be 20 mm Hg
lower in that arm.
• A bruit may be heard over the subclavian artery. Stenosis of the
left subclavian artery is responsible for this syndrome in most
patients.
• Subclavian endarterectomy may be curative

16. Coronary-Subclavian Steal Syndrome
• A rare complication of using the left internal mammary artery for
coronary revascularization is coronary-subclavian
stealsyndrome.
• This syndrome occurs when proximal stenosis in the left
subclavian artery produces reversal of blood flow through the
patent internal mammary artery graft .
• This steal syndrome is characterized by angina pectoris and a
20-mm Hg or more decrease in systolic blood pressure in the
ipsilateral arm.
• Angina pectoris associated with coronarysubclavian steal
syndrome requires surgical bypass grafting

17. Acute Arterial Occlusion
• Systemic emboli may arise from a atrial fibrillation valvular heart
disease, prosthetic heart valves,infective endocarditis, and
paradoxical emboli from a patent foramen ovale.
• Noncardiac causes of acute arterial occlusion include
atheroemboli from an upstream artery, plaque rupture,and
hypercoagulability derangements
• Aortic dissection and trauma can acutely occlude an artery by
disrupting the integrity of the vessel lumen.

18. Signs and Symptoms
• Intense pain, paresthesias, and motor weakness distal to the
site of arterial occlusion
• Loss of a palpable peripheral pulse, cool skin, and sharply
demarcated skin color changes (pallor or cyanosis) occur distal
to the arterial occlusion.

19. Treatment
• Surgical embolectomy is used to treat acute systemic embolism,
• Once the diagnosis of acute arterial embolism is confirmed,
anticoagulation with heparin is initiated to prevent propagation of
the thrombus
• Intraarterial thrombolysis with urokinase or recombinant tPA may
restore vascular patency in acutely occluded arteries and synthetic
bypass grafts.
• The clinical outcome is highly dependent on the rapidity of
revascularization.
• Amputation may be necessary in some patients

20. Raynaud Phenomenon
• Raynaud phenomenon is episodic vasospastic ischemia of the
digits.
• It affects women more often than men and is characterized by
digital blanching or cyanosis in association with cold exposure
or sympathetic activation
• Vasodilation with hyperemia is often seen after rewarming and
reestablishment of blood flow.

21. Diagnosis
• History and physical examination
• CREST is an acronym for
• Subcutaneous calcinosis
• Raynaud phenomenon
• esophageal dysmotility,
• sclerodactyly (scleroderma limited to the fingers),
• telangiectasia.

22. Treatment
• Conservative Management- preventiontion hands and feet from
exposure to cold.
• calcium channel blockade or α-blockade may be helpful in
some patients
• surgical sympathectomy is considered for treatment of
persistent severe digital ischemia.

23. Management of Anesthesia
• Increasing the ambient temperature of the operating room
• maintaining normothermia
• Noninvasive blood pressure measurement techniques may be
strongly considered to avoid any arterial compromise of
potentially affected extremities
• Regional anesthesia is acceptable for peripheral surgeries
• To avoid undesirable vasoconstriction, epinephrine in the local
anesthetic solution is avoided.

24. PERIPHERAL VENOUS DISEASE
• Superficial thrombophlebitis,
• Deep vein thrombosis (DVT),
• Chronic venous insufficiency.
• Factors predisposing to venous thrombosis- virchow’s triad,
(1) venous stasis -due to immobility
(2) hypercoagulability-due to inflammation and acute surgical stress,
(3) disruption of vascular endothelium-due to perioperative trauma.

26. Superficial Thrombophlebitis
• Superficial venous thrombosis of a saphenous vein or its tributary
often occurs in association with intravenous therapy,varicose veins,
or systemic vasculitis
• It causes localized pain,superficial inflammation along path of the
vein.
• Superficial thrombophlebitis is rarely associated with pulmonary
embolism.
• The intense inflammation rapidly leads to total venous occlusion.
• vein can be palpated as a cordlike structure surrounded by an area
of erythema, warmth, and edema

27. Deep VeinThrombosis
• Associated with
• Generalized pain of the affected extremity
• Tenderness
• Unilateral limb swelling
• Doppler ultrasonography with vein compression is highly
sensitive for detecting vein thrombosis
• Venography and impedance plethysmography are also
• potential diagnostic

29. Treatment of Deep Vein Thrombosis
• Anticoagulation is the first-line treatment.
• Unfractionated or low-molecular-weight heparin [LMWH]
• Therapy with warfarin, an oral vitamin K antagonist, is initiated
during heparin treatment
Complications of Anticoagulation
• Bleeding
• heparin-induced thrombocytopenia(HIT)

30. SYSTEMIC VASCULITIS
Large artery vasculitis
• Takayasu arteritis
• temporal (or giant cell) arteritis.
Medium artery vasculitis
• Kawasaki disease
Small-artery vasculitides
• Thromboangiitis obliterans,
• Wegener granulomatosis,
• Polyarteritis nodosa

