Acute Chronic Ischemia
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Transcript of Acute Chronic Ischemia
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Acute & Chronic Ischemia
Done by:
Muneera Al-Bassam
Hessah Al-Jerri
Naeemah AL-Faraj
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Acute ischemia
Definition:
Sudden occlusion of an artery is commonly
due to either emboli or trauma & it may alsohappen when thrombosis occur on plaque pre-
existing atheroma.
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Embolism, thrombosis & vascular injury are the causes of acute
lower limb ischemia.
Emboli:
The Sources of arterial emboli are :
Causes
Cardiac (90%Arrhythmia (atrial fibrillation
Valvular heart diseaes. ( MS
Prosthetic heart valves.
Hx of myocardial infarction.
Atrial myxoma.
Arterial source (9%Atherosclerotic aorta
Aneurysm
Other (1%
Pardoxial.
Hx of medication (oral
contraceptives
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Emboli usually impact at branching points in arterial
tree, particularly at the bifurcation of the aorta, the
common femoral bifurcation & popliteal trifurcation.
Sites of occlusion embloi to the
lower limb:
Femoral artery 45%
Aorta & iliac artery 26%
popliteal artery 15%
tibial artery 1%
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Thrombosis: Thrombosis usually occur on a pre-existing atherosclerotic lesion.
Occasionally thrombosis occur on relatively normal artery
In patients with hypercoagulabale states ex:
Pt with malignancy, polycythemia
or pt taking high doses of oestrogen.
Trauma It is important to determine a history of
arterial trauma, arterial catheterization,
intra-arterial drug induced injection,
aortic dissection, limb fractures.
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ClinicalFeatures
The6 Ps:
Pain.
Pallor.
Pulselessness.
Perishing cold.
Paraesthesia.
Paralysis.
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Embolism:
obvious cardiac source
No hx of cluadicationNormal pulses in contralateral limb
Angiogram: minimal atherosclerotic
Few collateral
Clinical differentiation between
thrombosis & embolism
Thrombosis:
No obvious cardiac source.
history of cluadication.
abnormal pulses in contralateral limb.
Angiogram: diffuse atherosclerotic
Well developed collateral
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Investigation
FBC : polycythemia. U&E: renal impiarment. Clotting screen. Arteriography. ECG ( MI, Atrial fibrillation Cardiac enzyme.
Doppler US. Duplex imaging.
find source of embolism:Holter monitring, echocariograph, us aorta for
aaa
Angiogram show occlusionof the right external iliac
artery
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Management
Immediately :
Anticoagulant with heparin to prevent propagation of
thrombus & distal thrombosis & this achieved by
giving a bolus of 10 000 units of heparin intravenously
& an infusion of about 1000 units of heparin per hour
after that.
In pt thrombosis is thought to be the dx arteriographyshould be considered to define the extant of problem
before revascularization.
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Management
Embolectomy :This operation usually
performed under local
anaesthesia.
A groin incision is made & thecommon femoral artery is
opened. often the clot is
found in the artery a Fogarty
balloon catheteris passed in
turn into the proximal &distal arteries the balloon is
inflated & the catheter
withdrawn removing the
clot. Fogarty balloon catheter
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Management
Thrombolytic therapy:
Percutaneous intra-arterial thrombolytic therapy.
Takes approximately 12-72 hours to dissolve the clot.
Agents used: streptokinase, urokinase & tissueplasminogen activator.
Mechanism:
The convert plasminogen to plasmin which the activelytic agent.
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ComplicationsCompartment syndrome
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Case
A 55 years old Saudi male complaining of sudden onset
of severe progressive pain in the distal part of his right
leg.
On examination : pale , cold & tender right leg withnormal pulses on left leg & absent on the right.
On investigation: The angiogram show minimal
atherosclerotic, sharp cut off & few collateral.
He has a history of mitral stenosis.
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Chronic Ischemia
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Chronic Arterial Ischemia
Definition:
It is the decrease in arterial blood supplyto the tissues due to partial occlusion of
arteries. Stenosis or occlusion producessymptoms & signs that are related to theorgan supplies by the artery. The severityof symptoms is related to the size of thevessel occluded & alternative routes(collaterals) available for blood flow.
