VASCULAR SURGERY

Assessment of arterial circulation in limp.

• Inspect: 1. Color: marble white, blue hue, cyanosed 2. Vascular angle- Burger's angle: lift leg to white look at

what angle the leg is. 3. Capillary filling time: after lifting the leg but it over the

bed and see how long it takes for skin to turn pink. 4. Venous filling: look for guttering, and angle of venous

loss. 5. Pressure areas: look particularly closely at these, as

changes will be first apparent here, trophic, ulceration, gangrenous changes-heel, malleoli, head of 5th metatarsal, tips of toes, between toes, ball of foot.

Assessment of arterial circulation in limp

• Palpation: – Temperature: after 5 min exposure to ambiant temp.

– Capillary refilling: press tip of toe.

– Pulses: fem, dorsalis pedis, posterial tibial artery (medial malleoli), popliteal.

– Test muscles/nerves- may be affected by ischaemia.

• Auscultation:– over all major arteries

– Blood pressure in both armes.

ISCHEMIA

It the condition of inadequate blood supply to an area of tissue producing harmful effect to its function &nutrition

Acute Ischemia

It the condition of inadequate blood supply to an area of tissue producing harmful effect to its function &nutrition of less than 2 weeks duration

Acute Ischemia ( etiology)

1. Embolism2. Thrombosis3. Others

– Acute arterial trauma– Dissecting aortic aneurysm– Compartmental syndrome– External compression– Poploteal entrapment– Cystic adventational disease

Acute Ischemia

I viableI viable

DescriptionDescriptionNot threatenedNot threatened

Muscle Muscle weaknessweakness

NoNo

Sensory lossSensory lossNoNo

Arterial on Arterial on DopplerDoppler

AudibleAudible

>30 mmHg>30 mmHg

Venous on Venous on DopplerDoppler

AudibleAudible

IIa

Marginally

Salvagable

With Tr

No

No

Inaudible

Audible

IIb

ImmediatelySalvagable with

re vascularization

Mild to moderate

Rest pain

Inaudible

Audible

III

Irreversable

Major loss & permanent

damage

Profound paralysis

anesthesia

Inaudible

Inaudible

Acute Ischemia

I viableI viable

DescriptionDescriptionNot threatenedNot threatened

ClinicallyClinicallyNormalNormal

IIa

Marginally

Salvagable

With Tr

Less sever

ischemia

IIb

Immediately

Salvagable with re

vascularization

Sever ischemia

III

Irreversable

Major loss & permanent

damage

Gangrenous

Acute Ischemialess sever ischemiaSever ischemia

onsetGradual over few daysSudden within hours

HistoryChronic ischemia with previous claudication or rest pain

Normal limb but with cardiac problem as a source of emboli

1. PainSever then decreaseSever resistant to analgesia

2. ParesisFoot drop & tender calf are bad signs

Unable to move

3. Par aesthesia

presentEven anesthesia due to nerve

ischemia

4. Perishing cold

Colder than other limbColder than other limb

5. PallorLimb dusky color

Sever pallor then marble due to purple batches then fixed

blue

6. Pulseabsentabsent

Acute Ischemialess sever ischemiaSever ischemia

Contra-lateral limb examination

May detect absent pulse due to

atherosclerosisUsually normal

Ipsi-lateral limb

examination

may detect poploteal aneurysm as a

source of emboli

Acute ischemia with Gangrene

ARTERIAL EMBOLISM (Sever Ischemia)1. PainSever resistant to analgesia

2. ParesisUnable to move

3. Par aesthesiaEven anesthesia due to nerve ischemia

4. Perishing coldColder than other limb

5. PallorSever pallor then marble due to purple batches then fixed blue

6. Pulseabsent

Less sever Ischemia1. PainSever then decrease

2. ParesisFoot drop & tender calf are bad signs

3. Par aesthesiapresent

4. Perishing coldColder than other limb

5. PallorLimb dusky color

6. Pulseabsent

Less sever Ischemia

Less sever Ischemia

Management of acute ischemia

• Investigations– Urea, electrolytes, BSL– ECG, chest x ray

• Initial treatment– Rehydration– I V analgesia– Heparinization

Acute IschemiaIIa

Marginally

Salvagable

With Tr

Less sever ischemia

Angiography

Then

Thrombo-lysis

Then

bypass

IIb

Immediately

Salvagable with re vascularization

Sever ischemia

Embolectomy

III

Irreversable

Major loss & permanent damage

Gangrenous

Amputation or

terminal care

Acute LL ischemiaAcute LL ischemia

Sever LL ischemiaSever LL ischemia(previously normal limb)(previously normal limb)

Less sever LL ischemiaLess sever LL ischemia(previously ischemic limb)(previously ischemic limb)

Fogarty embolectomyFogarty embolectomyArterio-graphy must be Arterio-graphy must be

done to determine done to determine site, size& extent of site, size& extent of thrombus occlusionthrombus occlusion

Sever LL ischemiaSever LL ischemia(previously normal limb)(previously normal limb)

Femoral embolectomyFemoral embolectomy(assess degree of inflow)(assess degree of inflow)

