Vascular Surgery Occlusive Peripheral Vascular Disease

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Vascular SurgeryOcclusivePeripheral Vascular
Disease

• Adrian P. Ireland BA(mod) MB MCh BAO FRCS(I)

Beaumont Theatre Nurses 13 Jan 2004
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Occlusive Peripheral Vascular Disease

• Peripheral vascular disease
• Includes any disease affecting the peripheral
  vascular system
• Occlusive essentially blocked arteries

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Outline

• Review of the circulation
• Pathogenesis of blocked arteries
• Manifestations of blocked arteries
• Monitoring the circulation
• Occlusive peripheral vascular disease
• Acute Ischemia
• Chronic Ischemia

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Review Of Circulation

• Cells need supply of nutrients and removal of by
  products
• In a unicellular organism this may occur via the
  cell membrane into say a pond or sea
• Multicellular organisms need a circulatory system

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William Harvey (1578-1657) On the Motion of the
Heart and Blood in Animals (1628)
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Problem With Blocked Circulation

• Tissues lack adequate supply of nutrients
• Tissues suffer build of toxic by products
• May cause symptoms and signs particularly when
  more blood flow is required
• To muscles during exercise
• To tissues that are injured (more blood needed)

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Pathogenesis Of Blocked Arteries

• Atherosclerosis
• Genes, hyperlipidemias
• Lifestyle
• Smoking
• High fat diet
• Lack of exercise
• Co-morbidities
• Diabetes, hypertension, hypothyroidism,
  homocysteine

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Manifestations Of Blocked Arteries

• Depends on circulation affected
• Heart
• Stable angina, unstable angina, myocardial
  infarction
• Brain
• Transient ischemic attact, stroke
• Kidney
• Hypertension, renal failure
• Legs
• Claudication, rest pain, necrosis

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Principal causes of death in Ireland (males)
Report on Vital Statistics Central Statistics
Office Ireland, 1995
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Annual Deaths Due toCerebrovascular Disease
andIschemic Heart Disease
Report on Vital Statistics Central Statistics
Office Ireland, 1995
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Manifestations Of Blocked Arteries

• Depends on speed of development of blockage
• Slow blockage
• Permits development of collateral blood supply so
  that occlusion may be asymptomatic
• Rapid blockage
• No time for development of collaterals
• Symptoms/ signs depend on adequacy of preexisting
  collaterals

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Monitoring Circulation

• Mottling, colour, temperature, movements,
  sensation
• Palpable pulses, doppler signals
• Non invasive pressure studies (Doppler)
• Duplex imaging
• Angiography (IAA, DSA, MRA)

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Non Invasive Pressure Studies(NIPS)
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Duplex of carotid stenosis
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Angiography(DSA)
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MRA
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Occlusive Peripheral Vascular Disease

• Classification based upon clinical presentation
• Acute ischemia
• Chronic ischemia
• Anatomic classifcation based upon site(s) of
  disease

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OPVD Anatomic Classification

• Aorto-iliac
• Le-Riche
• Femero-popliteal
• Tibio-peroneal

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Acute Ischemia
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Effects Of Acute Ischemia

• Reduced blood flow
• Pulseless, pallor, perishing cold
• Nerve ischemia
• Pain, paralysis, Paresthesia
• Muscle ischemia
• Rhabdomyolysis
• Compartment syndrome
• Ischemia reperfusion syndrome

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Compartment Syndrome

• Pathophysiology
• Diagnosis
• Management

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Compartment SyndromePathophysiology

• Strong fascia encases the limb to aid muscle
  function and return of venous blood
• Injury results in swelling
• Swelling raises pressure
• Pressure occludes lymphatic return, then venous
  return, then arterial inflow
• Result is dead or severly damaged tissues due to
  pressure and ischemia

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Compartment Syndrome Diagnosis

• Strong index of suspicion
• Nature of injury and duration of ischemia
• Clinical manifestations
• Nerve and muscle dysfunction
• Decreased perfusion
• Tense compartment
• May measure compartment pressure as adjunct to
  treatment gt 40 mm hg

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Compartment SyndromeManagement

• Fasciotomy

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Acute Ischemia

• Causes
• Thrombosis
• Embolism
• The Ps
• Thrombosis or embolism?
• Clinical assessment of severity
• Clinical algorithm

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Causes of Acute Ischemia

• Trauma
• Thrombosis
• Embolism
• Small print
• Aneurysm
• Thrombophilia
• Paradoxial embolism
• Anatomic variation
• Csytic adventitial disease

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Thrombosis

• Occlusive atherosclerosis
• Aneurysm
• Malignancy
• Thrombophilia

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Embolism

• Macro-embolism
• arterial side
• venous side (patent foramen ovale)
• Micro-embolism
• ulcerated atherosclerotic plaques
• aneurysm

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The P s

• No flow in artery
• Pallor
• Pulse absent
• Perishing cold
• Nerve becomes ischemic
• Pain
• Paresthesia / anesthesia
• Paralysis

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Thrombosis or Embolism?
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Clinical Assessment of Severity

• Viable no immediate threat
• Threatened
• Marginally ok if treated
  promptly
• Immediately ok if treated immediately
• Irreversible dead leg

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Irreversible Ischemia

• Sensory loss Profound, anaesthetic
• Muscle weakness Profound, paralysis
• Arterial doppler Inaudible
• Venous doppler Inaudible

Amputation
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Viable no immediate threat

• Sensory loss None
• Muscle weakness None
• Arterial doppler Audible
• Venous doppler Audible

Restore perfusion
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Clinical Assessment of Severity

• Viable No immediate threat
• Threatened
• marginally Ok if treated promptly
• immediately Ok if treated immediately
• Irreversible Dead leg

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Threatened Marginally

• Sensory loss Minimal (toes) to none
• Muscle weakness None
• Arterial doppler Inaudible
• Venous doppler Audible

Restore perfusion
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Threatened Immediately

• Sensory loss More than toes, Pain
• Muscle weakness Mild to moderate
• Arterial doppler Inaudible
• Venous doppler Audible

Restore perfusion
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Practical Questions

• Is this ischemia? (DDx stroke, TIA, cord)
• Is the limb viable, threatened or lost?
• If threatened how long can reperfusion be
  delayed?
• Is there a need for duplex or angiography?
• Should the patient be immediately heparinised?

