D.V.T & Arterial disorders

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Arterial disorders:

Arterial disorders M.RAVICHANDRA,M.S(G.S) ASSISTANT PROFESSOR OF SURGERY RIMS ,SRIKAKULAM DVT

DVT deep venous thrombosis :

DVT deep venous thrombosis Epidemiology:- It is common disease in surgical patient of all types estimated incidence without prophylaxis;- 22%-33% in intra-abdominal surgery. 45%66% in ORTHOPAEDIC surgery 50% prostatectomy 20% trauma 3% postpartum

DVT DEEP VENOUS THROMBOSIS :

DVT DEEP VENOUS THROMBOSIS EPIDEMIOLOGY:- IT IS COMMON DISEASE IN SURGICAL PATIENT OF ALL TYPES ESTIMATED INCIDENCE WITHOUT PROPHYLAXIS;- 22%-33% IN INTRA-ABDOMINAL SURGERY. 45%66% IN ORTHOPAEDIC SURGERY 50% PROSTATECTOMY 20% TRAUMA 3% POSTPARTUM

Etiology and risk factors:

Etiology and risk factors 3main factors contribute in development of DVT Stasis. Endothelial injury. Hypercoagulability. Theses are VIRCHOW'S TRIAD

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Stasis: mainly caused by heart failure, prolonged immobility Endothelial injury: mainly caused by either direct trauma (severed vein) or local irritation (by chemotherapy, past DVT, phlebitis) Hypercoagulability: inherited (AT III def., protein C, S deficiency) or acquired (malignancy, pregnancy, AT III def., protein C, S deficiency as in nephritic syndrome, DIC and liver failure.

Other risk factors:

Other risk factors Age>60 years Obesity Trauma Use of oral contraceptive

Pathogenesis:- :

Pathogenesis:- The thrombus usually originated in the soleal venous sinuses or valvular sinuses .the calf vein is the usual site It may also originate in the iliac or femoral vein.

:CLINICAL PRESENTATION-:

:CLINICAL PRESENTATION-

Symptoms:-:

Symptoms:- Dull pain, heaviness, oedema and warm limb With extensive DVT :-massive oedema, cyanosis, dilated superficial collateral veins and low grade fever. With ilio-femoral DVT :- Phlegmasia cerulea dolens (cyanosed limb due to obstructed vein) Phlegmasia alba dolens (pale, pulseless cold limb due to concurrent arterial spasm) AND THESE TWO UPPER CASES ARE LIMB THREATENING CONDITION!!

Signs:

Signs A SWOLLEN & PAIN FULL LIMB TENDERNESS ALONG THE FEMORAL ,POPLITEAL &POSTERIOR TIBIAL VEINS HOMAN'S SIGN (TENDERNESS DURING PASSIVE DORSIFLEXION OF FOOT). AND IT WAS CONTRAINDICATED WHEN THERE IS ALREADY SWELLING & PAIN BECAUSE OF IT ’ S ROLE IN THROMBUS DEATTACHMENT AND THUS EMOBILIZATION MOSE’S SIGN TENDERNESS ELICITED WHEN CALF MUSCLE IS SQUEEZED

INVESTIGATIONS::

INVESTIGATIONS: CBC for any abnormalities in Hb, WBC, and platelet count PT aPTT D-Dimer: too unspecific. prolonged

IMAGING STUDIES::

IMAGING STUDIES: *The standard tool for diagnosis is phlebography using fluoroscope .the use of this study limited by is complications which are allergy, nephropathy and phlebitis. *Duplex ultrasound: Test of choice Sensitivity and specificity >95% Include both β-mode and Doppler studies. Able to detect other pathology like BAKER cyst.

The finding are:-:

The finding are:- Acute DVT: Absence of spontaneous flow. Loss of flow variation with respiration. Failure to increase the flow after distal augmentation. Not visible thrombi (anechoic thrombi). Chronic DVT: Not well established Narrow vein Patent collateral Visible thrombi

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The only disadvantage of duplex study is that, it is highly operator dependant!!!

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*MRV (magnetic resonance venography):- Is promising tool for diagnosis, 100%sensitivity, 96% specificity.

Differential diagnoses: :

Differential diagnoses: Unilateral limb involvement : muscular strain, tendon rupture, cellulites, lymphodema or retroperitoneal fibrosis pressing over the vein. Bilateral limb involvement : liver, heart or renal failure or IVC obstruction.

Complication of DVT:

Complication of DVT Recurrent DVT Varicose vein Chronic venous insufficiency Post phlebitic syndrome (pain, oedema and ulceration) PE

MANAGEMENT:

MANAGEMENT The aim of management is:- Prophylaxis against DVT Treatment of ongoing DVT

Methods of Prophylaxis: :

Methods of Prophylaxis: 1) Mechanical Leg elevation Graded compression stocking. early ambulation Pneumatic compression boot .