Poor inflowGood inflow

Perform proximal Iliac embolectomy

Distal embolectomy

Perform intra-operative arteriogram To assess efficiency

No occlusionResidual thrombus

Close arteiotomy&Perform fasciotomy Thrombolysis

Poor inflow

Proximal vascularreconstruction

Less sever LL ischemiaLess sever LL ischemia(previously ischemic limb)(previously ischemic limb)

Arterio-graphyArterio-graphy

Thrombolysis

By pass procedure to site of occlusion or

angioplasty

If thrombo-lysis are contraindicated

After the underlying Cause is detected

Thrombo-lysis• This depend on per-

cutaneous delivery of thrombo-lytic drugs within the thrombus

• to dissolve it by intra-arterial catheter placed within the thrombus

• Most centers in UK have limited the technique for thrombus less than 30 days

Thrombo-lysis• Drugs

– Streptokinase– Urokinase– Recombinant TPA

• Technique– Local low dose– Pulse spray technique– High dose bolus technique

• Check angio-graphy is done every 8-9 hous and catheter tip repositioned as necessary

• Success is 60- 70 % with careful selection

Thrombo-lysis• Complications

– Mortality 1-2 %

– Major bleeding 10 %

– Minor bleeding 25 %

– Stroke

– Embolization

• Contraindications– Bleeding diathesis

– Long term anticoagulant

– Stroke

– Old age > 75 Y

– Peptic ulcer

Chronic LL ischemia (Risk factors)

Risk factors of LL ischemia

Age & sex

Diabetes

Smoking Hypertension

Hyper-lipidaemia

Obesity

Sedentary life

Chronic LL ischemia (Etiology)

Age above 45 Y Age below 45 years

Atherosclerosis Atherosclerosis is the commonest is the commonest

causecause

Diabetics Non Diabetics

Pre-senile atherosclerosis

In malessmokers In femaleIn both

Burger’s disease

Raynaud’sdiseaseArteritis

Chronic LL ischemia (Clinically)

Press & See How Color Fade (pre-gangrene) & (gangrene)

Pain Sensation Hotness Color Function

Pre-gangrene(Nutritional) Gangrene

Chronic LL ischemia (DD)

• Nerve compression (Sciatica)

• Veins ( CVI and DVT)

• Joints (arthropathy)

• Muscle ( myopathy)

• Bone pains

• Superficial lesions in skin& Sc tissue

Aortoiliac pattern

Femoropopliteal pattern

Distal circulation pattern

Inguinal ligament

Adductor hiatus

1. Claudication gluteal region

2. Wasting of thigh muscles

3. Lost or weak femoral pulses

4. Impotence if bilateral

1. Claudication calf2. Lost or weak popliteal pulse3. Beurger’s sign (pallor on

elevation and rubor on dependency)

Where is the site of occlusion ?

Chronic LL ischemia(thrombosis)

Le Riche syndrome• Claudication in gluteal

region • Wasting of thigh

muscles • Lost or weak femoral

pulses• Impotence

Aortoiliac pattern

Femoropopliteal pattern

Distal circulation pattern

Inguinal ligament

Adductor hiatus

1. Claudication foot2. Lost or weak dorsalis pedis and

or posterior tibial3. Beuger’s sign4. Nutritional changes (10 items)

1. Skin, 2. skin appendages, 3. subcutaneous fat, 4. muscles, 5. ulcers, 6. gangrene, 7. delayed venous filling,8. coldness, 9. motor and 10. sensory changes

Chronic LL ischemia

Chronic LL ischemia

Chronic LL ischemia

Chronic LL ischemia

Vascular lab1. Segmental limb

pressure

2. Ankle- Brachial Index

– Normal > 1

– Intermittent claudication 0.5- 0.9

– No healing < 0.5

– Rest pain 0.4

Vascular lab

1. Toe- brachial Index– Normal 0.8- 0.9

– Caludicate 0.35

– Rest pain 0.1

2. Toe pressures– Normal 90 – 100

mmHg

– CLI < 30 mmHg

3. Exercise tests

Non Invasive

• Doppler U/S

• Duplex U/S

• Plethysmography

• Isotope blood flow

• Trans-cutaneous oxygen tension

Invasive (Arteriography)It is the gold stander of

arterial tree

Methods

1. Directly trans-femoral if pulse is palpable

2. Seldinger approach

3. Digital sub-straction angiography contrast material injected I.V in large volumes or IA. In small tiny volumes

Invasive (Aorto-graphy)

»Translumbar if both F pulses are not felt

»Transfemoral aortography if one F pulse is felt

»Transbrachial if the entire distal aorta is occluded

»Digital sub-straction angiography

Invasive (Arteriography)Potential complications include • Contrast-related

– Anaphylactic reaction – Toxic reactions – Deterioration in renal function

• Technique-related – Haematoma – Arterial spasm – Sub-intimal dissection – False aneurysm – Arteriovenous fistula – Embolisation – Infection

New imaging modalites

• MR angiography (is now providing the most sensitive test for identifying tibial vessels)

• CT angiography which is articularly useful for the assessment of aneurysmal disease

