Surgical aspects of peripheral vascular diseases

Chronic lower limb ischemia

- Slow onset with gradual symptoms

- Allow the body to develop collaterals
- Mild, moderate, and severe (critical)
- Risk factors:
a- Non-modifiable: age, male gender, family history
b- Modifiable: smoking, DM, HTN, hyperlipidemia, and hyperhomocysteinemia

- The ankle brachial pressure index (ABPI):

➔ A tool used to determine the grade of the ischemia
➔ Measure the ankle systolic pressure (lower limb)
➔ Then we divide it by the brachial systolic pressure (upper limb)
➔ Normal range of ABPI is around 1.0-1.1

- Classification:

1- Stage 1 - Asymptomatic disease (the most common stage)

2- Stage 2 – Intermittent claudication:

➔ Cramping pain (not bursting) in group of muscles (calf, thigh or buttock)
➔ The pain is exacerbated by walking/exercise and relieved only by rest
➔ It usually occurs after walking a specific distance (claudication distance)
➔ The pain is reproducible and predictable
➔ Intermittent claudication indicates ischemia of muscle on exercise
➔ Predictor of coronary heart disease (CHD)

3- Stage 3 - Rest/Night Pain/Critical limb ischemia (CLI)

➔ Severe pain in the foot > 2 weeks (rest pain and tissue loss)
➔ Worse at night and awakens the patient
➔ Aggravated by elevating leg and relieved by hanging leg over side of bed
➔ Rest pain indicates ischemia of the skin and underlying tissue
➔ CLI has a malignant (progressive) course
➔ Decreases life span, the most common cause of death is CHD
 4- Stage 4 - Arterial ulceration of the leg and foot
➔ Minor injuries fail to heal and progress to ulceration
➔ Ulcers on distal extremities (toes) and pressure areas (heel/ball of foot)

5- Stage 5 - Gangrene of the leg and foot

➔ If left untreated, rest pain and ulceration may lead to gangrene
➔ The necrotic tissue may become → wet gangrene → septicemia & death
➔ Dry gangrene: well-demarcated, shrunken, odorless, limb-threatening
➔ Wet gangrene: ill-defined, swollen, smelly, associated with sepsis

- Management:
➔ Conservative: modification of risk factors and lifestyle
➔ Bypass surgery
➔ Balloon angioplasty
➔ Stent angiography

Acute lower limb ischemia

- Presentation is sudden [prompt] with rapid progression (6 Ps):

1- Pain (the earliest)
2- Paresthesia (late)
3- Paralysis (latest and worst outcome)
4- Poikilothermia/perishing cold (coldness)
5- Pallor (or cyanosis) (early)
6- Pulselessness

- Causes:
➔ Embolic diseases:
▪ Embolism is the most common cause of acute limb ischemia
▪ Embolism arises in the heart in IHD or atrial fibrillation
▪ Rheumatic fever is an uncommon cause
▪ Embolization secondary to atherosclerotic thrombus

➔ Thrombotic diseases:
▪ Acute thrombus may arise from chronic atherosclerosis
▪ Thrombus may arise in normal vessel in hypercoagulable states
▪ Popliteal aneurysms may thrombose
▪ Prosthetic or venous grafts may be targets for thrombosis
 - The limb will be salvageable up to 6 hours after the onset of pain
- The limb is non-salvageable after 6 hours or if the paresthesia & paralysis appear
- Management:
➔ Anticoagulants (stat dose of heparin; 5000 IU)
➔ To revascularize the ischemic area we may do embolectomy
➔ Amputation

Diabetic foot
- Spectrum of diseases
➔ Cellulitis ➔ Osteomyelitis
➔ Necrotizing fasciitis ➔ Deformity (Charcot joint)

- Management
➔ Debridement (removal of necrotic tissues)
➔ Control risk factors mainly diabetes (the major risk factor)
➔ Amputation (done if the conservative measure failed to save the leg):
▪ 85% of amputations are due to vascular causes
▪ Two main types:
✓ Minor limb amputation (below ankle + better outcome):
❖ Ray amputation (1+2): single toe amputation
❖ Trans-metatarsal (3+4): more than one toe
❖ Tarso-metatarsal [Lisfranc amputation] (5)
❖ Midtarsal amputation (6)
❖ Intertarsal amputation [Chopart amputation] (7)

✓ Major limb amputation (above ankle amputation):

❖ Below knee amputation (transtibial):
➢ Preferable more than above knee
➢ Better functional outcome
➢ Prosthetic artificial leg can be attached
➢ Needs more time to heal
❖ Above knee amputation (transfemoral):
➢ Worse functional outcome
➢ Needs less time to heal
Aneurysms
- Localized dilatation of a blood vessel
- Abnormal increase in a vessel diameter by 50% or more
- Diameter of the abdominal aorta is normally around 2-2.5 cm
- Diameter of abdominal aortic aneurysm (AAA) > 3.5 cm
- Classification:
a- True (involve all layers of the vessel) and false
b- Congenital and acquired
c- Based on shape:
➔ Fusiform (symmetrical dilation all over the diameter) = more common
➔ Saccular (only one side of the arterial wall will be dilated)
- The most common cause of AAA is degeneration due to aging (senile process):
➔ Localized stress or genetic predisposition causes inflammatory infiltrate
➔ Inflammatory infiltrate causes activation of metalloproteinases (MMP)
➔ Unregulated connective tissue turnover causes degeneration of the aorta
➔ Wall stress from blood flow causes dilatation and aneurysm formation

