Peripheral Vascular Disease(1)

Guo Xueli ( 郭学利 )

Dept. Vascular Surgery, First Affiliated

Hospital
Arteries
Diseases of arteries may take one of three forms:
occlusion dilatation arteritis
#occluded by atheroma, thrombosis, embolism
#dilatated due to degeneration of its wall
#the seat of inflammation
Arterial occlusion
Two types: partial or complete
Causes: atherosclerosis (most often)
embolism and trauma(common)
The severity of the symptoms depends upon
alternative route of blood flow (the form of
collaterals)
Clinical features of arterial occlusion in the
lower limbs
A limb with an occluded artery is usually
painful, pale, paralysed and pulseless.
Pain: two forms
intermittent claudication and rest pain
Intermittent claudication :
Starts to walk there is no pain. After walked a
few steps cramping pain appears.
Claudication distance:the distance a patient
can walk before pain comes on.
This distance is inversely proportional to the
severity of arterial occlusion.
Short----the degree of occlusion is severe.
Long---- the degree of occlusion is mild.
Rest pain
is severe pain felt in the foot even at rest .
Worse at night.
Aggravated by elevating the foot.
Relieved by lowering the foot.
Pallor
Ischaemic limb---pale
the limb is lowered--venous congestion---blue
extravasation of blood from the capillaries
---bright red spots
Paralysis
Ischaemic limb are often paralysed and without
sensation---bad sign
Pulselessness
Main artery is occluded---arterial pulses are
absent
Good collaterals---the pulses are diminished in
volume
The places of pulsation:
the radials, carotids , abdominal aorta,
femorals popliteals, posterior tibial and
dorsalis pedis arteries.
Temperature
severely ischaemic feet --- cold

Ulcers and gangrene

Severe arterial insufficiency--- ulcers form
The patch of skin becomes black and dry
--- gangrene
Murmurs
Narrow artery,
blood flowing through it produces turbulence
---systolic murmur being audible
A continuous machinery murmur
---intravenous fistula
Location of atheromatous plaques
atheromatous narrowing or occlusion sits:
the bifurcation , iliac arteries, femoropopliteal
segment, or the distal arteries.
Investigation
Most patients suffering from pathological processes
affecting the arteries tend to be elderly.
Metabolic and age-related diseases---
diabetes, hypertension, myocardial ischaemia
and bronchitis should be excluded.
Blood test: to detest abnormalities in the blood
Plain x-rays: show up calcification in arteries.
Blood flow:
three basic parameters---
pressure,volume and velocity
Pressure
ankle:brachial index > 1.0---normal
ankle:brachial index < 0.9---arterial disease
Doppler sensor is used to measure the pressure
Volume
air-filled plethysmograph is used to measure the change
Velocity
Doppler blood flow detector
Transcutaneous oxygen tension measurement
the oxygen tension is the best proof of
adequacy of the oxygen delivery system.
lower limb :
around 55mm Hg---normal
< 20mm---patient with rest pain and
ischaemic ulcers
Ultrasound(B-mode) images provide information
about the diameters of the various vessels at
different levels and very valuable adjuncts of
velocity measurements.
Arteriography
a radiopaque dye injected into an artery and x-ray
taken to show the dye in the vessels and show up
any stenosis,occlusion or dilatation.
Digital subtraction angiography can enhance the
outline of artery
Management of chronic arterial occlusion
general advice:diabetes or hypertension should
be kept under control meticulously.
smoking---given up
exercise---should be taken regularly
diet: two types of lipoproteins---
cholesterol and triglyceride
the former---low cholesterol diet
the latter ---weight reduction
 medical treatment:
aspirin---anti-adhesive effect
analgesics---paracetamol or diclofenac
vasodilators
care of the feet:
soft and comfortable socks
toe-nails---be trimmed carefully
Buerger’s exercise
can increase the circulation to the feet
raise the limb---2 minutes
lower it --- 2 minutes
repeat the cycle---12 times
daily for a few weeks
Sympathectomy
Its effect is mainly on the vessels in the skin and
subcutaneous tissues, may help some patients
with rest pain.
Surgical sympathectomy:
2 or 3 ganglia with the intervening trunk are
removed.
Chemical sympathectomy:
the phenol solution is injected beside the bodies
of the lumbar vertebrae by a long lumbar puncture
needle.
