PERIPHERAL ARTERIAL DISORDERS are due to the stenosis or occlusion

by

 Atherosclerosis
 Thromboembolic diseases
 Trauma
 Inflammatory diseases
FEATURES OF CHRONIC ARTERIAL
STENOSIS/OCCLUSION IN THE LEG

INTERMITTANT CLAUDICATION

 Claudio :- “ I limp”
 Debilitating cramp like pain in the muscles due to the anaerobic
metabolism
 Brought on by walking
 Not present on taking the first step
 Relieved by rest in both the standing and sitting position usually within
5 minutes
CLAUDICATION DISTANCE

 The distance that a patient is able to walk without stopping

 Varies only slightly from day to day

 Decreased by increasing the work demands:-

Walking up hill
Increasing the speed of walking
Carrying heavy weights
 Decreased by conditions reducing O2 delivery capacity:-
Anemia
Cardiorespiratory disease
 The muscle group affected by claudication is classically one anatomical level
below the level of arterial disease

Most
common
 Foot – lower tibial & Plantar vessels
 Calf – femoropopliteal segment [Superficial Femoral Artery (70%)]
 Thigh,buttock – Aortoiliac disease(30%)

 INTERMITTANT BILATERAL CLAUDICATION OF THE BUTTOCKS &

THIGHS
 ABSENT / DECREASED FEMORAL PULSE
 ERECTILE DYSFUNCTION
REST PAIN

 “Cry of dying nerves”

 Anaerobic respiration occurs even at rest
 Typically affects foot/ calf
 Exacerbated by lying down/elevation of the foot
 Worse at night
 Relieved in dependant position
 Hyperaesthesia
 Reduced by holding the foot with hand
 LIMB ISCHEMIA

 FUNCTIONAL ISCHEMIA
Blood flow is normal when limbs are at rest
But will not be increased during exercise
And presents as claudication
 CRITICAL LIMB THREATENING ISCHEMIA (CLTI)

Persistantly recurring ischemic rest pain × 2 weeks

Requiring regular analgesics for > 2 weeks
Or ulceration/gangrene of the foot/toes
With ankle SBP <50mmHg / toe SBP <30mmHg
Ankle Brachial Pressure Index <0.4

Urgent vascular assessment/revascularisation to prevent major amputation

 Drop in the resting ABPI of >20% after exercise is indicative of
FLOW LIMITING ARTERIAL DISEASE

 Artificially high ABI readings (>1.4)

Medial sclerosis & calcification of arterial wall
Vessel incompressibility
Falsely elevated ABI
DM
 Toe Brachial Pressure Index (TBI) <0.6 suggests
significant arterial lesion
 Absolute pressure from the hallux of <50mmHg indicates
severe ischemia
 While calculating the ABPI in patients
with PAD using the formula X/SBP of
the brachial artery,whats taken as the
value of X?

 Highest of SBP of dorsalis pedis,posterior tibial or peroneal artery

 1/3rd of systolic pressure of dorsalis pedis artery
 2/3rd of the systolic pressure of posterior tibial artery
 Sum of systolic pressures of dorsalis pedis and posterior tibial arteries
 GANGRENE
 Macroscopic death of tissue with or without
putrefaction
 Pallor,grayish,purple,brownish black due to
disintegration of haemoglobin to iron sulphide
 Absence of pulse, loss of sensation, loss of
function, loss of temperature

 Pregangrene :- Proximal ischemic features of rest

pain, colour changes & hyperaesthesia
LINE OF DEMARCATION

 Line between viable & dying tissue

 Indicated by a band of hyperaemia
 Indicates the disease is getting
localised
 Final separation by development of
a layer of granulation tissue
 Hyperaesthetic
 Limb salvage – depends on blood supply proximal to the gangrene
 Surgical revascularisation – more conservative debridement & distal
amputation
 Life threatening sepsis - amputation
 LOCAL CHANGES
 Pallor or purple blue cyanosed appearance
 Thinning of skin
 Diminished hair
 Loss of subcutaneous fat
 Brittle nails with transverse ridges
 Ulceration in digits
 Wasting of muscles
 Tenderness & temperature
 Capillary Filling Time
 Paraesthesia
SUNSET FOOT SIGN
 ARTERIAL PULSES

