Peripheral Vascular Disease Acute & Chronic Limb Ischemia Lipi Shukla.
Chronic limb ischemia
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Transcript of Chronic limb ischemia
CHRONIC LIMB ISCHEMIA
PROF. DR. A.B.SINGH UNITDepartment of Surgery
Patna medical college & hospital
CONTENT Anatomy of arteries of the limbs Etiology Clinical features History Clinical Examination Investigations Management
ARTERIES OF UPPER LIMB ARTERIES OF LOWER LIMB
Profunda fermoris
Palmar Arches
Chronic Limb ischemia = Decreased limb perfusion for > 2 weeks
2007 Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)
ETIOLOGYLOWER LIMB ISCHEMIA Atherosclerosis thrombangiitis obliterans
UPPER LIMB ISCHEMIA Aorto-arteritis (Takayasu arteritis )Raynaud's disease Thoracic outlet obstructionOther rarer causes mixed cryoglobulinemia, nodular periarteritis, dermatomyositis, systemic scleroderma
SENILE ATHEROSCLEROSIS IS COMMON IN
BOTH LOWER AND UPPER LIMB
RISK FACTORS
Old Age (>70 yrs) Male gender Diabetes Smoking Hypertension Hypercholesterolemia Hypertriglyceridemia Hyperhomocysteinemia Sedentary Lifestyle Family History Fatty diet Drugs ( beta blockers, OCP )
ATHEROSCLEROSIS It is a chronic complex inflammatory condition of elastic and
muscular arteries, involving as systemic and segmental. Common arteries involved are— infrarenal part of abdominal aorta,
coronary arteries, iliofemoral vessels, carotid bifurcation, popliteal arteries. It is less common in upper limb arteries, common carotid, renal and mesenteric arteries.
Brief
pathophysiology
Lipid deposition
calcification
Erosive area& ulceration
Prothrombotic cell activity
Plaque lipid core becomes necrotic covered by FIBROUS
CAP
Rupture, perceived as injury
laying down of platelets and formation of a
clot
THROMBOANGIITIS OBLITERANS SYN. BUERGER’S DISEASE exclusively seen in males of young age group
with history of smoking. Almost always starts in lower limb, may start on one
side and later on the other side. Only upper limb involvement can occur (not uncommon) but it is rare.
segmental, progressive, nonatherosclerotic inflammatory occlusive, disease of small and medium sized vessels with superficial thrombophlebitis often may present with microabscesses, along with neutrophil and giant cell infiltration, with skip lesions.
Intermittent claudication in foot and calf progressing to rest pain, ulceration, gangrene.
Recurrent migratory superficial thrombophlebitis. Absence/feeble pulses distal to proximal; dorsalis pedis,
posterior tibial, popliteal, femoral arteries. May present as Raynaud’s phenomenon.
Smoking Causes vasospasm and hyperplasia of intima
Thrombosis and obliteration of vessels occur, commonly medium sized vessels are involved
Panarteritis is common .Usually involvement is segmental
Eventually artery, vein and nerve are together involved Nerve involvement causes rest pain
Patient presents with features of ischaemia in the limb
If patient continues to smoke, disease progresses into the collaterals,
blocking them eventually, leading to severe ischaemiaand is called as decompensatory peripheral vascular
disease.
PATHOGENESIS
critical limb ischaemia. It causes rest pain, ulceration, gangrene
Classification of THROMBOANGIITIS OBLITERANS Type I: Upper limb TAO—rare.
Type II: Involving leg/s and feet crural/infrapopliteal.
Type III: Femoropopliteal. Type IV: Aortoiliofemoral. Type V: Generalised.
Shianoya’s criteria for Buerger’s disease
1. Tobacco use. 2.Only in males3. Disease starts before 45 years4. Distal extremity involved first without embolic or atherosclerotic features5. Absence of diabetes mellitus or hyperlipidaemia6. With or without thrombophlebitis
THORACIC OUTLET SYNDROMECauses of thoracic outlet syndrome Cervical rib Long C7 transverse process Anomalous insertion of scalene
muscles Scalene muscle hypertrophy Scalene minimus Abnormal bands and ligaments Fracture clavicle or first rib Exostosis Tumours in the region
Cervical rib
THORACIC OUTLET SYNDROMEArterial compromise Fatigue Weakness Coldness Upper limb claudication Thrombosis Paraesthesia Raynaud's phenomenon due to
thrombosis with distal embolisation
Venous compromise Edema Venous distension Collateral formation Cyanosis Paget-Schroetter syndrome –
effort thrombosis
Neural compromise Paraesthesia Pain in shoulder, arm, forearm
and fingers Occipital headache – referred
from tight scalene muscles Weakness of forearm, hand
TAKAYASU’S PULSELESS ARTERITISProgressive, initially symptomless panarteritis, probably immunological.common in young females (85%); common in Japan;subclavian artery (85%); involves all layers of arteries; often
bilateral.