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2) Pharmacological agents: Aspirin (anti platelet factor) not recommended currently. Dextran solution (40 and70) branched polysaccharide. Decrease platelets adhesiveness and aggregation. Disadvantages:- Increase rate of bleeding Pulmonary oedema (due to overload) Allergic reaction in 1% Recommended dose is15-20 cc/h IV infusion before surgery.

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Warfarine (coumadine):- Decrease incidence of DVTby66% and PE by 80%. Disadvantages:- Sever hemorrhage Must be started 2-3 days preoperative. Require careful monitoring for PT.

Heparin:

Heparin Unfractionated heparin:- Inhibits AT III and potentiate disintegration of thrombi that form while it administered Low dose regimen is 5000 IU twice daily SQ two hours pre-operatively then q12hours post operative till the patient is completely ambulating. For morbidly obese patient: - micro-heparin drip at 1u/kg/hour Disadvantages;- Risk of bleeding Thrombocytopenia (rare) Contraindicated in patient with actively bleeding peptic ulcer, uncontrolled HTN, bleeding disorder or recent use of ASA

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Heparin-dihydroergotamine (DHE) combination:- Cause vasoconstriction of capacitance veins and thus increase the venous return. Particular effectiveness in orthopedic cases. Contraindicated in case of hypotension, IHD and peripheral arterial occlusive diseases. Low molecular weight (enoxaparin):- Lesser effect on thrombin and platelets aggregation. Longer life time so the dose will be once daily. More expensive than unfractionated heparin .

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Fibrinogen-depleting compound New class of anticoagulants but not well known. Prophylactic IVC filter placement. Also known as Greenfield filter. Used in high risk patient when other methods are contraindicated. Effective in preventing PE not DVT.

An approach to Prophylaxis:

An approach to Prophylaxis 1/determine patient at risk Low risk (<40 years old, ambulating, minor surgery) Moderate risk (>40 years old, abdominal, pelvic or thoracic surgery) High risk (>60years old, prior DVTor PE malignancy, orthopedic surgery hypercoagulability state).

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2/prohylaxis of choice Encourage all patients to ambulate as soon as possible Low risk patient don't need prophylaxis. Moderate risk pneumatic compression boot or low dose heparin prophylaxis. High risk combination of pneumatic compression boot and low dose heparin prophylaxis or Dextran. Coumadine or IVCfilter are considered. Ophthalmology or neurosurgery patient are NOT candidates for prophylaxis.

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Treatment of DVT A: - ANTICOAGULATION Heparin bolus 100-150 u/kg IV stat then followed by constant infusion of 1000 u/hour with checking aPTT q4-6hours and keeping the ratio 50-70sec. Coumadine (Warfarine) usually started at day 3-5 after initial heparin is given and continue for 3-6 months .PT should be 17-20sec. and INR 2.0-2.5.

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B:- THROMOLYTIC TREATMENT( ALTEPLASE, STREPTOKINASE, UROKINASE) Promote rapid thrombus lysis.used in cases of sever PE .they have more bleeding complication. C:- VENAL CAVAL INTERRUPTION. (IVC FILTER) Prevent further embolism of thrombi D:- VENOUS THROMBECTOMY May be necessary in venous gangrene and septic thrombosis.

ARTERIAL DISORDERS:

ARTERIAL DISORDERS

TOPICS COVERED:

TOPICS COVERED 1.ARTERIAL STENOSIS/OCCLUSION 2.ACUTE ARTERIAL OCCLUSION 3.GANGRENE 4.AMPUTATIONS 5.ARTERIAL ANEURYSMS(ABDOMINAL AORTA) 6.ARTERITIS 7.VASOSPASTIC CONDITIONS

ARTERIAL STENOSIS/OCCLUSION:

ARTERIAL STENOSIS/OCCLUSION LOWER LIMB VESSELS CAROTID ART. SUBCLAVIAN ART. RENAL ART. ENTERIC ART.

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LOWERLIMB ARTERIAL OCLLUSION:

LOWERLIMB ARTERIAL OCLLUSION INTERMITTANT CLAUDICATION REST PAIN COLDNESS,NUMBNESS,PARESTHESIA COLOUR CHANGES ULCERATION PREGANGRENE GANGRENE DIMINISHED /ABSENT ARTERIAL PULSES ARTERIAL BRUIT VENOUS REFILLING HARVEY’S SIGN IMPOTENCE

INTERMITTENT CLAUDICATION:

INTERMITTENT CLAUDICATION CLADICATIO(LATIN)---TO LIMP ROMAN EMPEROR CLAUDICUS IT IS A CRAMP LIKE PAIN FELT IN THE LEG MUSCLES USUALLY BROUGHT ON AFTER EXERCISE / WORK IS NOT PRESENT ON TAKING THE 1 ST STEP IS RELIEVED BY REST LOCALISED TOA MUSCLE GROUP REPRODUCIBLE DISTRIBUTION OF PAIN INDICATES LEVEL OF ARTERIAL DISEASE

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CLAUDICATION DISTANCE:

CLAUDICATION DISTANCE IT IS THE DISTANCE OF WALKING AFTER WHICH THE PERSON DEVELOPS PAIN IT IS A FAIRLY CONSTANT DISTANCE WHICH VARIES VERY SLIGHTLY FROM DAY TO DAY IT IS A SUBJECTIVE DISTANCE IT IS ALTERED BY WALKING UPHILL WALKING AGAINST WIND SPEED OF WALKING ANAEMIA HEARTFAILURE

SITE OF CLAUDICATION:

SITE OF CLAUDICATION DEPENDS ON SITE OF OCCLUSION POPLITEAL/TIBIAL ART. --FOOT FEMOROPOPLITEAL JN. -- CALF OPENING OF SUP.FEM.ART. -- THIGH BIFURCATION OF COM.ILIAC ART . / AORTA , --BUTTOCK

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BOYD’S CLASSIFICATION:

BOYD’S CLASSIFICATION CLAUDICATION IS DUE TO ACCUMULATION OF SUBSTANCE P GRADE 1 AFTER THE PT. DEVELOPS PAIN HE HAS TO TAKE REST BUT IF THE PT. CONTINUES TO WALK INCREASED BLOOD FLOW SWEEPS AWAY THE SUBCTANCE P & PAIN DISAPPEARS GRADE2 P AIN CONTINUES BUT THE PT. CAN WALK WITH EFFORT GRADE3 THE PAIN COMPELLS THE PT. TO STOP WALKING

DIFFERENTIAL DIAGNOSIS:

DIFFERENTIAL DIAGNOSIS NERVE ROOT COMPRESSION ARTHROPATHY SPINAL CANAL STENOSIS

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INT. CLAUD. & DIABETES:

INT. CLAUD. & DIABETES 30% ARE DIABETICS INCREASES RELATIVE RISK OF DEATH BY 3 FOLD 50% HEART DISEASE 15% STROKE

REST PAIN:

REST PAIN IT IS A SEVERE,CONTINUOUS & ACHING PAIN DUE TO ISCHAEMIC CHANGES IN THE SOMATIC NERVES CRY OF THE DYING NERVES THE PAIN IS WORSE AT NIGHT INCREASES BY LYING DOWN&ELEVATION RELIEVED BY HANGING THE FOOT OUT OF BED OR SLEEPING IN A CHAIR NIGHT CRAMPS WHICH ARE SHORT,SEVERE MUSCLE CRAMPS SHOULD NOT BE CONFUSED

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COLOUR CHANGES:

COLOUR CHANGES BLANCHED/PALE ON ELEVATION PURPLE ON DEPENDENCY BRIGHT RED SPECKLING IS DUE TO EXTRAVASATION OF R.B.C BUERGER’S POSTURAL TEST BUERGER’S A NGLE

SKIN CHANGES:

SKIN CHANGES THINNING OF SKIN DIMINISHED GROWTH OF HAIR SHININESS LOSS OF SUB CUTANEOUS FAT TROPHIC CHANGES IN THE NAILS BRITTLENESS TRANSEVERSE RIDGES MINOR ULCERATIONS IN PRESSURE AREAS HEEL,MALLEOLI,BALL OF FOOT ,TIPS OF TOES

VENOUS REFILLING:

VENOUS REFILLING AN ELEVATED NORMAL HEALTHY LIMB WHEN KEPT IN HORIZONTAL POSITION VENOUS REFILLING OCCURS WITHIN SECONDS REDUCED VENOUS FILLING OCCURS IN SEVERE FORMS OF ART. INSUFFICIENCY ALSO COMMON IN VASOSPASTIC CONDITIONS &COLD WEATHER

HARVEY’S SIGN:

HARVEY’S SIGN INCREASE D VENOUS RETURN &VARICOSE VEINS ARE ASSOCIATED WITH AV FISTULA DECREASE D RETUTN (DECREASED SPEED OF FILLING) INDICATES ISCHEMIA

COLDNESS,NUMBNESS,PARESTHESIA:

COLDNESS,NUMBNESS,PARESTHESIA COMMON IN MOD. TO SEVERE ISCHEMIA BUT IN THE ABSENCE OF COLOUR CHANGES NEUROLOGICAL CAUSE SHOULD BE EXCLUDED

ULCERATION:

ULCERATION ARTERIAL ULCERS COMMON SITES ARE SITES EXPOSED TO TRAUMA ANT.LAT. LEG DORSUM OF FOOT&TOES HEEL PAINFULLELEVATED POSITION DOES NOT HELP IN HEALING PUNCHED OUT EDGE PENETRATES DEEP FASCIA MINIMAL GRANULATION TISSUE UNDERLYING TENDONS,BONE OR JOINTS MAY BE EXPOSED THERE MAY BE A COEXISTING GANGRENE

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PRE GANGRENE:

PRE GANGRENE COMBINATION OF C OLOUR CHANGE H YPERESTAESIA O EDEMA & R EST PAIN CHOR WITH/WITH OUT ULCERATION

TEMPERATURE:

TEMPERATURE USUALLY THE ISCHEMIC LIMB IS COLD WHEN COMPARED TO OPPOSITE LIMB BUT,SOMETIMES PARADOXICALLY MAY FEEL WARMER AS IT TENDS TO TAKE ON THE TEMP. OF THE SURROUNDINGS AND MAY FEEL WARM UNDER BED CLOTHES