• Angioscopy• Intravascular ultrasonography

Treatment of chronic LL ischemia

I - Risk factor reduction – Stop smoking - arrests disease progression– Lipid-lowering drugs – Anti-platelet medication – Good diabetic control if appropriate

II- Regular exercise – as part of supervised exercise program – Lose weight

Treatment of chronic LL ischemia

III – Pharmaco-therapy• Vasodilator drugs with small benefits

– Naftidrofyl oxalate, Praxiline – Pentoxyifyllin, Trental 400– Prostacyclin

• Vasodilator drugs with minimal benefits– Antiplatlets ( aspirin)– Prostaglandins– Ca channel blockers

Endo vascular surgery

Basic principles• The symptoms should be life-style limiting• Co-management of underlying conditions

likely to limit safety or success (smoking, heart failure etc)

• Proximal disease should be managed before distal ones

• Localized (<10 cm) non-ulcerating lesion is an ideal lesion

Endo vascular surgery

Basic techniques

• Balloon dilatation

• Stents

• Atherectomy devices

• Lasers

• Vibrating and rotating wires

Percutaneous transluminal angioplasty

• Angioplasty of the aorto-iliac segment has a 90% 5 year patency

• Angioplasty of the infra-inguinal vessels has a 70% 5 year patency

• Best results seen with short segment stenoses less than 2 cm long

Complications occur in less than 2% of patients o Wound haematoma o Acute thrombosis o Distal embolisation o Arterial wall rupture

Percutaneous transluminal angioplasty with stents

Use of stents • Most are used to correct inadequacies or

complications of PTA• To avoid re-stenosis which occurs within 90

days of PTA• When there is significant residual gradient or

stenosis following PTA• When there is acute occlusions during PTA• When there is dissection longer than PTA site

Surgical treatment of claudication and rest pain

• Indications for surgery:Indications for surgery: 1. claudication is a relative indication. 2. rest pain if fit for operation. 3. Ischaemic ulceration that does not respone

to conservative management. 4. acute occlusion.

• After decision on surgery is done do arteriography: site, type of operation and  if technically possible

Surgical treatment

Direct arterial surgery Indirect arterial surgery

BypassThromb

endarterectomySympathectomy Amputation

Thrombendarterectomy

Bypass ReconstructionSupra inguinal bypass

Anatomical reconstruction Aortobifemoral bypass with 90 % success

Extra anatomical reconstructionAxillobifemoral 33- 85 % successFemorofemoral 80 % success

Infra-inguinal bypass (Femoro-poploteal bypass graft)Reversed saphenousIn situo saphenousSynthetic Gortex

Bypass Reconstruction

• Femoro-poploteal Bypass graft– Supra-genicular

• Synthetic 80 % patency

• Vein 90 % patency

– Infra-genicular• Armed Gortex 50 %

patency

• Vein 75 % patency

Bypass Reconstruction

• Graft failure• < 30 day

– techniqual

• < 1 Y – neo-intimal hyper-

plasia or graft stenosis

• > 1 Y – progresion of distal

disease

Sympathectomy

Not very effective for claudication.

Works especially on skin and subcutaneous tissues. so may help ulceration and rest pain.

Chemical sympathectomy is an alternative to surgical but not if anticoagulants are used.

Sympathectomy (Indications)

1. In combination with major arterial surgery with poor run off

2. In combination with minor amputation to decrease major

3. Burger’s disease4. Resistant ischemic ulcer5. Other indications

– Vasospastic disoders– Hyperhydrosis– Dysmenorrhea– Cancer bladder

Critical limb ischemia (CLI)Defined as • Persistent rest pain for >2 weeks.Rest pain

is usually nocturnal at first due to 1. relative decrease in cardiac output at night,2. recumbancy makes the leg relatively elevated,

and3. warmth increase the metabolic rate of tissues of

the foot.

• Ankle systolic <50 mmHg and/or toe systolic <30mm Hg

• Ulceration or gangrene of feet or any degree of tissue loss of the feet.

Critical limb ischemia (CLI)On the basis of the workup, a preoperative plan

composed of 5 items should be considered

1. Severity of ischemia • Rest pain without tissue loss can be

treated only with proximal lesion correction,

• while foot tissue loss necessitates restoration of pulsatile flow to the foot

2. The inflow (The aortoiliac disease if present should be corrected first)

Critical limb ischemia (CLI)3. The outflow

• (Duplex, or arteriography or even MR should be used to demonstrate possible patent tibial vessels)

• ideally, a vessel with runoff into the foot should be chosen.

• If the patient has a non-healing foot wound, the ultimate goal is to restore pulsatile flow to the appropriate part of the foot

• (anterior tibial for toe ulcers, and posterior tibial for heal ulcers)

4. Choice of graft • The epsilateral or contralateral greater saphenous is the best

5. Configuration of the graft

Critical limb ischemia (CLI)

Limb Not Salvageable Limb Salvageable

Fitpatient

Unfitpatient

Amputation Terminalcare

Rest pain Without

Tissueloss

Rest pain With Tissueloss

Correct Proximal Lesion by

Endovascular or Bypass

Must pulsatile

Flow in thefoot

•Endovascular• Bypass

•Sequential surgery