Fever, myalgia, arthralgia, upper limb claudication & hypertension. Absence pulses in upper limb/limbs, neck Fainting on turning the neck or change in position; atrophy of face.
Optic nerve atrophy without papilloedema. Weakness and paraesthesia of upper limb.
DSA; MR angiography and Doppler are the investigations.
To suppress immunity prednisolone 50 mg/day and cyclophosphamide daily is given.
RAYNAUD’S DISEASE:
It is seen in females, usually bilateral.
It occurs in upper limb with normal peripheral pulses.
It is due to upper limb (hand) arteriolar spasm as a result of abnormal sensitivity to cold.
Patient develops blanching, cyanosis and later flushing as in Raynaud’s syndrome.
Occasionally if spasm persists it results in gangrene.
Symptoms can be precipitated and observed by placing hands in cold water.
Types of Raynaud’s phenomenon Vasospastic Obliterative
Raynaud’s syndrome
Local syncope
Local asphyxia
Local recovery Local gangrene
CHRONIC LIMB ISCHEMIA IN DIABETES
Thrombosis can be precipitated by infection causing infective gangrene.
High glucose level in tissues
A good culture media for bacteria
Diabetic microangiopath
y
blockade of microcirculation
Diabetic neuropathy
Glycosylated haemoglobin
Increased in blood causes defective
oxygen dissociation
Limb Ischemia
Diabetic Atherosclerosis
ULCER
Infection
Loss of sensation
Blockage occurs at plantar, tibial, and
dorsalis pedis vessels
Hypoxia
CLASSIFICATION OF LIMB ISCHEMIA
Functional Normal blood flow at rest, but
cannot be increased in response to exercise – Claudication
Three main clinical features Pain is always experienced
in muscle It is reproducibly precipitated
by walking Symptoms are promptly
relieved by rest
Chronic critical limb ischemia
Recurring ischemic pain at rest that persists for more than 2 weeks and requires regular analgesics with an ankle systolic pressure of 50 mm Hg or less Ulceration or gangrene of the foot or toes
PRESENTATION AND DIAGNOSIS OF CHRONIC LIMB ISCHEMIA !!
DEMOGRAPHY OF CLINICAL SYMPTOMS
~15%Classical (Typical) Claudication
~33%Atypical Leg Pain(functionally limited)
50%Asymptomatic
1%-2%Critical Limb Ischemia
CLINICAL PRESENTATIONS Pain( most common symptom)
– on walking (Intermittent claudication / Rest pain
Paraesthesia Pallor Diminished or absent pulse Cold limb ( Poikilothermia) Diminished hair , brittle nail ,
thinning & shining of skin Small Ulcer Gangrene
HISTORY RELATED TO CHRONIC LIMB ISCHEMIA Age : old age – atherosclerosis , young Age : TAO Pain ( intermittent/ continuous) Numbness / tingling / altered sensation Coldness of lower limbs
Later on Ulcer / blackening of part of lower limb other H/O – Fainting / Blackout/ Blurring of vision - Abdominal pain /chest pain - Difficulty in breathing - Weakness in upper limb - Failure of erection
Past History : Hypertension / Diabetes/ CVA
Boyd’s Classification Claudication of Pain
Grade I – Patient develops pain on
walking. But if he continues to walk, the pain disappears. This is due to the washing away of the Substance P
Grade I I– Patient develops pain on
walking. But if he continues to walk, the pain persists. But the patient can still walk with some efforts.
Grade I I I– Patient develops pain on
walking. The pain compels the patient to take rest.
Leriche – Fontaine clinical Classification Stage I : asymptomatic patient;
Stage II: intermittent claudication;
Stage III: pain during rest, lowered in orthostatism.
Stage IV: trophic changes ( ulcerations, gangrene) and permanent pain.