SENSATION& MOVEMENT:

SENSATION& MOVEMENT HYPERESTHESIA IN AREAS OF SKIN ON THE BORDER LINE OF GANGRENE IN CHRONIC LIMB ISCHEMIA PARALYSIS & LOSS OF SENSATION IS A FEATURE OF ACUTE LIMB ISCHEMIA

ARTERIAL PULSATIONS:

ARTERIAL PULSATIONS LOWER LIMB DORSALIS PEDIS POSTERIOR TIBIAL ANTERIOR TIBIAL POPLITEAL FEMORAL UPPER LIMB RADIAL BRACHIAL AXILLARY SUBCLAVIAN OTHER IMPORTANT ABD. AORTA CAROTID FACIAL SUP. TEMP. ART.

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ARTERIAL PULSES:

ARTERIAL PULSES MAY BE ABSENT OR DIMINISHED IF THERE IS GOOD COLLATERAL CIRCULATION THE SIGN OF DISAPPEARING PULSE

ARTERIAL BRUITS:

ARTERIAL BRUITS SYSTOLIC BRUIT IS DUE TO TURBULENCE AND INDICATES OCCLUSION OR STENOSIS CONTINUOUS MACHINARY MURMUR INDICATES THE PRESENCE OF AV FISTULA

IMPOTENCE:

IMPOTENCE OCCLUSION OF BIFURCATION OF AORTA OR COMMON ILIAC ARTERIES CAUSES IMPOTENCE(ERECTILE DYSFUNCTION)& PAIN IN THE THIGH THIS IS KNOWN AS LERICHE SYNDROME

GANGRENE:

GANGRENE DEATH WITH PUTREFACTION OF MACROSCOPIC PORTIONS OF TISSUES DRY GANGRENE RESULTS WHEN TISSUES ARE DESSICATED BY GRADUAL SLOWING OF BLOOD STREAM. TYPICALLY SEEN IN ATHEROSCLEROSIS MOIST GANGRENE RESULTS WHEN VENOUS AS WELL AS ARTERIAL OCCLUSION IS PRESENT& WHEN THE ART. IS SUDDENLY OCCLUDED

GANGRENE RELATED PHENOMENA:

GANGRENE RELATED PHENOMENA LINE OF DEMARCATION/SEPARATION SEPARATION BY ASEPTIC ULCERATION SEPARATION BY SEPTIC ULCERATION VAGUE DEMARCATION SIGNS OF SPREAD OF GANGRENE SKIP LESIONS BLEBS DIE-BACK

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AND ETIOLOGY OF PAD:

AND ETIOLOGY OF PAD RISK FACTORS

PAD IS A COMMON DISORDER :

PAD IS A COMMON DISORDER OCCURS IN APPROXIMATELY 1/3 OF PATIENTS OVER AGE 70 OVER AGE 50 WHO SMOKE OR HAVE DM STRONG ASSOCIATION WITH CAD OBVIOUS ASSOCIATED RISK OF STROKE, MI, CARDIOVASCULAR DEATH PROGRESSIVE DISEASE IN 25% WITH PROGRESSIVE INTERMITTENT CLAUDICATION/LIMB THREATENING ISCHEMIA OUTCOMES IMPAIRED QOL LIMB LOSS PREMATURE MORTALITY

RISK FACTORS:

RISK FACTORS HYPERTENSION DIABETES CIGARETTE SMOKING INSUFFICIENT PHYSICAL ACTIVITY OBESITY COMPETITIVE ,STRESSFUL LIFE STYLE TYPE A PERSONALITY USE OF O.C PILLS HYPERCHOLESTOROLEMIA HYPERLIPIDEMIA HYPERURICEMIA HYPERHOMOCYSTINEMIA HYPERLIPOPROTINEMIA HIGH CARBOHYDRATE DIET,HIGH FIBRIN LEVELS

RELATIVE RISK:

RELATIVE RISK MULTIPLE RISK FACTORS EXERT MORE THAN ADDITIVE EFFECT IN FRAMINGHAM STUDY 3 FACTORS R.R. IS SEVEN TIMES 2 FACTORS R.R. IS FOUR TIMES 1 FACTOR R.R. IS DOUBLE

RISK FACTORS FOR PVD: FRAMINGHAM HEART STUDY:

RISK FACTORS FOR PVD: FRAMINGHAM HEART STUDY Reduced Increased Smoking Diabetes Hypertension Hypercholesterolemia Hyperhomocysteinemia Fibrinogen C- Reactive Protein Alcohol Relative Risk .5 1 2 3 4 5 6 Mean follow-up 38 years

PAD IS ASSOCIATED WITH POOR OUTCOMES :

PAD IS ASSOCIATED WITH POOR OUTCOMES EVENT Annual Incidence Prevalence Mortality/yr (%) Stroke 0.73 4.6 28 TIA 0.50 4.9 6.3 ACS 2.3 12.6 45 PAD 8-12 4-25%