 Condition of the vessel wall

 Always compare with the opposite side

 Pulsation distal to arterial occlusion is usually absent

 Can be palpable – Highly developed collateral
circulation
 Pulse may disappear after exercising the patient to the
point of claudication
DISAPPEARING PULSE SYNDROME (unmask arterial
obstruction)

 Arterial bruit over the stricture-not in tight ones

 BUERGER’SPOSTURAL TEST

Buerger’s angle of vascular insufficiency <30⁰ → Severe ischemia

50yr old Diabetic man presents with a
progressive increase in pain in his right leg with
walking over the last 6months. He now has pain
when he lies down which is relieved by hanging
his leg.What is the expected Ankle Brachial
Pressure Index for this patient?

 <1.3
 <0.4
 <0.7
 <0.9
48yr old male who is a chronic smoker came
to the hospital with intermittent claudication
and pain in both the calves on walking for
about 500m.Which of the following is most
commonly involved in this condition?

 Arterial disease involving the popliteal artery

 Arterial disease involving the Superficial femoral artery
 Arterial disease involving the aortoiliac segment
 Arterial disease involving the profunda femoral artery
DOPPLER ULTRASOUND

 Normal artery – TRIPHASIC SIGNAL

 Qualitative
 ABI – quantitative
DUPLEX DOPPLER ULTRASOUND
 B mode ultrasound + Doppler study
 Site extent severity of block
 Arterial diameter,blood flow rate & velocity

 Audible sound – normal flow

 Turbulance – stenosis partially blocked artery
 Absent – complete block

 Difficulty in Aortoiliac segment ,intrathoracic arteries

 Heavily calcified vessels
 Operator experience
DIGITAL SUBTRACTION PERCUTANEOUS
ANGIOGRAPHY

 CFA – Radio opaque dye(Seldinger

technique)
 Images digitalised
 Eliminate background tissues
 Small lesions
 Dynamic arterial flow information
 Interventions can be done
 Expensive
 Bleeding
 Haematoma
 False aneurysm formation
 Thrombosis
 Arterial dissection
 Distal embolisation
 Thrombosis
 Renal dysfunction
 Hypersensitivity
CT ANGIOGRAPHY

 Minimally invasive
 3D image reconstruction
 Visualize & measure diseased arterial segments
prior to sx

 Ionizing radiation
 Iodinated contrast
 Contrast induced nephropathy
 MR ANGIOGRAPHY
 Non invasive
 No radiation
 No iodinated contrast
 Useful in DM – Calcified vessels
wall
 Separate out contrast from
calcified vessels wall

 Metallic implants, pacemakers

 Gadolinium induced nephrogenic
systemic fibrosis
MANAGEMENT

 Claudication is a marker of silent CAD

 50% Suffer MI or CVA in 10yrs
 ABI<0.5 deteriorate twice as fast as those above it

 MODIFIABLE RISK FACTORS:-

Smoking
DM
HTN
Hyperlipidemia
NON SURGICAL MANAGEMENT

 Structured exercise program

 2hrs/week × 3 months + smoking cessation
 Glycemic control
 Weight loss

 Improve claudication distance

 Decrease CAD risk
TRANSLUMINAL ANGIOPLASTY
& STENTING
SUBINTIMAL ANGIOPLASTY
 SURGERIES FOR ARTERIAL
OCCLUSION
 Aortoiliac occlusion- AORTOBIFEMORAL BYPASS
(Dacron graft)
AXILLOBIFEMORAL
BYPASS
Unilateral Iliac
artery occlusion:-

FEMOROFEMORAL
CROSSOVER
GRAFT
SFA – FEMOROPOPLITEAL BYPASS(PTFE graft)
LONG TERM GRAFT PATENCY

 Quality of inflow & outflow

 Graft length
 The conduit used for bypass
ISOLATED CFA/DFA - ENDARTERECTOMY
FEMORODISTAL BYPASS
PROFUNDAPLASTY
Which of the following is a late
procedure related perioperative
complication of aortobifemoral bypass?