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acute non traumatic ischemia
Irreversible
Threatened
Viable
Clear embolus
?Thrombosis
Duplex
Adequate
Inadequate
Angiogram
Treat
Amputation
Embolectomy
Thrombolyse /- PTA
Reconstruct
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Prognosis

• Embolism
• Overall 60 dead within three years
• One episode 15-20 mortality (in hospital)
• Two episodes 40 mortality (in hospital)
• Thrombosis
• Overall 40 dead within three years

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Chronic Ischemia
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LaFontaine Classification

• Stage 1 claudication
• Stage 2 rest pain
• Stage 3 necrosis/ulceration

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Prognosis in Claudicants

• About 15 will progress to requiring
  revasculartion or amputation
• Much higher risk of death from IHD and stroke
• Rule out diabetes, hypertension and
  hypercholesterolemia
• Exercise, Smoking cessation, Aspirin and a Statin
  control of risks

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Re-Vascularisation ?

• Risk factor control, aspirin, statin
• Pain control
• Dressing
• Sympathectomy (chemical, surgical)
• Iloprost
• Angioplasty /- Stent (? Drug elute)
• Surgical

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Surgical Re-Vascularisation

• Embolectomy and Thrombolysis
• Patchplasty (synthetic/ autogenous)
• Endarterectomy (open/closed/eversion)
• Bypass with synthetic material
• Bypass with autogenous material

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Definition Of Critical Ischemia

• Presence of tissue loss
• OR
• Rest pain with ankle pressure less than 50 mm Hg
• FOR
• More than 2 weeks

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Acute on Chronic

• Bypass

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J.C. 68 year old male

• Emergency admission 24.3.2000 to vascular service
  SVUH, via A/E
• Ischemic right foot

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History of Presenting Complaint

• Awoke with coldness and numbness in the right
  foot 2 hours ago
• Gradually sensation returned and foot became warm
  again
• Worsening claudication for two years, 100 metres

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Past History

• 1996 angina, failed angioplasty (aspirin)
• 1996 hypertension (atenalol)
• 1996 Hypercholesterolemia (diet)
• June 1999 dizzyness ? cause
• Carotid duplex showed non critical stenosis

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Social History

• Retired
• Lives with wife
• Ex smoker 20 cigarettes per day for 20 years
  (gave up 20 years ago)

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Clinical Examination

• No distress, vitals normal
• Regular pulse
• Left carotid bruit
• Normal examination of chest
• Normal examination of abdomen

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Examination - Right foot

• Absent pulses below femoral
• Pallor at 30 degrees
• Movements and sensation intact
• Hand held doppler reveals arterial signals over
  dorsalis pedis and peroneal, posterior tibial
  signal absent

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Investigations

• CXR - normal
• ECG BSR, Left axis deviation
• Old lateral MI
• UE - U 7.7, Creatinine 118
• FBC - Normal
• COAG - Normal

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Non Invasive Pressure Studies
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Digital Subtraction Angiogram
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Summary

• 68 year old male
• Acute on chronic ischemia right foot
• Previous, MI, OCD (dizzy turn)
• Critical ischemia
• Probable poor run off on angiogram

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Pre operative course

• Elected initial conservative management
• Anticoagulation with Heparin
• 28.3.2000 decision to proceed to elective surgery
  (next list 6.4.2000)
• 29.3.2000 further episodes of numbness, twice,
  and pallor on the flat
• proceed to urgent vascular reconstruction

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Vascular Reconstruction

• Right fem pop below knee bypass
• General anaesthesia
• Commenced 1605 finished 1910
• No transfusion

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Vascular Reconstruction

• Conduit - thin wall 6mm PTFE
• Long saphenous vein thrombosed below knee
• Poor quality vein in groin
• Inflow - CFA s/e 5/0 prolene
• Outflow
• Miller cuff to BK pop 6/0 prolene
• e/s PTFE to cuff 6/0 prolene

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Miller Cuff - technique
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Miller Cuff - technique
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Post Operative Course

• Day 14
• Palpable DP pulse in foot
• Wounds healing
• Discharge to Convalescence

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Chronic

• Endarterectomy

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Chronic

• In situ distal bypass
• Fem to distal 1/3 posterior tibial with insitu
  long saphenous vein

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Critical Limb Ischemia - Sweedish Data

• 30 d mortality 5.3
• 1 year mortality 22.9
• For those aged gt 75
• 30 d mortality 6.4
• 1 year mortality 26.4

Eur J Vasc Endovasc Surg 16137-141, 1998
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Critical Limb Ischemia - Finnish Data
Ann Chir Gyn 86213, 1997
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Effect of Vein Cuff on patency of PTFE fempop
Bypass
n 261 Randomised, BK 8462 2 y salvage
cuffnocuff
Stonebridge, Prescott and Ruckley. J Vasc Surg
26(4)543-50, Oct 1997