PVD ETIOLOGY:

PVD ETIOLOGY LARGE ARTERIES ATHEROSCLEROSIS THROMBOEMBOLISM TRAUMA ARTERITIS OF VARIOUS TYPES INCLUDING BUERGER’S DISEASE FIBROMUSCULAR DYSPLASIA TAKAYASU’S

PVD ETIOLOGY:

PVD ETIOLOGY MEDIUM AND SMALL VESSEL OCCLUSIONS DIABETES CHRONIC RECURRENT TRAUMA MULTIPLE SMALL EMBOLI COLLAGEN VASCULAR DISEASES DYSPROTEINEMIAS POLYCYTHAEMIA VERA PSEUDOXANTHOMA ELASTICUM DRUG REACTION VASOSPASM

PVD ETIOLOGY:

PVD ETIOLOGY SPECIFIC TO CERTAIN ANATOMICAL SITES CYSTIC ADVENTITIAL DISEASE OF THE POPLITEAL ARTERY POPLITEAL ARTERY ENTRAPMENT ILIAC ENDOFIBROSIS (CYCLISTS) VARIOUS NEUROVASCULAR COMPRESSION SYNDROMES AFFECTING THE UPPER LIMB CERVICAL RIB COSTOCLAVICULAR SYNDROME SCALENUS TUNNEL SYNDROME HYPERABDUCTION SYNDROME QUADRANGULAR SPACE SYNDROME

PVD DIFFERENTIAL DIAGNOSIS:

PVD DIFFERENTIAL DIAGNOSIS DEEP VENOUS THROMBOSIS MUSCULOSKELETAL DISORDERS OA RESTLESS LEG SYNDROME PERIPHERAL NEUROPATHY SPINAL STENOSIS (PSEUDOCLAUDICATION) WORSE WITH ERECT POSTURE (LORDOSIS) BETTER SITTING OR LYING DOWN. CAN FIND RELIEF BY LEANING FORWARD AND STRAIGHTENING THE SPINE (PUSHING A SHOPPING CART OR LEANING AGAINST A WALL).

DIFFERENTIAL DIAGNOSIS OF INTERMITTENT CLAUDICATION:

DIFFERENTIAL DIAGNOSIS OF INTERMITTENT CLAUDICATION INTERMITTENT CLAUDICATION VENOUS CLAUDICATION NEUROGENIC CLAUDICATION QUALITY OF PAIN CRAMPING "BURSTING" ELECTRIC SHOCK-LIKE ONSET GRADUAL, CONSISTENT GRADUAL, CAN BE IMMEDIATE CAN BE IMMEDIATE, INCONSISTENT RELIEVED BY STANDING STILL ELEVATION OF LEG SITTING DOWN, BENDING FORWARD LOCATION MUSCLE GROUPS (BUTTOCK, THIGH, CALF) WHOLE LEG POORLY LOCALIZED, CAN AFFECT WHOLE LEG LEGS AFFECTED USUALLY ONE USUALLY ONE OFTEN BOTH

EVALUATION OF PVD:

EVALUATION OF PVD

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HISTORY CLINICAL EVALUATION LABORATORY INVESTIGATIONS VASCULAR LAB NONINVASIVE INVESTIGATIONS INVASIVE INVESTIGATIONS

HISTORY:

HISTORY

PVD HISTORY:

PVD HISTORY USE OF THE HISTORY ALONE TO DETECT PERIPHERAL ARTERIAL DISEASE WILL RESULT IN MISSING UP TO 90 PERCENT OF CASES. ASYMPTOMATIC PATIENTS WITH ABNORMAL ABI HAVE 50% INCREASED RISK OF CARDIOVASCULAR COMPLICATIONS

(HISTORY CONTD…):

(HISTORY CONTD…) PAIN INTERMITTANT CLAUDICATION REST PAIN PARESTHESIAE,TINGLING&NUMBNESS ( SENSORY SYMPTOMS ) PARESIS (MOTOR SYMPTOMS) H/O ULCERATIONS OR GANGRENE (VASCULAR) H/O IMPOTENCY(IN BILATERAL PAIN) RISK FACTORS

(HISTORY CONTD…):

(HISTORY CONTD…) H/O SUPERFICIAL PHLEBITIS(BUERGER’S DISEASE) H/O OF SYMPTOMS THAT SUGGEST INVOLVEMENT OF OTHER ART. SYNCOPE& TIA IN CAROTID CHEST PAIN IN CORONARY BLURRED VISION(AMAUROSIS FUGAX) IN RETINAL ART. ABDOMINAL PAIN IN MESENTERIC FAMILY HISTORY PARTICULARLY IN ATHEROSCLEROSIS

CLINICAL EVALUATION:

CLINICAL EVALUATION

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INSPECTION PALPATION AUSCULTATION

INSPECTION:

INSPECTION INSPECTION OF GANGRENE INSPECTION FOR SPREAD OF INFECTION INSPECTION FOR SPREAD OF GANGRENE INSPECTION OF ISCHEMIC LIMB 1.COLOUR CHANGES 2.SKIN CHANGES 3.BURGER’S POSTURAL TEST 4.CAPILLARY FILLING TIME 5.VENOUS REFILLING

PALPATION:

PALPATION TEMPERATURE TENDERNESS PALPATION OF GANGRENE CREPITUS PROXIMAL LIMB TENDERNESS ALONG ARTERIES PITTING EDEMA CAPILLARY REFILLING VENOUS REFILLING (HARVEY’S SIGN) PALPATION OF PULSES SENSATIONS LOST IN FULLY ESTABLISHED GANGRENE HYPERESTHESIA AT LINE OF DEMARCATION IF ULCER IS SUPERFICIAL NEUROLOGICAL EXAMINATION TO EXCLUDE HEMIPLEGIA ,TRANSVERSEMYELITIS , SYRINGOMYELIA,TABES DORSALIS

SPECIAL TESTS:

SPECIAL TESTS FUSCHSIG’S TEST(CROSSED LEG TEST) COLD WATER TEST(RAYNAUD’S DISEASE) FOR THORACIC OUTLET SYNDROME ELEVATED ARMS STRESS TEST COSTOCLAVICULAR COMPRESSION MANOEUVRE(COSTOCLAVICULAR SYNDROME) HYPER ABDUCTION MANOEUVRE (PECTORALIS MINOR SYNDROME) ADSON’S TEST(CERVICAL RIB,SCALENUS ANTICUS SYNDROME) ALLEN’S TEST(PATENCY OF RADIAL & ULNAR ARTERIES) NICOLODANI’S/BRANHAM’S SIGN(AV FISTULA)

PHYSICAL EXAM: ELEVATION AND DEPENDENCY TEST :

PHYSICAL EXAM: ELEVATION AND DEPENDENCY TEST Halperin, Throm Res. 2002; 106: V303-311 Color Return(s) Venous Filling(s) Normal 10 10-15 Adequate Collaterals 15-25 15-30 Severe Ischemia >35 >40

AUSCULTATION:

AUSCULTATION ALONG BLOOD VESSELS SYSTOLIC BRUIT ART. OCCLUSION/STENOSIS ANEURYSM CONTINUOUS MACHINARY MURMUR AV FISTULA PRESSURE IN BOTH ARMS REACTIVE HYPEREMIA TEST(250mmHg for 5 minutes)

LABORATORY INVESTIGATIONS:

LABORATORY INVESTIGATIONS

BLOOD:

BLOOD F.B.S&P.P.BS HB% E.S.R T.R.B.C PLATELET COUNT BLOOD UREA ,B.U.N & S.CREATININE S.LIPOPROTIEN LIPID PROFILE S.URIC ACID S.HOMOCYSTIENE WASSERMAN REACTION S.FIBRIN

RADIOGRAPHY:

RADIOGRAPHY ARTERIAL CALCIFICATIONS IN ARTERIO SCLEROSIS(MONCKEBERG’S DEGENERATION) FLECKS OF CALCIUM OUT LINE ARTERIAL ANEURYSM DARK SPOTS IN SOFT TISSUE INDICATES GASGANGRENE CERVICAL RIB

CARDIAC EVALUATION:

CARDIAC EVALUATION E.C.G EXERCISE E.C.G RADIOISOTOPEVENTRICULOGRAPHY ECHOCARDIOGRAPHY

ANKLE BRACHIAL INDEX (ABI):

ANKLE BRACHIAL INDEX (ABI) CORNERSTONE OF LOWER EXTREMITY VASCULAR EVALUATION Blood pressure cuffs, Doppler Ankle (DP or PT) to brachial artery pressure NORMAL 0.96 CLAUDICATION 0.50-0.95 REST PAIN 0.21-0.49 TISSUE LOSS 0.20 SIGNIFICANT CHANGE 0.15 OR MORE

LIMITATIONS:

LIMITATIONS NONCOMPRESSIBLE VESSELS Diabetes Renal Failure ABI >1.5 Use toe-brachial index Normal >0.7 Rest pain <0.2 SUBCLAVIAN/BRACHIOCEPHALIC OCCLUSIVE DISEASE

SEGMENTAL PRESSURES:

SEGMENTAL PRESSURES PNEUMATIC CUFFS AT MULTIPLE LEVELS Doppler pressure at pedal artery Drop >30 mm Hg between levels Drop >20 mm Hg between limbs Reflects status of artery above drop in pressure Inaccurate with calcified vessels Rose SC. J Vasc Interv Radiol. 2000; 11:1107-1114

DOPPLER ULTRA SOUND:

DOPPLER ULTRA SOUND NORMAL ARTERY PRODUCES THREE SOUNDS IN OCCLUSION SOUNDS ARE COMLETELY ABSENT AT OBSTRUCTION & ABNORMAL SOUNDS DISTALLY SINGLE HIGH PITCHED CONTINUOUS SOUND JUST BELOW STENOSIS

DUPLEX DOPPLER :