Rutherford classificationGrade Clinical feature0 Asymptomatic1 Mild claudication2 Moderate claudication3 Severe claudication4 Ischaemic rest pain5 Minor tissue loss6 Major tissue loss
Characteristic features of Claudication paino 1. Always precipitated by activityo 2. Relieved by taking resto 3. It is a cramp like pain felt over the muscleso 4.Is always reproducible.
Claudication Distance It is the distance travelled by a person with Peripheral
Occlusive Vascular Disease before the onset of Pain. It is thought to be due to the accumulation of Substance P
and Lactic acid.
Factors Affecting Claudication DistanceClaudication Distance Decreases when- There is increased Speed of walking- Resistance offered for walking- Walking up hill Poor General Health & Systemic diseases of the patient
Pain upto
Buttock, hip
Thigh,upper2/3rd calf
lower 1/3rdCalf,
Obstruction level
Aorta oriliac artery(30%)
Femoral arteryor branches(60%)
Tibial & dorsalis pedis artery
Level of Claudication according to the site of obstruction
Popliteal artery
Ankel & foot
CLAUDICATION VS. PSEUDOCLAUDICATION
Claudication PseudoclaudicationCharacteristic of discomfort
Cramping, tightness, aching, fatigue
Same as claudication plus tingling, burning,
numbnessLocation of discomfort
Buttock, hip, thigh, calf, foot
Same as claudication
Exercise-induced Yes VariableDistance Consistent VariableOccurs with standing No YesAction for relief Stand Sit, change positionTime to relief <5 minutes 30 minutes
DIFFERENTIAL DIAGNOSIS OF LEG PAIN
Vasculara) Chronic venous insufficiency
Neurospinala) Degenerative disc Diseaseb) Spinal canal Stenosis (Pseudoclaudication)
Neuropathica) Diabetesb) Chronic alcohol abuse
Musculoskeletala) OA (variation with weather + time of day)b) Chronic compartment syndrome
Miscellaneousa) Restless leg syndromeb) Symptomatic baker’s cyst
Rest PainRest Pain is the pain felt even at rest. It is due to the Ischemia of the somatic nerves(cry of the dying nerves) Rest pain
Felt in the foot (most distal parts)Exacerbate on lying down or elevation of footWorse at night; patient sits in “hen-holding” positionPressure of even bed clothes worsens the painLessened by hanging the foot down or sleeping on a chair as the gravity aids in the blood flow to the nerves.Patient may commit suicide
hen-holding
Examination: What do to:Inspection
Expose the skin and look for:
• Colour Changes (pallor)• Thick Shiny Skin• Hair Loss • Brittle Nails• Muscle Wasting • Ulcers- number, site, shape,
size ,margin ,edge ,floor• Gangrene :type, colour, extent, line of demarcation
Palpation • Temperature (cool, bilateral/unilateral) • Sensation/Movement • Pulses: ?Regular,?diminished or absent• Capillary Refilling time(normal: <2 sec)• Venous refilling time( Harvey sign)
Auscultation • Systolic bruit may be heard over stenosed artery like subclavian artery, femoral artery, carotid artery, iliac, renal artery.
Buerger’s postural Test
• Ask the Patient lying in supine position to raise his leg and look for development of pallor
• In normal individuals pallor do not develops even at 90°
• Buerger’s angle of vascular insufficiency: It is the angle in which pallor develops on raising legs.
• If this angle is < 30°, it indicates severe ischaemia.
CLINICAL EXAMINATION Pulse Examination
Carotid Radial/ulnar Femoral Popliteal(cross leg test) Dorsalis pedis Posterior tibial
Scale: 0=Absent 1=Diminished 2=Normal 3=Bounding (aneurysm or
AI)
Abdomen should be examined for the presence of abdominal aortic aneurysms. It presents as pulsatile mass above the umbilicus, vertically placed, smooth, soft, nonmobile, not moving with respiration, resonant on percussion.Expansile pulsation is confirmed by placing the patient in knee-elbow position.
Hyperabduction manoeuvre (Wright test)
Allen’s testAdson’s test (Scalene manoeuvre)
Elevated arm stress test (EAST)
modified Roos test
Costoclavicular compression manoeuvre (Falconer test):
It is macroscopic death of tissue in situ with or without putrefaction.