 Chylous ascites
 Bowel ischemia/infarction
 Erectile dysfunction
 Anastomotic pseudoaneurysm
ATHEROSCLEROSIS

 Chronic complex inflammatory condition of elastic & muscular

arteries involving as systemic & segmental
 Begins in childhood as fatty streaks
PATHOGENESIS
 Endothelial injury
 Reduce atheroprotective features of Endothelial
1. Barrier function
2. Antiadhesive effect
3. Antiproliferative effect

 Progressive atheromatous plaque formation

 Thrombosis,migration & proliferation of
vascular smooth muscle cell
 Neointima
 Produce large quantity of matrix of the plaque
 Lipid oxidation
 Macrophages stabilize the plaque
 Atherosclerosis plaque contains
1. Smooth muscle cells
2. Connective tissue matrix
3. Macrophages
4. Lipids

 Ulceration & Calcification

 Thrombogenic
 Ischemia
 Infarction distally
 More at the dividing junctions
 Dynamic in nature
 Adaptation
 Stenosis>40% - CRITICAL
 Atrophy of tunica media
COMMON ARTERIES INVOLVED

 Infrarenal Abdominal Aorta

 Coronaries
 Iliofemorals
 Carotid bifurcation
 Popliteal arteries
 Veins not involved
 Arterial wall thickening
 Thrill
 Bruit
 Features of ischemia
 Abdominal aorta – aneurysm
INVESTIGATIONS

 CBC
 RBS
 RFT
 LIPID PROFILE
 Doppler
 CTA
 USG Abdomen
 ECG
 ECHO
MANAGEMENT
 RF modification
 Drugs

 PTA
 Surgeries
1. Thrombectomy
2. Endarterectomy
3. Profundaplasty
4. Reverse/saphenous vein graft
5. Bypass grafts(AF,IF,IP,FF)
6. Amputations
AORTO ILIAC OCCLUSSIVE DISEASE

 Infrarenal abdominal aorta & IliaC arteries

 Aortic Bifurcation – most common site of occlusion
CLINICAL FEATURES

 5th 6th decades

 Males
 Leriches syndrome
 Femoral Pulsation absent
 Bruit
 Embolus
 Aortic angiogram
MANAGEMENT

 RF modification
 Drugs

 Direct Anatomical
Reconstruction
1. AORTOILIAC
ENDARTERECTOMY- Type I
disease
SEMICLOSED
ENDARTERECTOMY
2.AORTOBIFEMORAL BYPASS GRAFT

 Gold standard
 Type I & Type II
 Long term potency 70-80%
 Woven Dacron Graft
COMPLICATIONS

 Bleeding
 Thrombosis
 Embolisation
 Graft blockage
 Graft failure
 Graft infection
 Graft leak
 Aortovenecaval/
aortoduodenal fistula
 Mesentric ischemia
 Impotence
3. INDIRECT EXTRA ANATOMICAL BYPASS

 Axillobifemoral graft
4.Non operative catheter based
endovascular procedure
 Stenosis < 5cm
 PTA with or without stent
 Short focal stenosis(Single/multiple)
 Long term potency equal
THROMBOANGITIS OBLITERANS/
BUERGER’S DISEASE
 Nonatherosclerotic inflammatory disorder
involving medium & small sized vessels with cell
mediated sensitivity to type I & III collagen

1. Segmental
2. Progressive
3. Occlusive
4. Superficial thrombophlebitis
5. Neutrophils & giant cell infiltration
6. Raynaud’s phenomenon
7. Skip lesions
CLINICAL FEATURES