DUPLEX DOPPLER COMBINES HIGH RESOLUTION TWO DIMENSIONAL B MODE ULTRASONOGRAPHY & DO PPLER U/S BOTH ANATOMICAL & FUNCTIONAL INFORMATION B MODE U/S ANATOMICAL DILENIATION DOPPLER U/S GIVES BLOOD FLOW & TURBULENCE COLOUR CODING INDICATE CHANGE IN DIRECTION

PLETHYSMOGRAPHY:

PLETHYSMOGRAPHY ASSESSES CHANGES IN VOLUME OF LIMB OR A DIGIT DURING CARDIAC CYCLE VENOUS OUTFLOW IS OBSTRUCTED & VOLUME CHANGE IS RECORDED WHICH GIVES AN INDICATION OF ARTERIAL IN FLOW AIR FILLED OR WATER FILLED VOLUME RECORDERS ARE USED MERCURY IN RUBBER/SILASTIC STRAIN GAUGE CAN BE USED OCULO PLETHYSMOGRAPHY

OSCILLOMETRY:

OSCILLOMETRY TO DETECT ARTERIAL PULSATIONS AT DIFFERENT LEVELS AT THE LEVEL OF OCCLUSION SUDDEN DECREASE IN MOVEMENT OF NEEDLE TO KNOW THE LEVEL OF AMPUTATION IN BUERGER’S DISEASE

ELECTROMAGNETIC FLOW METER:

ELECTROMAGNETIC FLOW METER BLOOD FLOW PRODUCES ELECTRIC POTENTIAL DIRECTLY PROPORTIONAL TO FLOW VELOCITY CAN DETECT CHANGES IN THE RATE OF BLOOD FLOW OF 1%

INVESTIGATION FOR VASOSPASM:

INVESTIGATION FOR VASOSPASM BROWN’S VASOMOTOR INDEX TO ASSESS THE VALUE OF SYMPATHECTOMY IN BUERGER’S & RAYNAUD’S DISEASES EARLY STAGES OF THESE DISEASES VASOSPASM IS THE CAUSE FOR ARTERIAL OBSTRUCTION IT IS AT THIS STAGE SYMPATHECTOMY IS USEFUL , LATER ORGANIC CHANGES DEVELOP.

BROWN’S VASOMOTOR INDEX:

BROWN’S VASOMOTOR INDEX NERVE BLOCK IS CREATED WITH LOCAL ANAESTHETIC POST. TIBIAL NERVE BEHIND MEDIAL MALLEOLUS ULNAR NERVE BEHIND MEDIAL EPICONDYLE SPINAL AENESTHESIA IN CASE OF ENTIRE LOWER LIMB

BROWN’S VASOMOTOR INDEX:

BROWN’S VASOMOTOR INDEX RISE OF SKIN TEMP.&RISE OF MOUTH TEMP RECORDED BROWN’S VASOMOTOR INDEX RISE OF SKIN TEMP.– RISE OF MOUTH TEMP. -------------------------------------------------------- RISE OF MOUTH TEMPERATURE SYMPATHECTOMY IS ADVISABLE ONLY WHEN THE INDEX IS 3.5 OR MORE

DOPPLER WAVEFORM ANALYSIS: Hemodynamic Information:

DOPPLER WAVEFORM ANALYSIS : Hemodynamic Information Sensitivity of 92.6% and specificity of 97% (angiography gold standard) Inaccurate at adductor canal and the aorto-iliac regions. 95% accuracy in the detection of bypass graft stenosis, but can overestimate stenosis. Polack JF. Duplex Doppler in peripheral arterial disease. Radiol Clin N Amer 1995; 33 : 71-88.

DOPPLER WAVEFORM ANALYSIS: Hemodynamic Information:

DOPPLER WAVEFORM ANALYSIS: Hemodynamic Information Qualitative assessment of waveform analysis Simple Equipment Not affected by medial calcinosis Supplements segmental pressures

IS THIS ENOUGH? :

IS THIS ENOUGH? Noninvasive lab documents presence and severity of disease No comprehensive anatomic information No ability to plan interventions

WHY ANGIOGRAPHY?:

WHY ANGIOGRAPHY?

ANGIOGRAPHY:

ANGIOGRAPHY CONVENTIONAL/CONTRAST ANGIOGRAPHY MR ANGIOGRAPHY CT ANGIOGRAPHY DIGITAL SUBTRACTION ANGIOGRAPHY

CONVENTIONAL ANGIOGRAPHY:

CONVENTIONAL ANGIOGRAPHY 1.RETROGRADE PERCUTANEOUS METHOD (SELDINGER TECHNIQUE) 2.DIRECT ARTERIAL PUNCTURE METHOD HYPAQUE45/SODIUM DIATRIZOATE FEMORAL/BTRACHIAL ARTERIES FREE FLUSH ARTERIOGRAPHY /SELECTIVE ARTERIOGRAPHY THROMBOSIS,ARTERIAL DISSECTION , HAEMATOMA,NEUROLOGICAL DYSFUNCTION & ANAPHYLAXIS