Arterial surgery for occlusion in the lower limb
Indications for operation:
1.Rest pain
2.Claudication
3.Ischaemic ulcers
4.Embolus: urgent embolectomy to save the
limb.
Operations for disease at different sites
Aorto-iliac artery stenosis
1.aortofemoral bypass: A synthetic arterial graft
is anastomosed above to the aorta and below to
the femoral artery.
2.iliac endarterectomy: the atheromatous plaques
is removed and use a vein patch to suture the
wound.
3.transluminal balloon angioplasty:inflation of the
balloon to dilate the stenosed part.
Femoral and profunda artery stenosis
The vessels above and below the block are
normal.
1.femoro-popliteal bypass graft
2. Profundoplasty
Arteries below the politeal
a high rate of graft failure
Results of operation
The reconstructive surgery of aorto-iliac
disease---excellent
Femoro-popliteal occlusion in the later stage
---compromised
the success rate at the end of 5 years---50%
Acute arterial occlusion
1. represents an emergency.
2.irreversible ischaemic changes begin about
6 hours after the acute arterial occlusion.
3.may result either from trauma or embolism.
Occlusion due to trauma
Blunt trauma to an artery:
1.the bruising may cause roughening of the intima---
thrombosis occurs---occlusion.
2.the intima may become detached from the underlying
muscle---sub-intimal haematoma---occlusion.
During a long march the muscle in the unyielding
anterior fascial compartment of the leg may be so
swollen as to compress the anterior tibial artery---
distal ischaemia and the crush syndrome ---urgent
fasciotomy
Management
to examine the palpation of the pulses.
the pulses are absent and the limb is pale
and cold---arterial occlusion.
1.the artery must be immediately exposed.
2.the affected part may be resected and an end-to-end
anastomosis or a vein graft employed.
3. the artery is bruised---in spasm---4% lignocaine
4.to open the artery to deal with the thrombosis or
subintimal haematoma---usually to resect the involved
segment of the artery.
Embolic occlusion
An embolus is a body which is foreign to the blood
stream and which may get lodged in a vessel and
cause occlusion.
Emboli consist of the blood clot, air or fat.
the blood clot---the most common
The most frequent origin sites:
1.the roughened intima over necrosed cardiac
muscle
2.the left atrium in a case of mitral stenosis
3.the cavity of a large aneurysm
Sites of lodgement of emboli
Emboli can get lodged in any organ ---producing
ischaemia of the part
the most common sites---the lower limbs
#cerebral embolism---hemiplegia
#retinal arterial embolism---blindness
#mesenteric artery---gangrene of the intestine
#pulmonary artery---pulmonary embolism---
death
Clinical features
1.the source of the emboli
2.severe pain ,cold with mottled blue and white
patches
3.paralysis occurs within 4-6 hours after the
onset of pain
4.lost the movement of the toes and touch
sensation
5.the distal pulses are absent,the femoral pulse
may be forceful
The embolic cause include
cardiac arrhythmia
myocardial ischaemia
valvular disease
atherosclerosis
Treatment
1.An infusion of 5,000-10,000 units of
heparin to prevent thrombosis.
2.Severe ischaemic pain requires with
analgesics .
3.Urgent embolectomy.
4.Anticoagulant therapy is continued
postoperatively.
Air embolism
Air embolism---right-sided heart failure
1.sucked into an open vein
2.reach the venous system after insufflation into
the fallopian tube, or during illegal abortion
3.rigid bottles with air vents were used for
intravenous infusion
The collapsible bottles in use nowadays
Treatment
1.the Trendelenberg position(the head side is
low) and turned onto his left side.
2.aspirate the air from the right ventricle by
needle.
3.to expose the heart for aspiration under
direct vision.
Fat embolism syndrome
Cause: extensive and multiple fractures
Fat droplets---platelet aggregation---consumption
coagulopathy
Fat droplets---fatty acid---acute lung injury
clinical feature: dyspnoea, skin petechiae,
hypoxaemia, thrombocytopenia, falling
haemoglobin and fat globules in the urine.
Symptoms arise 2 or 3 days after injury.
Two types
Cerebral type:drowsy, restless, disoriented,
and later comatose.
Pulmonary type:increasing cyanosis with
signs of right heart failure.