- Risk factors of AAA is the same risk factors of atherosclerosis, except for DM
- We don't have a screening program for AAA, some countries do abdominal
ultrasound screening any male > 60 or female > 65 years
- Asymptomatic large AAA can be found incidentally
- AAA could be presenting as hip joint pain
- Complications of aneurysms include:
a- Rupture: the main concern of AAA (might lead to death)
b- Thrombosis
c- Embolisms
d- Compression on the adjacent organs/structures

- The decision of treating the aneurysm or not depends on the symptoms & size:
➔ Any symptomatic AAA must be treated
➔ Any aneurysm > 5 cm in diameter must be treated even if asymptomatic
- Two surgical approaches to treat AAA:
➔ Open repair:
▪ Large incision in the abdomen to expose the aorta
▪ A graft is used to repair the dilated portion
➔ Endovascular:
▪ A catheter is inserted through the femoral artery to the target site
▪ Stent graft is inserted at the site of aneurysm
Venous drainage of the lower limb

- Two venous drainage systems:

➔ Superficial venous drainage system (long and short saphenous veins)
▪ Long saphenous vein runs anterior to medial malleolus
▪ Long saphenous vein is intimately attached to saphenous nerve
▪ Short saphenous vein runs posterior to lateral malleolus
▪ Saphenofemoral junctions: 2-4 cm inferiolateral to pubic tubercle
▪ Connected to the deep system via perforators
▪ Affected by certain diseases like varicose veins
▪ Spare system, and converted to be the main system in DVT
▪ Before treating varicose veins, rule out the presence of DVT
➔ Deep venous drainage system: affected by DVT

Deep vein thrombosis (DVT)

- Virchow's triad lists the three causative agents of DVT:
a- Stasis of blood
b- Hypercoagulability state
c- Vessel wall trauma or injury

- Risk factors for DVT include:

a- Female gender
b- Having malignancies
c- Using of oral contraceptive pills (OCP)
d- Sedentary lifestyle
e- Familial coagulopathies (factor V Leiden disease, protein C & S deficiency)

- Classification of DVT:
➔ According to the presence of risk factors:
▪ Provoked (presence of risk factors)
▪ Unprovoked (absence of risk factors)
➔ According to the site of thrombus:
▪ Proximal: worse clinical prognosis
▪ Distal: better clinical prognosis

- DVT of the leg usually occur in the deep veins of the calf around the valve
- Minority in the ilio-femoral area due to direct trauma (surgery/ catheter)
- 80% dissolve completely and 20% propagate proximally
- Propagation usually occurs before embolization
 - Anyone who is admitted to the hospital for a scheduled surgery or for a long
duration must be given a prophylactic anticoagulant to prevent DVT

- The most serious complication of DVT is pulmonary embolism (PE)

- The risk of DVT after a surgery depends on the type of the surgery, usually > 5%
- Risk of DVTs after orthopedic surgery without prophylactic anticoagulants is
around 60-80%, especially in hip or knee replacement
- DVT incidence is usually underestimated, 65% of cases are asymptomatic
- DVT can predispose to secondary varicose veins

- Signs and symptoms:

➔ Bursting pain and tenderness
➔ Swelling and discoloration
➔ Phlegmasia cerula dolens: painful blue inflammation = ischaemic cyanosis
➔ Phlegmasia alba dolens: painful white inflammation = ileofemoral
obstruction and arterial spasm
➔ Increased local temperature and mild fever
➔ Asymptomatic: 65% are asymptomatic and rarely embolize
➔ Shortness of breath: suggestive of pulmonary embolism (PE)

- Management of DVT:
➔ Done mainly using anticoagulants
➔ 80% of DVTs will be resolved during 2-3 months of using anticoagulants
➔ Pneumatic device or elastic stoking can be also used

Varicose vein

- The superficial venous system of the lower leg: greater & lesser saphenous veins
- Diseases of this superficial system are classified depending on the diameter of
the dilated vein into:
a- Telangiectasia / spider naevi (vein diameter is less than 1 mm)
b- Reticular vein (1-3 mm in diameter)
c- Varicose vein (the diameter is more than 3 mm)
- The most common site of varicose vein is the lower limb
- Varicose vein occurs due to a defect in the valvular mechanism of the vein
- Varicose veins can be familial and are more frequent in females
- Varicose veins classification:
a- Primary (idiopathic, congenital or familial): majority
b- Secondary (minority):
➔ Pelvic mass/obstruction to outflow
➔ Previous DVT
➔ AV fistulae
➔ Klippel-Trénaunay Syndrome → triad of the following:
1- Limb bone/subcutaneous tissue hypertrophy
2- Cutaneous capillary malformation (port wine stain)
3- Atypical lateral varicose veins

- Cases of varicose vein are usually asymptomatic

- The most common cause of surgical intervention is cosmetic (aesthetic)
- Sometimes it can cause itching, bleeding or ulcerations
- Venous ulcers occur around the medial malleolus (gutter area)
- Management:
➔ Surgery: vein stripping
➔ Closure: Laser, Radiofrequency ablation
➔ Ultrasound guided injection of sclerosing agent (foam)
➔ Compression garments only

- Lipodermatosclerosis:
➔ Complication of venous hypertension
➔ Associated with hemosiderin deposition
➔ Inverted champagne bottle appearance
➔ Presents as:
a- Scaly skin
b- Discoloration and pigmentation