MRA: CURRENT TECHNIQUE:

MRA: CURRENT TECHNIQUE GADOLINIUM ENHANCED 20-40 cc Automated Scan delay Renal arteries to toes 45-min exam

MRI:

MRI

LIMITATIONS OF MRI:

LIMITATIONS OF MRI UNCOOPERATIVE PATIENT CLAUSTROPHOBIA METAL ARTIFACT PACEMAKERS LACK OF VISUALIZATION OF CALCIUM

CTA of PVD:

CTA of PVD MULTIDETECTOR CT SCANNER NECESSARY MANY HOSPITALS NOW HAVE 64 SLICE Iodinated contrast volume similar to conventional angiography 80-150 cc Automated Scan Delay Renal arteries to ankles 20-minute exam High powered post processing software crucial

CTA of PVD:

CTA of PVD

CT LIMITATIONS:

CT LIMITATIONS WITH SIGNIFICANT AND DENSE CALCIFICATIONS, A FALSE DIAGNOSIS OF PATENCY CAN RESULT. UNCOOPERATIVE PATIENT PREGNANCY INCONSISTENT PEDAL VESSEL VISUALIZATION RENAL FAILURE/CONTRAST ALLERGY

DIGITAL SUBTRACTION ANGIOGRAPHY (DSA):

DIGITAL SUBTRACTION ANGIOGRAPHY (DSA ) GOLD STANDARD OF ARTERIAL IMAGING Has almost totally replaced conventional cut film angiography COMPARES A PRE CONTRAST IMAGE WITH A POST CONTRAST IMAGE USING A COMPUTER, AND "SUBTRACTS" ELEMENTS COMMON TO BOTH. Prevents images of objects like bones etc from obscuring vascular details. Contrast resolution is improved through use of image enhancement software.

DIGITAL SUBTRACTION ANGIOGRAPHY (DSA):

DIGITAL SUBTRACTION ANGIOGRAPHY (DSA) ADVANTAGES RADIATION EXPOSURE AND CONTRAST VOLUMES ARE LOWER THAN CONVENTIONAL ANGIOGRAPHY IMAGES ARE IMMEDIATELY AVAILABLE FOR REVIEW. IMAGES ARE STORED IN DIGITAL FORMAT ON COMPUTERIZED DATA STORAGE MEDIA INTERVENTIONAL PROCEDURES CAN BE PERFORMED

DIGITAL SUBTRACTION ANGIOGRAPHY (DSA):

DIGITAL SUBTRACTION ANGIOGRAPHY (DSA) DRAWBACKS PRECLUDING USE AS A SCREENING MODALITY TECHNIQUE IS INVASIVE AND EXPENSIVE. REQUIRES ARTERIAL PUNCTURE LONGER STUDY THAN CT CONTRAST NEPHROTOXICITY

MANAGEMENT:

MANAGEMENT

PowerPoint Presentation:

Goals of treatment for claudication relieve exertional symptoms improve walking capacity improve QOL Goals of treatment for critical leg ischemia relieve ischemic pain at rest heal ischemic ulceration prevent limb loss

Modification of risk factors:

Modification of risk factors Smoking cessation Rx of hyperlipidemia Rx of DM Rx of HT Additional approach

ATIPLATELET AGENTS:

ATIPLATELET AGENTS ASPRIN(325 mg PO DAILY) TICLOPIDINE 120mg /day(GINKGO BILOBA) CLOPIDOGREL 75mg/day

OTHER DRUGS:

OTHER DRUGS PENTOXYPHYLLINE(TRENTAL) 400mg PO TID DECREASES BLOOD VISCOSITY BY CAUSING DEFORMATION OF RBC CILASTAZOLE A PHOSPHODIESTERASE INHIBITOR 100mg PO BID ,IMPAIRS PLATELET AGGREGATION& CAUSES CALCIUM MEDIATED VASODILATATION PROPIONYL-L-CARNITINE 1000mg PO BID ,IMPROVES SKELETAL MUSCLE METABOLISM

SYMPATHECTOMY:

SYMPATHECTOMY NOT EFFECTIVE IN CLAUDICATION MAY RELIEVE REST PAIN & ULCERATION SURGICAL&CHEMICAL(5ml OF PHENOL IN WATER 1:16 IS USED)

OTHER SURGERIES:

OTHER SURGERIES PTA ATHERECTOMY INTRALUMINAL STENTS METAL STENTS SELF EXPANDING STENTS BYPASS GRAFTS SAPHENOUS VEIN ,DACRON (KNITTED/WOVEN) PTFE,DACRON SUPPORTED HUMAN UMBILICAL VEIN SUTURE MATERIAL MONOFILAMENT POLY PROPYLENE/PTFE

THE MOST IMPORTANT CLOTTING FACTOR?:

THE MOST IMPORTANT CLOTTING FACTOR?

THE SURGEON!:

THE SURGEON!

HAVE A NICE DAY& READ WELL FOR INTERNALS :

HAVE A NICE DAY& READ WELL FOR INTERNALS

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