 Males
 20-40yrs
 Smoking,Tobacco-SMOKER’S DISEASE
 Start on lower limb first
 Intermittent claudication
 Rest pain,Ulceration,Gangrene
 R/C migratory superficial thrombophlebitis
 Absence/feeble pulses distal to proximal
PATHOGENESIS
 CO & Nicotinic acid
 Carboxyhaemoglobin

 Vasospasm & intimal hyperplasia of medium sized vessvessels

 Thrombosis
 PANARTERITIS(segmental)
 Artery,vein,nerve involvement
 Ischemia in limb
 Collateral formation – COMPENSATORY PVD

 Progress into the collateral - DECOMPENSATORY PVD[CLTI-Rest pain,Ulceration,Gangrene]

SHIANOYA’S CRITERIA

 Tobacco use
 Start before 45yrs
 Distal extremity first involved
without embolic/atherosclerotic features
 Absence of DM / DLP
 With or without thrombophlebitis
CLASSIFICATION OF TAO

 TYPE I : Upper limb

 TYPE II : Legs & feet(infrapopliteal)
 TYPE III : Femoropopliteal
 TYPE IV : Aortoiliofemoral
 TYPE V : Generalised
INVESTIGATIONS

 Hb
 RBS
 Arterial Doppler &
Duplex scan

 Transfemoral Angiogram
1. Site Extent Severity
2. Cork screw appearance
3. Inverted tree/spider leg
4. Rippled artery
5. Distal run off

 Biopsy
 INVERTED TREE/SPIDER LEG  CORRUGATED/RIPPLED ARTERY
COLLATERALS
TREATMENT

 Stop smoking

 Vasodialators- Nifedipine
 Pentoxiphylline
 Aspirin
 Prostacyclins Ticlopidine Praxilene
 Clopidogrel
 Atorvastatin
 Cilostazole
 Xanthine nicotinate
CARE OF THE LIMBS

 Buerger’s position & exercise

 Chiropady(care of feet)
1. Avoid exposure to cold and warm temperatures
2. Avoid even minor traumas
3. Avoid dryness
4. Wear socks
5. Heel rise
 Chemical sympathectomy
1. Xylocaine 1%/5ml phenol in water
2. L2 3 4
3. Paravertebrally

 Omentoplasty
 Lumbar sympathectomy
 Amputations
 Ilzarov method

 Gene therapy - VEGF

 RAYNAUD’S PHENOMENON

 Episodic arterial spasm

 Leads to a sequence of clinical features called Raynaud’s syndrome

1. LOCAL SYNCOPE :- White cold palm & digits with tingling & numbness
2. LOCAL ASPHYXIA :- Due to accumulation of deoxygenated
blood→bluish discoloration with burning sensation
3. LOCAL RECOVERY :-Flushing & pain in palm
4. LOCAL GANGRENE:-If spasm persists more than 1hr
 COFFMAN CRITERIA

 Episodic attacks
 Well demarcated
 Reversible
 Self limiting
 Colour changes for 1-20 minutes
 On exposure to cold/emotional stimuli
 Symmetrical/bilateral
 Lasting for 2yrs
CAUSES FOR RAYNAUD’S
PHENOMENON
 RAYNAUD’S DISEASE
 VIBRATION WHITE FINGER
 COLLAGEN VASCULAR DISEASE(Scleroderma,RA,)
 CERVICAL RIB
 BUERGERS DISEASE
 SCALENE SYNDROME
FEATURES OF RAYNAUD’S DISEASE

 Bilateral
 Young females
 Western white women
 Medial 4 digits & palm. Thumb spared
 Pallor → Cyanosis → flushing/red engorgement
 If vasospasm prolongs-gangrene over fingertips
 Peripheral pulses normal
 Episodic attacks
INVESTIGATIONS

 DUS
 DSA
 MRA
 X RAY
 ANA

 Segmental blood pressure gradient from brachial-forearm-wrist-fingers

 Fingertip thermography
 Cold recovery time >30 minutes
 Reactive hyperaemia time
TREATMENT

 Treat the cause

 Avoid precipitating factors

 VASODIALATORS:-Pentoxyphylline Nifedipine
 STEROIDS:- secondary raynauds
 ACE inhibitors
 Nitrates
 Epoprostenol
 Iloprost
 Bosentan
A young female who presented with the history of
intermittent attacks of pallor and cyanosis in
upper limbs was diagnosed with Raynaud’s
disease. Which of the following options represents
the correct sequence of events seen in this
condition?