31. Temporal (Giant Cell) Arteritis
• Temporal arteritis is inflammation of the arteries of the head and neck,
• Manifestation- headache,
- Scalp tenderness,
- Jaw claudication
• Diagnosed when patient older than age 50 c/o of a unilateral headache
• Superficial branches of the temporal arteries are often tender and
enlarged
• Arteritis of branches of the ophthalmic artery may lead to ischemic optic
neuritis and unilateral blindness
• Initiation of treatment with corticosteroids

32. Thromboangiitis Obliterans
(Buerger Disease)
• It is an inflammatory vasculitis leading to occlusion of small and
medium-sized arteries and veins in the extremities.
• prevalent in men, onset is before age 45. predisposing factor
is tobacco usage.
• The disorder has been identified as an autoimmune response
triggered when nicotine is present.
• The diagnosis is confirmed by biopsy of active vascular lesions.

33. Signs and Symptoms
• Forearm, calf, foot claudication
• Rest pain, ulcerations, and skin necrosis.
• Commonly associated raynaud phenomenon
• Treatment
• Smoking cessation
• Surgical revascularization
• Gene therapy with vascular endothelial growth factor

34. Management of Anesthesia
• Avoidance of events that might damage already ischemic
extremities
• Positioning and padding of pressure points.
• The operating room ambient temperature should be warm,
• Inspired gases should be warmed and humidified to maintain
normal body temperature
• Systemic blood pressure by non invasive method is preferred.
• Regional or general anesthetic techniques can be used in these
patients

35. Polyarteritis Nodosa
• Polyarteritis nodosa is an ANCA-negative vasculitis that sometimes
occurs in association with hepatitis B, hepatitis C, or hairycell leukemia.
• Males more frequently contract this disease
• Small and medium-sized arteries are involved, with inflammatory
changes resulting in glomerulonephritis, myocardial ischemia,
peripheral neuropathy, and seizures.
• The diagnosis of polyarteritis nodosa depends on histologic
• evidence of vasculitis on biopsy specimens
• Treatment is empirical and usually includes corticosteroids and
cyclophosphamide,removal of offending drugs, and treatment of
underlying diseases such as cancer.

36. • An aneurysm is a dilatation of all three layers of an artery.
• 50% increase in diameter compared with normal, or greater
than 3cm in diameter.
• Aneurysms may occasionally produce symptoms because of
compression of surrounding structures, but rupture with
exsanguination is the most dreaded complication.
• Dissection of an artery occurs when blood enters the medial
layer.
• The media of large arteries is made up of organized lamellar
units that decrease in number with distance from the heart.
• Blood surges through the intimal tear into an extraluminal
channel called the false lumen.

38. ANEURYSMS AND DISSECTIONS OF THE
THORACIC AND ABDOMINAL AORTA
• The incidence of descending thoracic aneurysms is 5.9–10.4
per 100,000 person-years, and rupture occurs at a rate of 3.5
per 100,000 person-years.

39. Etiology
• Aortic aneurysmal disease
• hypertension
• Atherosclerosis,
• Older age,
• Male sex,
• Family history of aneurysmal
disease,
• Smoking
• Aortic dissection
• Blunt trauma
• use of crack cocaine, and
• Iatrogenic dissection may occur
secondary to aortic
cannulationincluding cardiac
catheterization, cross-clamping,
aortic
• Manipulation, or arterial incision
for surgical procedures
• Such as aortic valve
replacement, bypass grafting, or
aneurysm operations.

40. • Thoracic aortic aneurysms and dissections associated genetic
syndromes
• Marfan syndrome,
• Ehlers-Danlos syndrome,
• bicuspid aortic valve, and
• Non syndromic familial aortic dissection.

41. Classification
• classified morphologically as either fusiform or saccular. In
fusiform aneurysm there is a uniform dilatation involving the
entire circumference of the aortic wall,saccular aneurysm is an
eccentric dilatation of the aorta that communicates with the
main lumen by a variably sized neck.
• Aneurysms can also be classified based on the pathologic
features of the aortic wall atherosclerosis or cystic medial
necrosis

43. Signs and Symptoms
• Asymptomatic
• Hoarseness -stretching of the left recurrent laryngeal nerve.
• Stridor -to compression of the trachea.
• Dysphagia - compression of the esophagus.
• Dyspnea-compression of the lungs
• Plethora and edema- compression of the superior vena cava
• Acute, severe, sharp pain in the anterior chest, the neck, or
between the shoulder blades is the typical presenting symptom
of thoracic aortic dissection.

44. • Other symptoms andsigns of acute aortic dissection, such as
• Absence of peripheral pulses,
• . Neurologic complications of aortic dissection may include
• Stroke-occlusion of a carotid artery,
• ischemic peripheral neuropathy
• associated with ischemia of an arm or a leg, and paraparesis or
paraplegia caused by impairment of the blood supply to the spinal
cord.
• Myocardial infarction (MI) may reflect occlusion of a coronary artery.
• Gastrointestinal ischemia may occur.
• Renal artery obstruction is manifested by an increase in serum
creatinine concentration.
• Retrograde dissection into the sinus of Valsalva with rupture into the
pericardial space leading to cardiac tamponade is a major cause of
death.

