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Chronic arterial occlusive diseases

Chronic arterial occlusive diseases. Aetiology. Atherosclerosis( most common cause) Aneurysms Thrombangitis obliterans Inflammatory arteritis. Common sites of occlusive diseases. Lower limb AOD. Essentials of Diagnosis General: Decreased pulses. Low ankle-brachial index.

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Chronic arterial occlusive diseases

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  1. Chronic arterial occlusive diseases

  2. Aetiology Atherosclerosis( most common cause) Aneurysms Thrombangitisobliterans Inflammatory arteritis

  3. Common sites of occlusive diseases

  4. Lower limb AOD Essentials of Diagnosis General: Decreased pulses. Low ankle-brachial index. Intermittent claudication. Cramping calf pain with walking. Critical Limb Ischemia: Rest pain of the foot relieved by dependency. Ulceration of the foot or ankle. Pallor of foot on elevation, rubor on dependency. Gangrene and atrophy

  5. Examination of the legs in a patient with peripheralvascular disease. Inspection Colour Posture of the limb Venous guttering Gangrene Ulceration Palpation Temperature Capillary refilling Pulses Sensation and movement Auscultation Bruits

  6. Intermittent claudication pain in muscles of the lower extremity associated with walking and relieved by rest. symptoms are completely relieved after 2–5 minutes of inactivity. Occlusions proximal to the origin of the profundafemoris can extend the pain to involve the thigh. Leriche syndrome occurs in men with aortoiliac disease and includes claudication of calf, thigh, and buttock muscles; impotence; and diminished or absent femoral pulses.

  7. Rest pain Ischemic rest pain, a grave symptom caused by ischemic neuritis, indicates advanced arterial insufficiency that carries a risk of gangrene and amputation if arterial reconstruction cannot be performed. The pain is severe and burning, usually confined to the forefoot distal to the metatarsals. aggravated by elevation of the extremity or by bringing the leg to the horizontal position

  8. DX Non invasive: ABI(normal=1.0),0.7>intermittent claudications, 0.3> rest pain. Diabetics may have false value need toe brachial index. Treadmill+segmental BP after exercise cause drop in BP distal to the lesion

  9. Imaging Dopler US Colour duplex ultrasound CT angiography& MRA Conventional angiography

  10. MX Aims Relieve symptoms Prevent limb loss Maintain bipedal gait

  11. Non op.MX (1) medical management of cardiovascular risk factors(stop smoking,aspirin,statins,ACEinhibitors,B-blockers,mx of diabetes) (2) exercise rehabilitation, (3) foot care, and (4) pharmacotherapy.

  12. Operative MX Endovascular therapy (ballooning or stenting) Lower short term morbidity & mortality Usually for short segment lesions Long term effect ? Surgery remains superior

  13. Surgicalaortoiliac reconstructions Aortofemoral bypass (for aorto iliac occlusive diseases iliofemoral bypass if the disease is unilateral or femorofemoral bypass Axillofemoral bypass for high risk patients

  14. Femoropopliteal disease Femoropopliteal bypass The procedure essentially for limb salvage, severe claudication. Safenous vein is the conduit of choice PTFE is also used specially for above knee reconstructions. Below knee bypass SVG is superior in terms of patency

  15. Tibioperoneal reconstructions Used for limb salvage Endovascular treatment is not used frequently SVG is preferred conduit

  16. Buergers disease Thromboangiitisobliterans is a clinical syndrome characterized by segmental thrombotic occlusions of small and medium-sized arteries in the lower and often the upper limb, accompanied by a dense inflammatory infiltrate that affects the arterial wall and often the adjacent veins and nerves as well.

  17. aetiology Unknown men (90%) and there is a clear association with smoking.

  18. Clinical features Clinical Males under 45 years old at onset of disease Upper and lower limb involvement Heavy smokers Absence of embolic source, trauma, autoimmune disease, diabetes or hyperlipidaemia Arteriogram Normal proximal arteries Distal occlusions Corkscrew collaterals

  19. mx Complete Cessation of tobacco Aspirin, CCB of doubtful benefit. Lumbar sympathectomy may be of benefit 30% limb loss

  20. Extra cranial vascular diseases Symptoms most often not the result of hypoperfusion but are caused by emboli. The most common lesion is at the bifurcation of the carotid artery.

  21. Clinical features Asymptomatic TIA CVA Carotid bruit

  22. Investigations Doppler Duplex CTA and MRA angiography

  23. Indications for carotid endarterectomy Carotid distribution transient ischaemic attacks > 70% ipsilateral stenosis > 50% ipsilateral stenosis with ulceration Stroke with good recovery after 1 -month delay > 70% ipsilateral stenosis > 50% ipsilateral stenosis with ulceration Controversial indications Asymptomatic carotid stenosis Vertebrobasilar symptoms with combined vertebral and carotid disease Acute stroke within first few hours of occurrence

  24. Tx Aspirin and clopdogrel Endovascular treatment Surgery(carotid endarterectomy)

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