 LOCAL syncope→recovery→asphyxia→gangrene
 LOCAL asphyxia→recovery→syncope→gangrene
 LOCAL syncope→asphyxia→recovery→gangrene
 LOCAL asphyxia→syncope→recovery→gangrene
ACUTE ARTERIAL OCCLUSION

 Embolism
 Thrombosis due to trauma
 Subintimal haematoma
 Acute compartment syndrome
 Femoral /brachial artery catheterization
EMBOLIC ARTERIAL OCCLUSION

 SOURCE:-

CARDIAC (80%) – LA(AF); LV(MI)

Vegetations (endocarditis,prosthetic valve)
Intracardiac tumors
NON CARDIAC - Aneurysms,Atherosclerosis plaque
VENOUS EMBOLI
FAT EMBOLISM
AIR EMBOLISM
CLINICAL FEATURES
 Most common site –
 Bifurcation of CFA(40%)>PA>(15%)>CIA(12%)>Aortic Bifurcation

 ACUTE LIMB ISCHEMIA – Embolism/Trauma/Thrombosed PA/PA

entrapment
 5P
1. Pain
2. Pallor
3. Paraesthesia
4. Paralysis
5. Pulselessness

 Thrusting femoral pulse

 Rhabdomyolysis
 Concurrent venous Thrombosis- very poor prognosis
INVESTIGATIONS

 ECG
 Coagulation profile
 Creatinine Kinase
 RFT
 DUS
 CTA (gold standard)
TREATMENT
 Irreversible change in 6hrs

 Stasis→Thrombosis
 Heparin
 Analgesics

 Embolectomy
 Thrombolysis(Tissue Plasminogen Activator)

1. Recent CVA,Sx,Bleed
2. Bleeding diathesis,Gastric/Duodenal ulcer
3. Pregnancy,uncontrolled HTN
4. >80yrs old
COMPLICATIONS

 Reperfusion injury
 No reflow phenomenon
 Compartment syndrome
 Sepsis
 Reblock
 Bleeding
 Which of the following is not an absolute
contraindication to the thrombolytic
therapy?

 Recent (<10 days) GI Bleed

 Puncture of non compressible vessel
 Intracranial malignancy / metastasis
 Established cerebrovascular events in the last 2 months
AMPUTATION

 Considered when tissue is dead

 Life saving operation
 Antibiotic cover
 Gas gangrene,neoplasm,AVF
GANGRENOUS TOE

 Local amputation of the digits

 Metatarsophalangeal joint –
RAY AMPUTATION
TRANSMETATARSAL
AMPUTATION
ANEURYSMS
 Dialatation of localised segments of arterial system(>50%)
 Ectatic(<50%)
 CLINICAL FEATURES
 Expansile Pulsation
 Thrill
 Bruit
 Reduction in size when pressed proximally
 Soft warm compressible swelling
 Altered sensation due to compression of nerves
 Erosion into
bones,skin,veins,joints,trachea,esophagus,stomach
 Thrombosis & distal ischemia
 Acute arterial occlusion
 Rupture
 Infection
 ABDOMINAL AORTIC ANEURYSM

 Most common large vessel aneurysm

 Incidence 2%
 Males(4:1)
 Old age
 Smokers (8:1)
 95% have atheroscleromatous degeneration
 95% occur below renal arteries
 Transverse diameter >3cm
 CLINICAL FEATURES