Treatment :vasopressors, inotropes and
mechanical ventilation.
high-dose corticosteroids, low molecular
weight dextran.
Gangrene
Gangrene:death with putrefaction of
macroscopic portion of tissue.
Necrosis:the death of individual cells or
groups of cells.
Sequestrum: a dead piece of bone.
Slough: a piece of dead soft tissue e.g. fascia,
tendon or skin.
The classic presentation of gangrene---the distal part
of a limb.
Certain viscera may be affected by gangrene, the
appendix, small intestine, and gallbladder.
Causes
1.ischaemia:
i.atherosclerosis
ii.embolism
iii.diabetes
iv.thromboangiitis obliterans(Buerger’s disease)
v. Raynaud’s disease and ergotism
vi.inadvertent intra-arterial injection of drug,
thiopentone and cytotoxic drugs.
2.infections
3.trauma: i.direct trauma
ii.indirect trauma
4.physical agents: burns due to heat, boiling
liquids, chemicals, electricity and irradiation.
Clinical appearance
The gangrenous part:
1.cold and motionless
2.arterial pulsation, capillary response---absent
3.the colour changes
at first---pallor
later---dusky grey or purple discoloration
(the pooling of blood in the part)
finally---greenish or brownish black
(the disintegration of haemoglobin
and formation of iron sulphide)
Types
dry gangrene: occluded gradually, the part is dry,
wrinkled, and black. No foul smell.
moist gangrene: occluded suddenly, putrefaction
of the tissue, anaerobic infection. Foul smell.
moist gangrene is seen in the following conditions:
1. occluded suddenly by a ligature or embolus
2.venous obstruction along with arterial occlusion
3.infection in diabetic tissues
4.in an internal organ, e.g. in acute appendicitis
and strangulated bowel
infection by gas-producing organisms---crepitus be
felt on palpation
Nature history
untreated gangrene---circumscribed or
spread in extent
the line of demarcation between the gangrenous
and healthy
In dry gangrene:
the line of demarcation ---a few days
separation---with the minimum infection
the bone gangrene separation takes longer time
In moist gangrene:
favourable for the growth of bacteria
the line of demarcation at a high level---more of the
limb lost
convert moist gangrene into the dry type
Spread of gangrene:
the moist type---spread upwards
black patches of skin at higher level than the
gangrenous part
infection---spread upwards
a local amputation---the risk of leaving
gangrenous tissues behind
to avoid this possibility---an above-knee
amputation
Treatment :as far as possible try to save the limb
1.to improve the blood supply---
direct arterial surgery and interruption of
the sympathetic nerve supply
2.good blood supply---a conservative excision
3.gas gangrene or rapidly spreading gangrene---
amputation to save his life
General treatment :
in embolic gangrene---to treat cardiac failure,
atrial fibrillation and anaemia
diabetes--- be controlled
pain --- non-narcotic drugs
Local treatment:
#limb ---exposed to encourage dryness, and cool to
reduce the metabolic rate and the need of the
oxygen
#protect the pressure areas
#release underlying pus
Special varieties of gangrene
Diabetic gangrene
three factors---the development of diabetic
gangrene
1.the peripheral neuritis of diabetes---trophic
changes
2.atheroma of the arteries---ischaemia
3.an excess of sugar---lowers their resistance to
infection
the neuropathy---a harmful effect in two ways
1.impaired sensation---neglect of minor injuries
2.the muscular involvement---deformities in the
foot---the pressure on the metatarsal heads---
callosities
So that the infection can rapidly spread upwards.
Major arterial disease is usually absent.
the dorsalis pedis and posterior tibial pulses
---palpable
no intermittent claudication and pain
 to examine any pus
to test the blood and urine for detecting the
presence and severity of diabetes
Treatment
1.be brought under control by diet and drug
2.gangrene is managed along the usual lines
3.free drainage of the area with removal of
sloughs
Traumatic gangrene
direct traumatic gangrene
bedsore---most common
ulcers---result from the pressure of splints or plasters
bedsores ---in a bedridden patient, specially who has
suffered injury or disease of the spinal cord.