Dry gangrene Wet gangreneDry, shriveled, mummified Odematous, putrified and
discolouredOccurs due to slow and gradual loss of blood supply
Occurs due to sudden loss of blood supply
Infection not present Infection present offensive odor)
Cold temp. ,dull aching pain skin changes colour to dark brown→ dark purplish→ completely dark
offensive odorSwollen, red and warm
Clear line of demarcation is present Vague/ No line of demarcationNo proximal extention Proximal extensionLimited amputation High amputation
INVESTIGATION Routine Blood investigation
sugar , urea , creatinine Serum cholesterol ,
Triglyceride Urine sugar X- ray of lower limb –
calcification of vessels, condition of underlying bone
Ankle-Brachial Index Usg Duplex Arteriography Biopsy of the vessels
Other investigation - USG whole abdomen - ECHO - ECG
Recent Advances in investigations
Xenon 133 Isotopes scanning Trans-cutaneous oximetry
HEMODYNAMIC NONINVASIVE TESTS
Resting Ankle-Brachial Index (ABI)
Exercise ABI Segmental pressure
measurement
These traditional tests continue to provide a simple, risk-free,
and cost-effective approach to establishing the limb ischemia diagnosis
as well as to follow up after the procedures.
EXERCISE ABI Confirms the limb
ischemia diagnosis
Assesses the functional severity of claudication
May “unmask” limb ischemia when resting the ABI is normal
INTERPRETATION OF ANKLE / BRACHIAL INDICIES (ABI’S)
Normal ABI 0.9 – 1.2Mild limb ischemia ABI 0.7 – 0.9Minimal symptomsModerate limb ischemia ABI 0.4 – 0.7
ClaudicationSevere limb ischemia ABI < 0.4
Rest pain, Tissue lossNon-compressible ABI > 1.2
SEGMENTAL PRESSURE MEASUREMENTS
Segmental BP is measured at multiple levels (upper and lower thigh, upper calf and ankle);
pressure reductions between levels help to localise the occlusion;
normally pressures increase as one moves further down the leg (>20 mmHg gradient abnormal); test is inaccurate in calcified artery walls.
ARTERIAL DUPLEX ULTRASOUND TESTING
However, the data that might support use of duplex ultrasound to assess long-term patency of PTA is not robust.
STENOSIS OF SUPERIOR FEMORAL ARTERY BLOCKAGE OF FEMORAL
ARTERY
It is combination of B mode ultrasound and Doppler study. Difference in transmitted beam of the ultrasound and reflected beam is called as Doppler shift which is assessed and converted into audible signals. It is used to study the site, extent, severity of block, and also about collaterals.
ANGIOGRAPHY produces a road map of the blood vessels.
Shows site ,extent and severity of blockage
In Thrombangitis Oblitrans corkscrew apperance Distal run-off inverted tree/ spider leg apperance Corrugated , ripped artery
TYPES Free flush Selective
Collaterals
Blockage at right common iliac Artery
TREATMENT OF CHRONIC LIMB
ISCHEMIA
TREATMENT OFTHORACIC OUTLET SYNDROME
Non operative treatment Posture improving exercises. Breathing exercises. Avoid aggravating activities. Avoid repetitive upper extremity
mechanical work and muscular trauma.
Analgesics,muscle relaxants, antidepressants.
Physiotherapy .
Surgical Indications: Symptoms persists with non
operative treatment. Associated vascular
compression. Progression of neurological
symptoms. Nerve conduction velocity <
60m/s Trans cervical or trans axillary
(Roos) resection of 1st rib often with release of scalene muscles.
Cervical rib excision.
TREATMENT Life style modification Stop smoking Supervised exercise Regular walk Fat free diet Weight reduction limb care buerger’s excercise foot cleaning Application of mousteriser
Avoid precipitating factors— Cold/ Drugs
Strict control of Blood pressure Blood sugar Cholesterol
MEDICAL TREATMENT Vasodialators – Nifedipine Xanthinol nicotinate Pentoxifylin 400 mg TDS PO Decreases blood viscocity Increases flexibity of RBC
Anti-Plateletes Drugs Low dose Asprin 75 mg OD PO Clopidogrel 75 mg OD PO Cilastazole - 100 mg BD PO
Hypolipidimics - Atrovastatin 10- 40 mg OD PO ANALGESICS
Indications: claudication interfering with lifestyle critical limb ischemia
Angioplasty : Conventional Sub- intimal
End artrectomy : Open Semiclosed Weily eversion technique Stenting
Arterial bypass Graft : Natural : Insitu sephanous
Reverse sephanous Artificial : Anatomical Extra Anatomical
Amputation :
SUMMARY OF PREFERRED OPTIONS
PERCUTANEOUS TRANSLUMINAL BALLOON ANGIOPLASTY (PTA):
It is useful in cases of localised stenosed areas. Through trans femoral Seldinger approach, initially angiogram is done. Then
under guidance (fluoroscopic) stenosed area is approached.