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Causes:
Atherosclerosis
Burgers disease
Raynauds disease
Others
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Atherosclerosis
Definition:
It is the process underlying the formationof focal obstructions or plaques in large &
medium sized arteries. It is characterisedby the presence of focal intimal thickening,these intimal elevations being made up ofaccumulations of cholesterol rich & a
proliferation of connective tissue. Anessential component of atherogenesis isinflammation involving monocytes /macrophages, T lymphocytes & mastcells.
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Risk factors Smoking
Hypertension
Hyperlipidaemia (raised LDL) High risk factors
High fat diets
Diabetes mellitus
Elevated blood uric acid (gout) Hypothyroidism
Renal disease Other risk factors
Familial history of premature atherosclerosis
Male sex & age
Sedentary life
Obesity Factors having an uncertain role
Anxiety
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Common sites of plaque formation in
arteries:
Branch points.
Tethered sites like in superficial femoral artery in
Hunters canal in the leg.
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Peripheral vascular disease
It is occlusive atherosclerotic disease in the
lower extremities.
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Symptoms
Intermittent claudication
Rest pain
Erectile dysfunction
Sensorimotor impairment
Tissue loss
Signs Muscular atrophy
Decrease hair growth
Thick toenails Tissue necrosis ulcers infection
Absent pulses
Bruits
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Buergers disease
(Thromboangitis obliterans)
Definition:
It is occlusive disease of small & mediumsize arteries, thrombophlebitis of
superficial or deep veins & Raynaudssyndrome.
It occurrs in male patients with heavysmoking & usually under the age of 30years.
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Histology:
Localised inflammatory changes occur in
walls of arteries and veins leading to
thrombosis.
Clinical picture:
The usual symptoms and signs of arterial
occlusive disease are present.
Gangrene of the toes and fingers is
common and progressive.
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Raynauds disease
Idiopathic condition usually occurs in
young women & affects the upper
extremities more than lower.
Peripheral pulses are normal.
It is attributable to abnormal sensitivity in
the direct response of the arterioles to
cold.
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When cooled, these vessels constrict &
the part becomes blanched & incapable offiner movements.
The capillaries then dilate & fill with slow
flowing deoxygenated blood, the digits
therefore becoming swollen & dusky.
As the attack pass off, the arterioles relax,
oxygenated blood returns into the dilated
capillaries & the digits become red.
Often accompanied by pain.
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Raynaud syndrome
It is peripheral arterial manifestation of
collagen disease such as SLE or RA
Clinical features: same as for Raynauds
disease but may be more aggressive.
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Lower limb ischemia
Intermittent claudication:
ABI: 0.5-0.9
Cludication distance Calf is the most common
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Rest pain
Worst at night,lying, relieved by putting the
leg in dependent site
Coldness
Numbness
Parasthesia
Color change Differentiated from night cramps
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Ulcers and gangrene
Gangrene Between the toes
Ulcers at the foot dorsum and leg shins
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Aortoilliac Claudication of both buttoks, thighs andcalves, femoral and disal pulsesabsent,bruits, impotence
Illiac Unilateral claudication of thigh, calf
Unilateral absence of femoral and distal
pulses
femoropopliteal
Unilateral claudication in calf , femoralpulse palpable with absent unilateral
distal pulsesDistalobstruction
Femoral & popliteal pulses palpable, ankle pulsesabsent, cluadication in calf & foot
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investigation
General Diabetes
Lipid profile
Anemia High viscosity
Full blood count
Plasma fibrinogen Blood and urine glocuse
ECG
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Investigation (non-invasive.)
Doppler ultrasound
ABI( rest and exercise )
Duplex imaging: Blood flow and turbulence
Plethysmography
treadmill
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Investigation( invasive)
Arteriography To decide whether intervention is needed
Seldinger technique
Hazards: Thrombosis
Dissection
Heamatoma
Neurological dysfunction Anaphylaxis
Digital substraction angiography
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Management
Explanation and advice
Life style adjustment
Smoking Exercise
Diet
Heal raise Analgesics and use of position
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Sympathectomy
Transluminal angioplasty: usually
percutaneous
Iliac success more than the leg arteries
bypass
Atherectomy
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Aortoilliac artery
PTA with or without stent
Iliac endarterectomy
Bypass If inable to operate:
Illiofemoral or femorofemoral crossover
Axillobifemoral
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Superficial femoral and profunda
femoris
Long distance
claudication:
Conservative
PTA bypass Popliteal artery
bypass
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