the factors in the development of bedsores:
#pressure
#loss of the trophic influence of nerves
two important factors
#anaemic or malnourished of nerves
#moisture---increase the rate of extension
the most common sites:
the sacrum, the greater trochanter and the heels
the prevention of bedsores:
1.a foam mattress
2.the bedsheets must be kept free of all wrinkles
3. sweat, urine or faeces not be allowed to collect
over the skin
4.the posture must be changed two-hourly
5.a mattress with a honeycomb of cavities
the treatment is difficult
hence the very great importance of prevention
Treatment
1.the preventable measures must be continued
2.pent up pus---evacuation
3.small sloughs---Eusol solution
large sloughs---surgical removal
4.oedmatous granulation---magnesium sulphate
glycerine paste
5.shifting a skin flap to cover the raw area
Indirect traumatic gangrene
due to occlusion of an artery
1.pressure, e.g.from a broken bone in a fracture
2.thrombosis, e.g. following injury
3.ligation of a main artery
the collateral circulation is adequate---no gangrene
Treatment
#to deal with the causes
#dry gangrene---amputation above the line of
demarcation
#moist gangrene---amputation to save the life
Frostbite
due to exposure to cold
the vessel---oedema, blistering, finally gangrene
Treatment
#warmed gradually to body temperature
#wrapped in cotton wool
#warm drinks, analgesics or paravertebral
injection of the sympathetic chain
Amputations
indications :
1.dead i.e.gangrene is present
i.major vessels, e.g. from atherosclerosis or
embolism
ii.peripheral vessels,e.g. in diabetes, Buerger’s
disease, Raynaud’s disease,etc.
2.dangerous. Moist gangrene and gas gangrene. the
danger to life arises from the absorption of the
potent toxins of the clostridia or other anaerobic
bacteria.
3. A total loss
i. multiple severe lacerations and fracture due
to a bomb-blast injury or a road accident.
ii. severe contractures or paralysis make the
limb impossible to use, and interfere rather
than help with locomotion.
iii. severe rest pain make life miserable,
amputation improves the quality of life.
Amputation at different levels
Minor(distal) amputations
a finger or toe injury, a small vessel disease
(diabetes or Buerger’disease), where gangrene of
the toes occurs but the blood supply to the
surrounding tissues is good.
in diabetes---excision of a metatarsal bone
in Buerger’disease--- trans-metatarsal amputations
a long plantar flap---the suture line is on the dorsal
side, away from the weight-bearing area.
Major amputation
above-knee and below-knee amputations.
above-knee amputations---abundant blood
supply to an absolute guarantee of sound
healing of the stump; the function of the
artificial limb is not good.
below-knee amputations---a lesser certainty of
sound healing of the stump; the function of
the artificial limb is good.
In the past:
Twice as above-knee amputations were
performed as below-knee
During recent years:
the ratio has been reversed, partly
because arterial surgery is available to
improve the blood supply to the limb.
Flaps
muscles which have a rich blood supply---be
raised as a part of the flap to cover the bony
stump--- sound healing of the wound
above-knee amputations---equal anterior and
posterior flaps.
below-knee amputations---a single long
posterior flap
through-knee amputations
a long anterior flap,
the patellar tendon is sutured to the hamstrings so that
both the rectus femoris and the hamstrings help in
stabilizing the hip joint in the erect posture.
Symes amputations
The lower ends of the tibia and fibula are sawn across
just above the line of the ankle joint.
a posterior flap consisting of the skin of the heel with
its underling pad of fibrofatty tissue.
Points in technique
the main artery and vein individually
ligated---to avoid the arteriovenous fistula.
the nerves---gently drawn down
cut with a sharp knife
allowed to retract upward
so that the stump neuroma which inevitably
forms should be away from pressure.
the bone---cut with a saw and any splinter
removed
absolute haemostasis is ensured.
suction drains to prevent the collection of
serum or blood.
the muscles---stitched together over the bone
incorporate the deep fascia
Postoperative care of an amputations
#.a gauze and cotton wool dressing
#.a demoralizing operation, with a inflatable
prosthesis a lower limb amputee can get on his
feet the day after the operation.
#.exercise:
in the past---an important part of rehabilitation and
prepared the stump for the prosthesis
nowadays--- prosthesis mobilization automatically
provides exercises for the stump muscles, preventing
the development of disuse atrophy and contractures.
Complications
#reactionary haemorrhage, haematoma
formation, infection, sequestrum formation,
wound dehiscence and gangrene of the flaps.
at a later stage---an adherent scar
# phantom limb