approach in vascular patient กิตติพันธุ์ ฤกษ์เกษม phd, faca
TRANSCRIPT
Approach in Vascular Patient
กิ�ตต�พั�นธุ์� ฤกิษ์เกิษ์ม PhD, FACA
Topic
• Artery - Limb Ischaemia
- Aneurysm
• Venous - Varicose vein
• Leg ulcer
Limb Ischaemia
• Aetiology: most often atherosclerosis > trauma
• Most management decisions are based upon1.Differentiation acute vs chronic2. Mechanism of occlusion 3.Location of the occlusion4.Status of limb5.Fitness of patients
1.Differentiation
acute vs chronic
What is acute ischaemia?
Acute ischaemia
• Period of onset in minutes or hours
• Sudden catastrophic
• Less effect in upper extremity and leg affected by chronic ischaemia
Acute ischaemia
• Symptom 5P
pain
pulselessness
paresthesia
pallor
paralysis
Marble white right foot in acute limb ischaem
ia
What is chronic ischaemia?
Chronic ischaemia
• Symptom of limited circulation over months or years
• Slow deterioration of function
• Gradually symptom
• Life style changes-stop smoking or exercise: remission collateral vv
Chronic ischaemia
• Symptom and sign
Claudication
rest pain
ulceration/gangrene
Why should the effectes of acute arterial ischaemia occlusion be less in someone affected already by symptom of chronic ischaemia or in upper limb?
Collateral vessels!!
2. Mechanism of occlusion
Acute iscahemia caused by
•Trauma
• Non trauma
- embolus
- thrombosis
Trauma-fracture tibia
Embolus
• Mobile solid mass
• Free floating in blood
• Capable of occluding a vein or artery distal to its site of origin
Composition of embolus
• Atheromatous debris or thrombus(clot) (common)
Common source of atheromatous or thrombus emboli
• Left ventricle wall after MI• Left atrium in atrial fibrillation• Diseased mitral valve or aortic valve• Atheromatous plaques in aorta or iliac
vessels
This embolus lodge at the area where arterial tree is smaller than the embolus e.g. bifurcation or pre-existing stenosis
Atheromatous debris-blue toe syndrome
Thrombosis
• Rupture of an atheromatous plaque esp moderate and severe stenosis
• Virchow’s triad: abnormality of flow, blood, vessel wall
Is it possible to differentiate between thrombosis and embolus as a cause
of acute ischaemia??• Sometimes!!!
• Previously asymptomatic, preexisting cause with sudden onset of severe ischaemia (normal contralateral pulse) = embolus
• Previous claudication and sudden onset of acute ischaemia = thrombosis
Chronic ischaemia
• Progressive narrowing• Cause : Atheromatous disease is the common cause
Other uncommon cause: Aneurysm: » popliteal aneurysm: special nature» Diabetes
Some rare disease » Buerger’s disease» Hyperhomocysteineaemia» Takayasu’s disease
3. Location
• Acute occlusion: more proximal, the more extensive ischaemia
• Diagnostic location determines the best treatment
3. Location-aorto-iliac disease
• Chronic: claudication at buttock, thigh calf, loss of femoral pulse
in men: Leriche syndrome (French surgeon who described distal aortic occlusion and erectile impotence)
• Acute: catastrophic for ipsilateral limb, buttock, perineum
Distal aort a occlusion
Location Common femoral disease
• Chronic: thigh and calf claudication, palpable the femoral pulse just below inguinal ligament
• Acute: femoral bifurcation is the common site of embolus-typical ischaemic limb
Location-superficial femoral disease
• Chronic :a very common place for stenosis or occlusion where it passes posteriorly through adductor hiatus (Hunter’s canal)
It can produce calf claudication, but rarely severe in presence of profunda femoris artery
• Acute: rare
Bilateral occlusion of superficial femoral artery with collateral circulation via profunda
Location-popliteal atery dsease
• Chronic: calf claudication
• Acute: sudden occlusion from thrombus or embolus causes severe ischaemia due to occlusion geniculate arteries
Location: crural arterial disease
• Occlusion only one out of three vessel can asymptom unless either chronic or acute disease involve all three vessels
4. Status of the limb-acute iscahemia
Determine chance of saving limb vs amputation
• Pain: severe pain not response to opiate with tenderness in muscle:often irreversible ischaemia
• Paresthesia: range from percentible alternation to numbness. Numbness indicate acute critical ischaemia
• Pallor: pale -> unfixed mottling ->fixed mottling (do not blanch on pressure) frequently beyond salvage
4. Status of the limb-acute ischaemia
• Pulselessness
• Paralysis: stiff of the limb, when patient cannot move ankle joint indicated severe ischaemia
4. Status of the limb –chronic ischaemia
Early calf claudication like angina
i.e.tight, stiff or crushing pain
What factors influence claudication distance?
