ARTERIAL DISORDERS

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DR. A. NATARAJAN PROF. OF SURGERY MMCH & RI

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ARTERIAL DISORDERS INTRODUCTION: Common cause of morbidity & mortality in western countries due to atheroma. Disorders of artery supplying heart muscle causes coronary thrombosis & MI. In brain it causes stroke. Here arteries of body other than heart & brain will be discussed.

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ARTERIAL STENOSIS & OCCLUSION: CAUSE OF EFFECT: Atheroma, emboli or trauma. Lower limb – claudication, rest pain & gangrene. Kidney – HT & renal failure. Intestines - abdominal pain & infarction.

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SYMPTOMS & SIGNS OF LOWER LIMB ARTERIAL STENOSIS OR OCCLUSION: INTERMITTENT CLAUDICATION: Brought by walking. Relieved by standing still. Rest pain. Cold, Numbness, paraesthesia, colour change.

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Cont - Ulceration & gangrene. Sensation decreased. Diminished or loss of movements. Decreased or absent pulsation. Arterial bruits. Decreased venous refilling.

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INTERMITTENT CLAUDICATION: Crampy pain in the muscles of lower limbs, due to accumulation of lactic acid & ‘P’ substance in the muscles. Distance walked before the onset of pain called claudication distance. Common in calf, thigh or buttock. Pain buttock occur on walking, & associated sexual impotence, from arterial ischemia – leriche syndrome. Less common in upper limb in subclavian, axillary or brachial artery. Pain brought by manual work.

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REST PAIN: Severe pain felt in foot at rest. Worse by lying down or elevation of foot. Relieved by hanging the foot out of bed. COLDNESS, NUMBNESS, PARAESTHESIA & COLOR CHANGE: Common in moderate & severe ischemia in the absence of color change. Blanched on elevation, purple discoloration on dependency due to extra vasation of RBCS through capillary walls. Angle of elevation at which blanching occus called bourger;s angle of ischemia.

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ULCERATION & GANGRENE: Painful, superficial erosion between toes. Small, shallow ulcers occur on the dorsum of feet, shins & around malleoli. Combination of rest pain, colour change, hyperaesthesia with or with out ischemic ulcer– pregangrene. Blackened, mummified skin & tissues – gangrene.

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TEMPERATURE SENSATION & MOVEMENT: Usually cold, but paradoxically may be warm by taking the surrounding temperature. Limb becomes paralysed without sensation, hyperaesthesia in pregangrenous state.

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ARTERIAL PULSATIONS: Below the occlusion in main artery, pulse absent, but feeble with good collaterals. Expansile pulsation with a mass - aneurysm. “Disappearing pulse” may be useful . (patient exercised to get claudication & cause palpable pulse to disappear) Systolic bruit heard over an artery due to turbulence caused by stenosis. Continuous ‘ machinery’ murmur due to A.V. fistula.

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VENOUS REFILLING: Limb elevated for 30 secs & laid flat on the bed-normal refilling occur in few secs. Reduced venous filling occur in arterial insufficiency, vasospastic disease & cold weather, Two index fingers placed firmly side by side on a vein, the finger nearer heart moved to empty a short segment, & release of distal finger allow speed of venous refilling ( Harrey’s sign) Increased venous return &varicosities of veins associated with arteiro venous fistula

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INVESTIGATIONS: Complete hemogram (RBC count, Hb, ESR, platelets, fibrinogen, protein electrophoresis, cholesterol, sugar & urine glucose etc.) Plain X-ray abdomen (to show arterial calcification, flecks of ‘Ca’ outlining aneurysm neoplasm & lung diseases. ECG – to rule out CCF, MI & HT. PFT. RFT ( to rule out renal failure). IVP

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Cont- Doppler ultra sound blood flow detection. Ankle – brachial pressure index (ABPI) (ratio of systolic pressure at ankle & brachial) Normal – 1, below -1 indicate arterial obstruction. Duplex doppler – shows direction & velocity of blood flow, the condition of vessel wall & the site of obstruction. Treadmill – to detect fall in ABPI after exercise- indicating occult arterial stenosis.