Balloon of the angioplasty catheter is inflated at stenosed area for one minute and repeated if required. Plaques should rupture. Catheter is withdrawn.
ENDARTERECTOMY
For focal/ isolated block It is removal of thrombus
along with diseased intima through an arteriotomy.
Endothelium of the vessel is removed, hence the name.
There are three methods—(1) Open method(2) Semi-closed(3) Wiley’s eversion endarterectomy
Advantages are—it avoids prosthetic graft and its
complications—reocclusion and restenosis.
PROFUNDAPLASTY:
localised block in opening of profunda femoris (deep femoral).
Profunda femoris is opened, thrombus if present, is removed.
Opening is widened using either venous or synthetic (Dacron or PTFE) grafts.
ARTERIAL/VENOUS GRAFTS:
Synthetic Dacron woven /knitted graft Dacron coated PTFE—polytetrafluoroethylene graftNatural Long saphenous vein either reverse or in situ Umbilical vein graft (cryopreserved)—3 mm
vein is the minimum diameter required
REVERSE SAPHENOUS VEIN GRAFTAdvantages over synthetic graft Better patency rate ( 5 yr rate : 60% compared to 50% of synthetic graft ) Less prone to thrombus Lesser tendency to dilate
Disadvantage : High skill requiredMore morbid procedure Early Graft Necrosis ( rare now )
ANATOMICAL BYPASS
Femoro-popliteal bypass graft Aortofemoral bypass graft
Aortofemoral Femoropopliteal Poplitealtibial
Complication Hemorrhage Adjacent organ damage Autonomic nerve damageCardiac/Renal/Respiratory Failure Colonic/ pelvic ischemia Aorto-enteric Fistula
EXTRA-ANATOMIC BYPASS
Axillofemoral Axillobifemoral bypass Femoral-Femoral bypass
Axillobifemoral bypass
Axillofemoral bypass
Indications :1.Difficulty in Abdominal / retroperitoneal access2.Abdominal infection/malignancy3.Pt . Unfit for major vascular surgery
LUMBAR SYMPATHECTOMY:
Indications: Peripheral vascular disease like TAO. To promote healing of cutaneous ulcers. To change level of amputation and to
make flaps to heal better after amputation. Causalgia of lower limb (it is common in
upper limb).
Chemical sympathectomy: It is done in lateral position using a long spinal needle under local anaesthesia. Position is confirmed by injecting dye under fluoroscopy. Later 5 ml of phenol in water or absolute alcohol is injected lateral to the vertebral bodies of fourth and second lumbar vertebrae. Care should be taken to see that the needle does not enter IVC or aorta. Procedure is contraindicated in patients with bleedingdisorders and in patients who are on anticoagulants.
OMENTOPLASTY
It promotes ulcer healing, reduces the pain and controls the features of ischaemia.
It can also be used in upper limb ischaemia. If patient continues to smoke, disease spreads to
these omental vessels also.
Complications of omentoplasty:
1.Abdominal sepsis.2. Incisional hernia, 3.Adhesions and intestinal obstruction.
AMPUTATIONS Indications- Gangrenous Non salvageable limb
Evaluation of the Patients who need Amputation1. Haematocrit, 2.control of anaemia by transfusing blood/ packed cells.3.Control of infection using antibiotics.4.Decision of level of amputation by skin temperature, arterial Doppler. 5.Informed consent should be taken.6.Plan for prosthesis and rehabilitation by physiotherapist and rehabilitation team.
FACTORS INFLUENCING SURGICAL TREATMENT RESULTS
AgeAtherogenic risk factorsCo-morbiditiesClinical indication for treatmentSeverity of ischemiaSegmental anatomy of arterial occlusive
diseaseChoice of treatment (open or endovascular)Technical difficultyChoice of materials