 Back pain
 Abdominal pain
 Mass abdomen
 Ureteric obstruction
 Aortocaval fistula – steal phenomenon
 Aortoenteric fistula due to erosion
 Inflammatory aneurysm(5%)
 INVESTIGATIONS
 Blood work up
 ECG
 ECHO
 DUS
 CTA
 MRA
 DSA

 Screening tool is USG

1. CAD(60-85yrs)
2. Family history(50yrs)
3. Asymptomatic AAA
Annually(4-4.5cm)
Once in 6months(>4.5cm)
 MANAGEMENT
 CONSERVATIVE MANAGEMENT
 Low risk AAA
1. Age<70yrs
2. Physically active
3. No CVS Resp Renal disease
4. Noninflammatory aneurysm
5. <5cm
6. Growth rate <0.5cm/yr

 Risk factor modification

 Alpha blockers, Elastase inhibitors(Indomethacin),MMP inhibitor(Doxycyclin)

 Periodic size assessment with USG every 6 month

INDICATIONS FOR SURGERY

 Asymptomatic AAA >5.5cm

 Growth rate >0.5cm/yr
 Painful tender aneurysm
 Thrombosed aneurysm with distal emboli
 ENDOANEURYSMORRHAPHY WITH
INTRALUMINAL GRAFT PLACEMENT

 OPEN ANEURYSM REPAIR

ENDOVASCULAR
ANEURYSM REPAIR
(EVAR)

 Old age (>65yrs)

 Unfit for Sx
 Size <5.5cm(Male)
 Size <5cm(females)

 Aneurysm exclusion method

RUPTURED AAA

 Anterior rupture (20%)

 Posterior rupture (80%)

 Triad:- Severe abdominal pain/back pain

Hypotension
Pulsatile abdominal mass
 Shock, Absent femoral pulsations
COMPLICATIONS
 POPLITEAL ANEURYSM
 Men
 7th decade
 Most common peripheral aneurysm(70%)
 50% bilateral
 25% associated with AAA

 Swelling behind knee-mimic pyogenic abscess

 Thrill
 Bruit
 Distal ischemia –Thrombosis & embolism
 Rupture-torrential bleed
INVESTIGATIONS

 DUS
 CTA
 MRA
 DSA
EXCLUSION
BYPASS

 >20mm – elective repair

 All symptomatic patients
INLAY REPAIR
FEMORAL ANEURYSM
An elderly man presents with severe worsening
abdominal pain for the past day.He underwent
angioplasty for CAD 2yrs back.The patient was
haemodynamically stable.On examination a
pulsatile mass was present in the abdomen.USG
revealed an intzct abdominal aortic aneurysm of
4.5cm.What should be the management plan for
this patient?

 Follow up every 6 months; operate if size increases > 5.5cm

 Follow up every 2 months; operate if size > 5 m
 Immediate surgical repair of the aneurysm
 Follow up every 3 months; operate if more than 5.5cm
AORTIC DISSECTION

 Dissection of media of the

aorta after splitting through
intimate creating a channel
in the media
CLINICAL FEATURES

 Thoracic aorta –
Ascending aorta(70%)
 Double Barelled Aorta

 Pain
 Ischemia

 Rupture into
pericardium/
Pleura-dangerous types
 INVESTIGATIONS

 CXR – mediastinal widening

 Arterial doppler
 Angiogram
TREATMENT

 Antihypertensive

 INDICATIONS FOR Sx
1. Progressive disease
2. Significant ischemia
3. Impending rupture
4. Type A aortic dissection

 Dacron Graft Reconstruction of aorta using cardiopulmonary bypass

A 65yr old man presents with acute pain in
the chest radiating to the interscapular region
of the back.He is a known hypertensive for the
past 10 years. His CT Thorax is given
below.Which of the following statements
regarding his condition is false?

 Stanford type B always require emergency repair

 Commonly associated with marfan syndrome
 The descending type can cause paraplegia
 Cardiac tamponade can occur as a complication