Anything increases work of walking
• Excess weight• Walking uphill• Walking against wind• Carry shopping
More severe form
• Very short distance- a few steps
• Rest pain first felt in the distal parts such as toes and dorsum of the foot – awake patient need rise from bed and walking around to relieve
• Unable to lie flat without pain patient sleep with hanging leg out of beds cause edema and worsen microvascular perfusion
Hanging foot
Last stage of chronic
• Gangrene, clinical depend on the degree of decomposition
• Range from ulcer (skin necrosis) to gangrene of toe and foot
• Gangrene: wet gangrene: black, soggy, discoloured green
and malodorous requires urgent amputation
Dry gangrene: black hard, brittle, wrinkle rarely
odour : may autoamputation or surgery in proper time
5. Fitness of patient
• Determine investigation and treatment“ surgeon need to consider the ability of the patient to
withstand our effort. Our job should be relieve the symptom of which the patient complain”
• Common causes of unfitness- pre-event unfitness: cardiac e.g. MI, Lung-renal-metabolic disease
- per-event unfitness: dehydration, acidosis, uncontrolled DM
- postevent unfitness: myoglobinaemia, severe acidosis, MI
Investigation of occlusive disease
• Clinical examination: full history» Presence or absence of pulse » Status of the limb
» Other test
BUN, CR, electrolyte
CBC, plasma viscosity
Coagulation
EKG, CXR
Fixed wave Doppler examination• Ankle brachial pressure index (ABPI)
0.5-0.9 claudication
< 0.5 critial limb ischaemia
< 0.3 gangrene
Treadmill testing
• Walking incline 10% at speed 3 km/hr
• Test of function to allow monitoring disease and the result of therapeutic effort
Ultrasound-duplex scan
• Composed of 1. B-mode ultrasound reveal the anatomy:aneurysm,
occlusive lesion
2. Doppler signal: flow indicate stenosis
Duplex scan of SFA stenosis
Contrast arteriography
• Injection contrast agent make lumen visible
• Conventional angiogram: direct intraarterial route
• Now we have digital subtraction angiogram(DSA)
• CT angiogram: need of arterial puncture
• From the picture, what is the diagnosis?
Computerised tomographic (CT) angiograhy
• Helical CT scan with intra-arterial contrast injection
• Look the relation between artery and other structure well
Carotid body tumor
Magnetic resonance arteriography(MRA)
• without contrast or IV gadolinium
• Suitable in patient should not given iodine containing contrast due to renal disease or allergy
Aneurysm
• Pulsatile expansile mass
Clinical feature:
• invade surrounding tissue cause- pain
• rupture
• embolisation - ischaemia e.g. claudication, trash foot
Ruptured AAA
Trash foot-multiple small atheromatous debris
Investigation
• Ultrasound
• CT scan
• ??? angiogram
CT scan “Infrarenal A
AA”
Angiogram of popliteal aneurysm
Venous disease
Functional anatomy
• Superficial venous system devided into 3 parts
Long saphenous vein (LSV)
Short saphenous vein (SSV)
Perforating or communicating vein (PV)
Superficial venous system
• LSV: medial malleolus to groin
• SSV: outer border of foot behind lateral malleolus ascend to middle of the calf 60% to pop V., 20% to LSV and 20% wherelse
Superficial venous system
• PV connnect superficial and deep vein
• > 50 PV in one leg
• PV in thigh connect directly between superficial and deep system, in leg connect indirectly via venous plexus
Deep venous system
• 3 artery below knee, there are 2 vein beside of artery from foot up to knee joint
• Then pop V beside artery then in thigh ->superficial femoral vein join with profunda femoris vein -> common femoral vein
Physiology of venous drainage
• Normal: superficial to deep and from distal(foot) to proximal(thigh and heart )
• ?? At standing position, blood at ankle has to return against gravity to heart over a distance of > 1 metre “how”
How
4 factors support this system• Functioning vein valves: resist > 300 mmHg• Functioning foot and calf muscle pumps: weight
compress venous plexus in foot and calf muscle compress sinusoidal and deep vein in leg
• Residual arterial pressure• Negative intrathoracic pressure
“ however absent valve or damaged valve, the muscle pump cannot work efficiently”
Pathophysiology of varicose vein
• Abnormal dilated and tortuous superficial vein of the leg
• Response to a pathological increase in the vein’s intraluminal pressure
• This increases due to higher intraluminal pressure of deep vein (necessary to allow movement of blood out of leg)
from deep to superficial system
Aetiology
• Primary e.g. saphenofemorla valve incompetence
Aetiology
• Secondary mostly due to previous DVT– Simple obstruction– Destroying the valves within deep veinThese lead to blood move to superficial system
(compensatory mechanism)
** a must to know this, otherwise we may worsen patient with VV surgery**
Primary VV or secondary VV
Clinical feature of varicose vein
• Cosmetic presentation• Discomfort and pain• Cramps• Swelling• Complication
- thrombophebitis
- haemorrhage
- CVI
Patients assessment in VV(1)
• History: past Hx of DVT
• Examination:
standing position
Area of VV
Brodie Tredelenberg test
Perthes’ test
Continous wave Doppler
VV
Brodie Tredelenberg test
Patients assessment in VV(2)
• Radiological evaluation when suspected of previous DVT
Duplex scanAscending venography (inject radioopaque in foot and
watching it rise in the deep vein)
Varicose eczema
Chronic leg ulcer
Neuropathic ulcer
Venous ulcer
Arterial ulcer
Acute non-traumatic leg pain
Localised to skin soft tissue, vein-cellulitis-lymphagitis-thrombophlebitis
Pain radiate from backExacebate by bending-lumbosacral N root compression
Deep pain in whole legThigh, calf
Pain, uniform swellingNo paresis or sensory loss
DVT, rupture of baker’s cyst
5P
Emboli source, no IC,N contralat pulse*heparin
+ac emboli - ac thrombosis
Chronic non-traumatic leg pain
Pain radiate from backExacebate by bending-lumbosacral N root compression
Pain in calf, footNot radiate to back
Critical limb ischaemiaRest pain, gangrene, ulcer
claudication
Varicose vein
Primary VV Secondary VV
History of swelling, DVTConfirm with duplex scan
InterventionSx, sclerotherapy
Supportive treatment
Ulcer
edge
base
position
Punch out
Black, dryDeep to tendon
Digit, heel
Ischaemic ulcer
Flat, sloping edge, soft
Shallow, edema, erythremaInfection, granulation tissue
Digit, pressurePoint, heel, metartarsal head
Sensory ulcer
Above medial malleolusAsso DVI
Venous ulcer