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ANGIOGRAPHY: Injection of radiopaque solution in to femoral artery by retrograde percutaneous catheter method. DSA- by arterial injection of contrast. MRA.

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NON- SURGICAL MANAGEMENT: Walking excise to the limit of disability- to develop good collaterals. Fat free diet. Forbidden of smoking. Anti hypertensive ( β - blockers), anti diabetic & anticholesterolemia drugs to be given. Anti platelet drugs ( aspirin – 75 to 150 mg/ daily, or clopidogrel) Vaso dilators ( praxidene) Trental & prostacyclin- lowers blood viscosity.

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TRANSLUMINAL ANGIOPLASTY & STENTING : By inserting balloon catheter in to narrowed , blocked area of artery, inflated for 1mt & deflated. Then the metal stent kept.(iliac vessels , upper & lower limb vessels) OPERATIONS FOR STENOSIS OR OCCLUSION: Aorto iliac occlusion– Aorto femoral - bypass. If the block limited in extent - iliac endarterectomy or percutaneous transluminal angioplasty ( PTA) with stent may be advised.

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Cont- In patients not with stand abdominal – surgery , and has pronounced ischemia – femoro femoral or ilio femoral cross over by pass considered in unilateral disease. If both iliac segments diseased – axillo bifemoral by pass indicated. Superficial femoral & profunda femoris artery block-angioplasty or femoro -popliteal by pass, using patients saphenous vein as reversed conduit. Polytetrafluoroethylene (PTFE) graft can be used.

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OTHER SITES OF ATHEROMATONS OCCLUSIVE DISEASE: Carotid stenosis due to atheroma, may cause transient ischemic attacks (TIA) - carotid endarterectomy. Subclavian artery stenosis, cause claudication & ischemia of arm-percutaneous transluminal balloon angioplasty preferable. If due to cervical rib, it is to be excised. Subclavian steal syndrome occur, if 1 st part of subclavian artery obstructed- the vertebral artery provides collateral circulation to arm causing cerebral ischemia (syncopal attack, visual disturbances & low BP in the affected limb.

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Cont- Treated by percutaneous transluminal angioplasty or endartercetomy or bypass from ipsilateral common carotid artery to 3 rd part of subclavian artery. Enteric artery occlusion cause pain after food & weight loss. Coeliac axis, superior mesenteric or inferior mesenteric artery may occlude to produce intestinal claudication- treated by balloon angioplasty, endarterectomy or by pass.

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Cont- Renal artery stenosis causes HT & loss of renal function.Hypertension treated by antihypertensive drugs. The stenosis treated by PTA, endarterectomy aortorenal bypass, renal artery revascularisation using splenic artery to renal autotransplantation.

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ACUTE ARTERIAL OCCLUSION: Sudden occlusion of an artery is due to either embolic or trauma. Due to thrombus on a plaque of preexisting atheroma. EMBOLIC OCCLUSION: Foreign body (thrombus) causing vascular occlusion. Causes cardiac arrhythmias, atrial fibrillation, mural thrombus due to myocardial infarction & aneurysms.

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CLINICAL FEATURES: Symptoms in lower limb are pain, pallor, paresis, pulse lessness, paraesthesia. The limb cold & cannot be moved. In venous occlusion muscle function not affected. In brain middle cerebral artery or its branches affected & causing temporary or permanent hemiplegia. Mesenteric vessels occlusion causes engorgement & gangrene of corresponding loop of intestines.

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Cont – In spleen causes local pain. In kidneys- loin pain & hematuria. In lungs may cause fatal, but in living patients hemoptysis & dyspnoea. TREATMENT: Injection heparin 5000 iu, IV Analgesic (aspirin). Embolectomy or thrombolysis using tissue plasminogen activator (TPA), strepto kinase or urokinase.