45. Diagnosis
• Widening of the mediastinum on chest radiograph- diagnostic
of a thoracic aortic aneurysm.
• Computed tomography (CT) and magnetic resonance imaging
(MRI) are the other methods to diagnose thoracic aortic
disease,
• echocardiography with color Doppler imaging
• Transesophageal echocardiography (TEE),

46. Medical Management of Aortic
Aneurysms
• Careful management of blood pressure, hyperlipidemia,
andnsmoking cessation are essential.
• Avoidance of strenuous exercise, stimulants such as cocaine,
and overall stress.
• β-blockers,
• Angiotensin converting enzyme (ACE) inhibitors,
• angiotensin-II receptor blockers,
• statins

47. Management of Anesthesia
• Surgical repair of a thoracic aortic aneurysm requires aortic cross-
clamping just distal to the left subclavian artery or between the left
subclavian artery and the left common carotid artery.
• Therefore blood pressure monitoring must be via an artery in the right
arm, since occlusion of the aorta can prevent measurement of blood
pressure in the left arm
• Blood flow to tissues below the aortic cross-clamp is dependent on
perfusion pressure rather than on preload and cardiac output. Therefore
during cross-clamping of the thoracic aorta,proximal aortic pressures
should be maintained as high as the heart can safely withstand
• Nitroprusside may decrease spinal cord perfusion pressure both by
decreasing distal aortic pressure and by increasing CSF pressure as a
result of cerebral vasodilation
• Temporary shunts to bypass the occluded thoracic aorta may be
considered when attempting to maintain renal and spinal cord perfusion

48. Monitoring Neurologic Function
• Somatosensory evoked potentials (SEPs) and
electroencephalography(EEG) are monitoring methods
• Spinal cooling with epidural instillation of iced saline during cross-
clamping in thoracic aneurysm surgery has been employed successfully
for many years in some institutions across the United States on the
basis that lowering the spinal cord temperature directly will improve
recovery of potentially poorly perfused tissues
• spinal drainage has been used to decrease pressure around the spinal
cord and avoid ischemia in a confined space if the spinal cord dilates
after adequate perfusion is reestablished

49. Monitoring Cardiac Function
• During operations on the thoracic aorta, TEE can provide
valuable information about the presence of atherosclerosis in
the thoracic aorta, the competence of cardiac valves, ventricular
function, adequacy of myocardial perfusion, and intravascular
volume status.

50. Monitoring Intravascular Volume and
Renal Function
• Use of diuretics such as mannitol before aortic clamping may
also be useful. Mannitol improves renal cortical blood flow and
glomerular filtration rate
• Renal protection is achieved by direct instillation of
renalpreservation fluid (4°C lactated Ringer solution with 25 g of
mannitol per liter and 1 g methylprednisolone per liter) and can
be administered directly by the surgeon into the renal artery.

51. Induction and Maintenance of Anesthesia
• Induction of anesthesia and tracheal intubation must minimize
undesirable increases in systemic blood pressure that could
exacerbate an aortic dissection or rupture an aneurysm
• Use of a double-lumen endobronchial tube permits collapse of the
left lung and facilitates surgical exposure during resection of a
thoracic aneurysm.
• Combinations of volatile anesthetics and/or opioids are commonly
used Continuous epidural anesthesia combined with general
anesthesia may offer advantages by decreasing overall anesthetic
drug requirements,attenuating the increased systemic vascular
resistance associated with aortic cross-clamping, and facilitating
postoperative pain management.

52. • Patients undergoing thoracoabdominal aortic aneurysm repair
usually experience significant fluid and blood losses.
• Administration of a combination of balanced salt and colloid
solutions (and blood if needed) guided by appropriate
monitoring of cardiac and renal function facilitates maintenance
of adequate intravascular volume, cardiac output, and urine
formation.
• Balanced salt and/or colloid solutions should be infused during
aortic cross-clamping to build up an intravascular volume
reserve and thereby minimize unclamping hypotension.

53. • alteration in anesthetic depth or infusion of vasodilators may be
necessary in some patients to maintain myocardial performance
at acceptable levels
• Hypotension may occur when the aortic cross-clamp is removed
gradual opening of the aortic crossclamp may minimize the
decrease in systemic blood pressure by allowing some pooled
venous blood to return to the central circulation.

54. Postoperative Management
• Pain relief is commonly provided by neuraxial opioids and/or local
anesthetics. Intrathecal or epidural catheters providing intermittent or
continuous infusion of analgesic medications can be adapted to
provide an element of patient-controlled analgesia as well.
• Patients recovering from thoracic aortic aneurysm resection are at
risk of developing cardiac, pulmonary, and renal failure during the
immediate postoperative period.
• Cerebrovascular accidents may result from air or thrombotic emboli
• Spinal cord injury may manifest during the period immediately after
surgery as paraparesis or flaccid paralysis.
• Delayed appearance of paraplegia (12 hours to 21days
postoperatively) has been associated with postoperative hypotension