arterial diseases
Download
Report
Transcript arterial diseases
Objectives:
• TO UNDERSTAND THE NATURE OF OCCLUSIVE ARTERIAL DISEASE AND ITS
ASSOCIATED SYMPYOMS AND SIGNS
•TO ABLE TO ASSESS ACUTE AND CHRONIC ARTERIAL INSUFFICIENCY AND
KNOW TREATMENT OPTIONS.
•TO KNOW ABOUT GANGRENE AND ITS MANAGEMENT
•TO KNOW OTHER ARTERIAL DISEASES LIKE ANEURYSMS,
ARTERITIS AND VASOSPASTIC DISEASES & AVFistula
Arterial Occlusion
Occlusive arterial disease
Types
Acute arterial occlusion
Chronic arterial occlusion
ACUTE ARTERIAL OCCLUSION
CAUSES EMBOLIC
THROMBOTIC
Heart diseases-Atrial fibrillation,mural thrombus, Post MI
Rheumatic valvular heart diseases
Paradoxical embolism- venous thromboembolism due to patent
foramen ovale
Arterio- arterial embolism- dislodgement of atheromatous
plaques
Angiographic procedures
Accidental- intraarterial injection- Ergot,thiopental
Trauma.
Embolism
Brain-MCA
Retina-Amaurosis fugax
Mesenteric vessel Spleen
Kidneys
Lungs-pulmonary embolism
ACUTE ARTERIAL OCCLUSIONEmbolism
C/F FIVE Ps
PAIN
PARALYSIS
PALLOR
PULSELESSNESS
PARAESTHESIA
Relation ship of symptoms to the site of obstruction
Aorto-iliac obstruction
Iliac obstruction
Caludication in both buttocks,thighs & calves. Femoral &
distal pulses absent in both limbs. Impotence.bruit over
aortoiliac region.
U/l claudication in thigh & calf buttocks.
Bruits over iliac region
Femoro-popliteal obstruction
U/L absence of femoral or distal pulses.
Distal obstruction
U/L claudication in calf. Femoral pulse palpable with
absent u/l distal pulses
Femoral & Popliteal pulse palpable
ankle pulses absent
claudication in calf & foot
Arterial Stenosis
Investigations:
GeneralCBC,ESR,
PLASMA -fibrinogen, protein, electrophoresis,
Glucose- blood n urine.
Lipid profile
Doppler -USG blood flow detection
Duplex imaging.
Echocardiography
Arteriography
DSA
ECG
Hand held Doppler
COLOUR DUPLEX
ARTERIOGRAM
DSA
Angioscope
Treatment.
Embolic arterial occlusion is an emergency!!!
THROMBOLYSIS – Immediate -Intra Venous Heparin 5000U
to prevent distal and proximal extension of thrombus.
Contraindications
Recent stroke
Active peptic ulcer
Bleeding disorders
Pregnancy
Hydration
EMBOLECTOMY
THROMBECTOMY.
Fogarty catheterization- for removing proximal and distal
extension of thrombus.
Postoperatively- heparin and oral anticoagulation
Intrarterial Thrombolysis
Only if ischemia is not so severe that immediate operation
is mandatory, it is possible to treat thrombus or embolus by
intra arterial thrombolysis
Agents-TPA-tissue plasminogen activator**
Streptokinase
Urokinase
Identify and treat the basic cause.
SFA thrombolectomy
Removed thrombus
Arterial Catheters
Chronic Arterial Insufficiency
Etiology
Atherosclerosis
Buerger’s disease
Artritis
Arterisclerosis
Diabetes
Risk Factors
Hypertension
Diabetes
Strong family history
Smoking
Lipid abnormalities
Chronic Limb Ischemia
Ischemia of the lower limb may be minimal to critical
Also called Chronic arterial insufficiency or
Peripheral Vascular disease-PVD.
Clinical presentationIntermittant Claudication-commonest complaint. Fatigue,
aching or crampy pain occuring with exertion and relieved
by rest, reproducible at the same distance.
Claudication distance- distance at which the pain appears
Rest pain
Critical ischemia- severe ischemia with actual or potential
tisssue loss.
Signs of chronic ishemia
Loss of muscle mass/bulk
Loss of subcutaneous fat
Skin shiny
Loss of hair
Brittle nails
Gangrene and ulcers of foot.
???
GANGRENE
Def: death, often with putrifaction of macroscopic portion of
tissues.
VARIETIES ACCORDING TO THE CAUSE-
Secondary:
Thrombus in atherosclerotic artery.
ATRIAL FIBRILLATION-embolus.
Arteritis from NEUROPATHY
BUERGERS DISEASE
RAYNAUDS DISEASE/ERGOTISM- causing arterial shutdown
INTRARTERIAL INJECTIONS- thiopentone & cytotoxic
materials.
GANGRENE
Primary:
INFECTIVE- boils, carbuncles, gas gangrene, gangrene of
scrotum (Fournier’s gangrene)
TRAUMATIC- crush, pressure sores & constriction grooves
PHYSICAL- burns, scalds,frostbite,chemical irradiation &
electricity.
VENOUS
C/F
Pulseless,painnless,funtionless, with colour change.
Lacks capillary refill and venous return.
Black,brown, greenish black.
GANGRENE
CLINICAL TYPES- DRY & MOIST
DRY gangrene dessicated tissues,part becomes dry and wrinkled.
