vascular diseases and surgery khaled daradka faculty of medicine / university of jordan general...

VASCULAR DISEASES

AND SURGERY

VASCULAR DISEASES

AND SURGERY

Khaled Daradka

Faculty of Medicine / University of Jordan

General Surgery Department

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Peripheral Arterial Disease Peripheral Arterial Disease

Definition:• Also known as PVD.

• Occlusive disease of the arteries of the lower extremity.

• Most common cause:o Atherothrombosiso Others: arteritis,

aneurysm + embolism.

• Has both ACUTE and CHRONIC Px

PAD PAD

Pathophysiology:• Arterial narrowing

Decreased blood flow = Pain

• Pain results from an imbalance between supply and demand of blood flow that fails to satisfy ongoing metabolic requirements.

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Introduction

Atherosclerotic changes

Introduction

Atherosclerotic changes

Normal Artery Diseased Artery

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Introduction

Disease evolution

Introduction

Disease evolution• Claudication

• Rest pain

• Ulceration

• Gangrene

• Limb loss

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Risk FactorsRisk Factors

• Tobacco abuse

• Diabetes

• Hypercholesterolemia

• Hypertension

• Obesity

• Sedentary lifestyle

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DiagnosisDiagnosis

• Patient history

• Physical examination

• Laboratory values

• Noninvasive vascular studies

• Angiography

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Patient HistoryPatient History

• Risk factors

• Exercise-induced symptoms

• Rest pain

• Ulceration

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Patient HistoryPatient History

Historical clues to the diagnosis of intermittent claudication

Variable Symptom ComplexSymptoms in the legs that are provoked

by walking and relieved by rest

Pain Aches Tiredness

Tightness Soreness Weakness Numbness

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Is it vascular limb pain?Is it vascular limb pain?

Patient HistoryPatient History

Historical Vascular NeurogenicClue Etiology Etiology

Onset Predictable Variable

Only withwalking? Yes No

Relief with stopping or Yes Variablestanding?

Absent pedal Variable Variablepulses at rest

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Patient History

Differential diagnosis of PAD

Patient History

Differential diagnosis of PAD• Intermittent claudication

– Atherosclerosis– Non-atherosclerotic

Buerger’s Vasculitis

• Neurogenic causes– Lumbar canal stenosis– Peripheral neuropathy

• Venous claudication

• Musculoskeletal causes– Arthritis– Bursitis– Tendonitis

• Pediatric causes– Plantar fasciitis

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Physical ExaminationPhysical Examination

• Pulses

• Bruits

• Ankle-Brachial Index (ABI)

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Physical Examination

Ankle-Brachial Index

Physical Examination

Ankle-Brachial Index• Simple, painless, accurate, highly

reproducible examination

• Clinically useful– Identifies patients with PAD

– Major indicator of premature MI, CVA, mortality

• Indications– Any patient with suspicion for PAD

– Any patient at risk of PAD Age 50 or greater with history of DM or tobacco use Age 70 or greater regardless of risk factors

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Right ArmPressure:

Left ArmPressure:

Pressure:

PT

DP

Pressure:

PT

DP

Physical Examination

Ankle-Brachial Index

Physical Examination

Ankle-Brachial Index• How to perform

– Patient resting supine for 5-10 minutes

– Continuous wave, hand-held Doppler

– Measure systolic BP in both arms

Higher value is DENOMINATOR of ABI

– Measure systolic BP in DP and PT

Higher value is NUMERATOR of ABI

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Physical ExaminationPhysical Examination

ABI = Ankle Systolic Pressure

Brachial Systolic Pressure

>0.9 = Normal

>0.4-0.9 = Moderate disease

<0.4 = Severe disease

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Above 0.90 — Normal

0.71-0.90 — Mild Obstruction

0.41-0.70 — Moderate Obstruction

0.00-0.40 — Severe Obstruction

Physical Examination

Interpretation and limitations of ABI

Physical Examination

Interpretation and limitations of ABI

ABI Interpretation Two Main Limitations

Calcified ankle vessels result in artificially “normal” ABI (DM, RF)

Normal ABI in patient with Aortoiliac Disease— only becomes abnormalwith exercise testing

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Noninvasive Vascular StudiesNoninvasive Vascular Studies

