surgical management of occlusions of peripheral artery

1.  BOGOMOLETS NATIONAL
MEDICAL UNIVERSITY
 Submitted by : Shanudas Vishnu
 Group no. : 6612m1 a
 Course of study : 5th

2. CHRONIC LOWER LIMB ISCHEMIA DEFINITION :
• Increased limb ischemia for more than 2 weeks
• Gradual and progressive decrease in blood flow
• Decrease in tissue perfusion
ETIOLOGY :
– ATHEROSCLEROSIS
– THROMBOANGITIS OBLITERANS (BUERGER’S DISEASE)

3. DEFINITIVE
• Hypercholesterolaemia >200mg/dl
• Hyperlipidaemia LDL >100mg/dl; HDL
• Cigarette smoking
• Hypertension
• Diabetic mellitus
RELATIVE
• Elderly
• Male predominance
• Sedentary life
• Obesity
• Family history

4. Atherosclerosis
• Chronic, complex inflammatory condition of elastic and
muscular arteries, involving as systemic or segmental
• Lipid plaque forms inside the arterial wall, cause
narrowing and hardening of artery
Commonly involved arteries
• Infrarenal part of abdominal aorta
• Iliofemoral artery
• Popliteal arteries

5. Infrarenal aorta and iliac arteries
• Types :
– Type 1: disease localised to distal
abdominal aorta and common iliac
arteries
– Type 2: wide spread aortic and iliac
disease
– Type 3: multiple level disease along
with infrainguinal diseases

7. Clinical features
• Pain
– Intermittent claudication
– Rest pain
• Paraesthesia
• Pallor
• Diminished or absent pulse
• Thinning of skin
• Loss of subcutaneous fat
• Diminished hair/ brittle nail or shining of skin
• Ulcer or gangrene

8. Boyd’s classification of claudication
• Grade I: Patient developed pain on walking,
but if continues to walk, pain disappears. This is
due to washing away of substance P.
• Grade II: Pain persist on walking but can walk
with effort.
• Grade III: Due to severe pain patient seeks
rest

10. Examination
• Buerger’s postural test
• Capillary filling time
• Harvey’s sign
• Fuchsin's test Cont..
• Ankle brachial pressure index
• Segmental pressure measurement
• Treadmill exercise- to unmask the preliminary stage
of arterial occlusion (disappearing pulse) (due to
exercise increase in vasodilation and collateral
circulation coz decrease in pulse)

12. Investigation
• Routine blood examination
• Blood sugar
• HbA1C
• Serum creatinine
• Blood lipid
• Urine for sugar
• Straight x- rays
• Doppler scan/ Duplex imaging- Doppler shift
• Angiography(sodium diatrizoate) – Retrograde transfemoral seldinger
angiography
• Free flush arteriography
• Selective angiography – Direct aortic angiogram – Digital subtraction angiogram
– CT Angiogram/ MR Angiogram

14. General Treatment
Stop smoking
Change in lifestyle
• Healthy eating habits
• Reduction of weight
• Exercise Buerger’s position and exercise
Care of foot

15. DISORDER PHARMACOLOGY PURPOSE
Dyslipidaemia Statin
Gemfibrozil
Target LDL<100/DL
Hypertension Beta blocker
ACE inhibitor
Decrease risk of cardiovascular
events
Diabetics Insulin therapy or Oral hypoglycaemic agent Proper foot care HbA1C <7%
Atherosclerosis Aspirin
Clopidogrel
Cilostazol
Reduce the chance of vascular
events

21. • Lumber sympathectomy – abolish vasomotor activity
vasodilation improve circulation
• Omentoplasty – rich in blood supply and heals ulcers
• Amputation – depends upon extent of gangrene, site of
block and amount of collaterals