Wrinkled ,discolourd from disintegration of Hb. & greasy
to touch.
MOISTgangrene:
when venous & arterial obstruction is present, when artery
is suddenly occluded by a ligature or embolus & in
diabetes..
Infection & putrifaction is present.
Part is swollen& discoloured.
Crepitus may be present.
GANGRENE
SEPERATION OF GANGRENE SEPERATION BY DEMARCATION
SEPERATION WITHOUT DEMARCATION.
Vague DEMARCATION & skip lesions.
TREATMENT OF GANGRENE GENERAL PRINCIPLES- limb saving attitude.
Cardiac failure
Atrial fibrillation anaemia. Nutritious diet.
Control of diabetes.
Analgesics.
LOCAL TREATMENT dry.protection of pressure areas. Cleanniess.
VARIETIES OF GANGRENE
DIABETIC GANGRENE- three factors Trophic changes from peripheral neuritis.
Atheroma of artries causing ischemia
Excess sugar –decreases resistance to infections esp. fungal infection
DIRACT TRAUMATIC GANGRENE
BEDSORES-(Decubitus Ulcers) 5 factors
1.
2.
3.
4.
5.
Pressure
Injury
Anemia
Malnutrition
Moisture
Pressure Sore
Gangrene
INDIRECT TRAUMATIC GANGRENEInterference with blood vessels from pressure by a
fractured bones
/ strangulation
Thrombosis of an artery
Ligation of an artery
poor technique for digital anesthesia
ERGOT- claviceps purpurea.
Fingers,nose & ears .
Seen in migrane suffers.
PHYSICAL AND CHEMICAL CAUSE
OF GANGRENE
.
FROST BITE- cold+wind. Damage to Vessel wall with
transudation & edema. Pain initially later painless &
gangrene
TRENCH FOOT-cold+ moist+ muscular inactivity.
Ill fitting boots.
I/V INJECTION OF THIOPENTONE
DRUG ABUSE
CHEMICAL GANGRENE- carbolic acid(phenol).
Frost bite
ANEURYSMS
ANEURYSMS- dilatation of a localised segment of the
arterial system.
True- all three layers involved.
False- single layer of fibrinous tissue as the wall of the sac.
According to the shape
-fusiform
-Saccular
-Dissecting
Eti0logy-traumatic/atherosclerotic/syphilitic/collagen
disease(Marfan,syndrome), mycotic(bacterial)
ANEURYSMS
Symptoms- due to expansion, thrombosis, rupture or release of
emboli.
Symptom relate to the vessel affected, the site supplies or the
tissue compressed.
Clinical features
Intrinsic-expansile pulsation along the course of an artery.
proximal compression decreases pulsations
Palpation- thrill
Auscultation-bruits??
Extrinsic- neighboring or distal structures are affected.
Nerve
Veins
Tubes-trachea ,esophagus
D/D
Swelling under an artery- cervical rib(subclavian)
Swelling over an artery-pancreatic cyst
Pulsatile tumors-sarcoma,osteoclastoma & metastsis
from hypernephroma.
abscess
serpentine artery- innominate,carotid.
ANEURYSMS
Abdominal aortic aneurysm Commonest large vessel aneurysm
2% population
95% atherosclerotic
95% below the renal arteries
Symptomatic/asymptomatic
Symptoms-back pain, sudden – mild-sudden severe.
ANEURYSMS
Ruptured AAA Anterior
Posterior
Free bleeding into the peritoneal cavity(20%)
Retroperitoneal hematoma(80%)
Profound hypotension
Severe pain
ANEURYSMS
Investigation:
USG abdomen
CT Chest & abdomen.
AORTOGRAM
ANEURYSMS
Procedure
Open surgical procedure
Endoluminal stent graft procedure.
Complications:
Respiratory
H’ge
Colonic ischemia
Renal failure
Infection of the graft.
Sexual dysfunction
Fistula formation.
Spinal cord ischemia.
Peripheral aneurysms
Popliteal aneurysms- most common
Femoral
Iliac
Ascending aorta & arch
AVF:
Communication between an artery & vein.
Congenital
Acquired-
trauma, penetrating wound or sharp blow, surgical
for renal failure.
Structural effect- arterialized veins. Dilated tortuous veins
Physiological effect- Increased VR, Increased VP, Increased HRIncreased CO.
PP-HIGH
LVF
Cardiac failure
Cong Fistula- Overgrowth of limb.
Persistent ulcer due to distal ischemia.
???
AVF
Clinical signs:
Pulsatile swelling
Thrill on palpation
Bruits on ausculatation
Dilated veins
Nicoladoni-Branham’s test- Decreased thrill, reduction in
size and bradycardia on pressing the artery proximal to
fistula
Treatment
Embolization
Ligation of feeding artery???
Surgery- Separation of artery & vein
ARTERITIS
Thromboangitis obliterans/ Buerger’s disease
Small & medium sized arteries.Occlusive disease
2. Thrombophebitis of superficial/ deep veins.
3. Raynauds syndrome, male, young patients
1.
VASOSPASTIC CONDITIONS:
Reynaud's syndrome:
Primary/ idiopathic form.
Secondary
Pallor- blanching
Blue- cyanosis
Redness-red engorgement.
Accompanied by pain.
Treatment - conservative
Tab. nicotinamide
Secondary Reynaud's syndrome due to some other problem like-collagen disease, atherosclerosis, thoracic
outlet syndrome, carpal tunnel syndrome