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