• Vascular ultrasound

• CT angiography

• Magnetic resonance angiography

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Noninvasive Vascular Studies

Post-intervention iliac imaging

Noninvasive Vascular Studies

Post-intervention iliac imaging

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Noninvasive Vascular Studies

MRA in PAD

Noninvasive Vascular Studies

MRA in PAD

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RightFem-Pop

BPG

DSA(Pre-PTA)

LeftSFA

Stenosis

Noninvasive Vascular StudiesNoninvasive Vascular Studies

CTA

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Normal Abnormal

Invasive Vascular Studies

Diagnosis−angiography

Invasive Vascular Studies

Diagnosis−angiography

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TreatmentTreatment

• Risk factor modification

• Medical management

• Minimally invasive techniques

• Surgical intervention

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GoalsGoals

Identify and treat systemic

atherosclerosis

Improve functional status and quality

of life

Preserve the limb

Prevent progression ofatherosclerosis

PAD Therapeutic Goals

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Risk Factor ModificationRisk Factor Modification

• Tobacco cessation

• Exercise

• Weight reduction

• Pharmacologic intervention– Hypercholesterolemia

– Hypertension

– Diabetes

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Minimally Invasive Techniques Minimally Invasive Techniques

• Percutaneous transluminal angioplasty (PTA)

• Stenting

• Thrombolysis

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Minimally Invasive Techniques Minimally Invasive Techniques

Guidewire placement

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Minimally Invasive Techniques Minimally Invasive Techniques

Guidewire advanced past lesion

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Balloon dilatation

Percutaneous Transluminal Angioplasty

Minimally Invasive Techniques Minimally Invasive Techniques

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Minimally Invasive Techniques Minimally Invasive Techniques

Stent expansion by a balloon catheter over a guidewire

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Post-PTA/stent placement

Minimally Invasive Techniques Minimally Invasive Techniques

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Thrombolysis

Post-thrombolytic infusion revealing stenosis

Minimally Invasive Techniques Minimally Invasive Techniques

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Case Study #1Case Study #1

Aorto/iliac disease

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Case Study #1Case Study #1

Aorto/iliac diseasepre-PTA stenting

Aorto/iliac diseasepost-PTA stenting

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Case Study #2Case Study #2

Pre-thrombolysis Post-thrombolysis

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Case Study #2Case Study #2

Angioplasty post-thrombolysis

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Surgical InterventionSurgical Intervention

• Bypass grafts

• Amputation

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Surgical InterventionSurgical Intervention

• Bypass grafts

What are the features of an

acute ischemic limb?

What are the features of an

acute ischemic limb?REMEMBER THE 6 P’S:

1.PAIN

1.PALLOR

1.PULSELESNESS

1.PERISHING COLD (POIKILOTHERMIA)

1.PARASTHESIAS

1.PARALYSIS

Venous Disease (CVI) Venous Disease (CVI)

Simple spider veins to complex dermal sclerosis and ulcer

formations.

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Venous Valves Venous ValvesPresence of

valves prevent reflux

Pressure generated in deep veins by the calf muscles are prevented from transmission to superficial veins by the valves

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Venous Pathology Venous Pathology

Obstruction

Reflux and/or incompetence

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Venous Obstruction Venous Obstruction

As a result of DVT or superficial phlebitis

As a result of extrinsic compression

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Venous Reflux Venous Reflux

Spider Veins Varicose Veins

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Venous Reflux Venous Reflux

Edema Venous Statis w/wo Ulcer

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Venous History of Patient Venous History of Patient

Pain

Edema

Ulcers

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Physical Exam of Patient Physical Exam of PatientSupine and Standing

Objective findings of spider or varicose veins

Skin changes (hyperpigmentation to atrophic blanch)

Edema (typically pitting)

Ulcer formation

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Diagnostic Testing

Duplex Scan

Diagnostic Testing

Duplex Scan

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Treatment Treatment

Medical Management

1. Leg elevation

2. Compression therapy

3. Exercise

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Interventional TherapyInterventional Therapy

Sclerotherapy

Endovenous Ablation

Surgical

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SclerotherapySclerotherapy

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Similarities and Differences Similarities and Differences

Arterial symptoms produced by exercise and relieved by resting

Venous symptoms worsened by standing and improved by exercise and leg elevation

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THANK YOU

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