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MESENTERIC ARTERY OCCLUSION: Due to atheromatous narrowing or embolic. Weight loss. Abdominal pain (Post prandial) Leucocytosis. Diarrhoea, hypovolemia & hemo -concentration.

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TREATMENT: Arteriography followed by percutaneous transluminal angioplasty or bypass - if bowel not infarcted. AIR EMBOLISM: Occur occasionally, when large veins of neck & axilla injured. Air enters right atrium, then to right ventricle causes air lock in pulmonary artery leading to right sided heart failure.

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TREATMENT: placing patient in trendelenburg position to allow air to pass in to veins of lower half of body. Also place the patient on left side, so that air float in to apex of ventricle, away from pulmonary artery. O 2 administered to counteract hypoxemia & to excrete nitrogen. In serious condition right ventricle aspirated by needle passed upwards & backwards from below left costal margin.

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Cont- In open heart surgery , injury to pulmonary vein, air may enter in to left side of heart, coronary or cerebral arteries- treated as same as venous air embolism. Air embolism also common in fallopian tube insufflation, illegal abortion, the air may travel through paravertebral veins to brain.

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FAT EMBOLISM: Due to severe injuries with fractures & electro convulsive therapy. Fat derived from bone marrow or adipose tissue & also by aggregation of chylomicrons. In cerebral type - patient drowsy, restless & disoriented, then to coma. Pupils small Pyrexia. In pulmonary type- cyanosis, signs of right heart failure.

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Cont – White froth at mouth & nostrils. Emboli in retinal arteries causing striate hemorrhages & patches of exudate. Examination of sputum & urine shows fat droplets. Low Hb & petechial hemorrhages occur. TREATMENT: Heparin IV low molecular weight dextran.

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OTHER FORMS OF EMBOLI: Infective embolus, masses of bacteria, infected clot, causes mycotic aneurysms pyrexia & infected infarcts. Parasitic emboli due to ova of tenia echinococcus & pilaria sanguinis hominis. Emboli of malignant cells (hypernephroma & cardiac myxoma)

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THERAPEUTIC EMBOLISATION: To arrest hemorrhage from GI, urinary & respiratory tracts. To treat arterio venous malformations by blocking arterial supply. To control growth of unresectable tumours. Left gastric or gastro duodenal artery occluded to treat bleeding ulcer. Occlusion of hepatic artery to relieve pain of primary & secondary liver tumours, & also control endocrine effects of hormone secreting tumours (metastatic carcinoid)

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Cont- Renal artery embolisation to devascularisc renal tumour prior to surgery & to arrest hemorrhage from unresectable tumour. In oesophageal variceal bleeding embolisation of portal system by percutanous catheterisation through liver & veins supplying varices. In arteries blood clot, gelfoam, sponge, human dura, plastic microspheres, balloons, ethyl alcohol, stainless steelcoils & wool are used.

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ACUTE ARTERIAL OCCLUSION DUE TO TRAUMA: In traumatic arterial occlusion, thrombus in the lumen, sub intimal hematoma in the wall & compartment syndrome involving surrounding tissues. Absent pulse with rest pain, skin colur & temperature changes suggest arterial occlusion. Common cause of arterial trauma is femoral or brachial artery cardiac catheterisation.

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MANAGEMENT: Pre- operative angiography to recognise pre- existing atheromatous disease. If laceration is small, single suture suffice to repair a leak. If damage is more & thrombus forms- resection of damaged segment & direct anastomosis of cut ends or short inter position graft (vein) preferred.

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Cont - Associated venous damage, tied to control bleeding (Deap or superficial femoral). Common femoral & popliteal repaired by direct anastomosis or interposition of graft. Fractures of bone require stabilisation (external fixation) to protect vascular repair.

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COMPARTMENT SYNDROME: In limbs, compression of main artery due to hematoma or edema in fixed fascial compartments can cause distal ischemia – fasciotomy. Anterior tibial compartment – fasciotomy at calf. Thigh & arm affect rarely.

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Thank you

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