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Clinical features of acute and
chronic arterial stenosis and
occlusion
Dr Sumer Yadav
MCh – Plastic and Reconstructive Sur...
What is PVD?
Definition:
• Also known as PAD or PAOD.
• Occlusive disease of the arteries of the lower
extremity.
• Most c...
The Facts:
1. The prevalence: >55 years is 10%–25%
2. 70%–80% of affected individuals are asymptomatic
3. Pt’s with PVD al...
Risk Factors:
Typical Patient:
• Smoker (2.5-3x)
• Diabetic (3-4x)
• Hypertension
• Hx of Hypercholesterolemia/AF/IHD/CVA
...
Chronic PVD History:
3. Critical Stenosis = >60%, impending acute ischemic limb:
- rest pain
- ischemic ulceration
- gangr...
Thigh Claudication
60% Upper 2/3 Calf Claudication
Lower 1/3 Calf Claudication
Foot Claudication
30% Buttock & Hip Claudic...
DDx of Leg Pain
1. Vascular
a) DVT (as for risk factors)
b) PVD (claudication)
1. Neurospinal
a) Disc Disease
b) Spinal St...
Physical Examination:
Examination: What do to:
Inspection
Expose the skin and look
for:
• Thick Shiny Skin
• Hair Loss
• B...
Pictures:
sumeryadav2004@gmail.com
What does the ABI mean?
ABI Clinical Correlation
>0.9 Normal Limb
0.5-0.9 Intermittent Claudication
<0.4 Rest Pain
<0.15 G...
Investigations:
NON INVASIVE:
Duplex Ultrasound
 normal is triphasic  biphasic  monophasic  absent
BLOOD TESTS:
1. Coa...
ANGIOGRAPHY:
Non-invasive:
• CT Angiogram
• MR Angiogram
Invasive:
• Digital Subtraction Angiography
 Gold Standard
 Int...
sumeryadav2004@gmail.com
Tardus et parvus = small amplitude + slow rising pulse
sumeryadav2004@gmail.com
CT Angiography Digital Subtraction Angiography
Value of angiographyValue of angiography
Localizes the obstruction
Visual...
Treatment:
1. RISK FACTOR MODIFICATION:
a) Smoking Cessation
b) Rigorous BSL control
c) BP reduction
d) Lipid Lowering The...
PCI/Surgery:
Indications/Considerations:
•Poor response to exercise rehabilitation + pharmacologic therapy.
•Significantly...
Some Bypass Options:
sumeryadav2004@gmail.com
Mr. X presents with an acutely
painful leg:
You have had a busy day in the ED and the next
patient to see is:
Mr. X – a 60...
What are the features of an
acute ischemic limb?
REMEMBER THE 6 P’S:
1. PAIN
1. PALLOR
1. PULSELESNESS
1. PERISHING COLD (...
History & Exam Findings
Further Hx:
• Smokes 20cigs/day for 30 years
• 4 months of ‘leg cramps’ in BOTH legs
• 2-3 weeks o...
What will you do now?
1. CALL THE VASCULAR REGISTRAR
2. ORDER INVESTIGATIONS
a) FBE
b) Coagulation Studies
c) Group and Ho...
Mr. X’s Complication
- Angiogram is done in radiology
- Shows acute thrombosis of L popliteal artery
- Cathetar induced ur...
Learning Outcomes
1. Risk factors for PVD
2. Recognise signs and symptoms of chronic ischemia of the lower limbs
3. Differ...
ACUTE ARTERIAL OCCLUSION
• “ The operation was a success but the patient
died”
• High Morbidity and Mortality
– Emergent o...
Evolution of Atherosclerosis
• Areas of low wall shear stress
• Increased endothelial permeability
• Sub-endothelial lipid...
Evolution of Atherosclerosis
• Rupture of Fibrous Cap
• • Pro-thrombotic core Exposed to lumen
• • Acute thrombosis
• • Em...
Thromboembolism
• Embolus- greek “embolos” means projectile
• Mortality of 10-25%
• Mean age increasing – 70 years
– Rhuma...
Macroemboli
• Cardiac Emboli
– Heart source 80-90% of thrombus macroemboli
– MI, A.fib, Mitral valve, Valvular prost hesis...
Thromboembolism
• 75% of emboli involve axial limb vasculature
• Femoral and Polilteal – >50% of emboli
• Branch sites
• A...
Thromboembolism
Thromboembolism Non-cardiac sources
• Aneurysmal (popliteal > abdominal)
• Paradoxical – Follows PE with P...
Atheromatous Embolization
• Shaggy Aorta – Thoracic or abdominal
• Spontaneous
• Iatrogenic – 45% of all atheroemboli
• “B...
Atheromatous Embolization
• Risk factors: PVD, HTN, elderly, CAD, recent
arterial manipulation
• Emboli consist of thrombu...
Atheromatous Embolization
• Affect variety of end organs
– extremities, pelvis ,GI, kidney, brain
• Work-up:
– TEE ascendi...
Atheromatous Embolization
• Reported incidence of 0.5-1.5% following
catherter manipulation
– Advance/remove catheters ove...
Atheromatous Embolization
Therapy
• Prevention and supportive care – Statins, prostacyclin analogs
(iloprost)
• Eliminatio...
Acute Thrombosis
• Graft thrombosis (80%)
– intimal hyperlasia at distal anastamosis (prosthetic)
– Retained valve cusp
– ...
Acute Thrombosis
Heparin Induced Thrombosis
• White Clot Syndrome
• Heparin dependent IgG anti-body against platelet facto...
Other causes of Thrombosis
– Anti-thrombin III Defiency
– Protein C & S Defiency
– Factor V Leiden
– Prothrombin 20210 Pol...
“The Cold Leg”
• Clinical Diagnosis
– Avoid Delay
– Anti-coagulate immediately
– Pulse exam – 6 P’s (pain, pallor, pulsele...
Diagnostic Evaluation
• SVS/ISCVS Classification
• – “Rutherford Criteria”
• • Class I: Viable – Pain, No paralysis or sen...
Therapeutic Options
– Class 1 or 2A
• Anti-coagulation, angiography and elective
revascularzation
– Class 2B
• Early angio...
Diagnostic Evaluation
• Modalities
– Non-invasive:
• Waveforms
• CTA / MRA : avoid nephrotoxity
– Contrast Angiography
• G...
Thrombotic –vs- Embolic
• Thrombotic
– History
• Claudication, PVD
• Bypass graft
– Physical
• Hair loss, shiny skin
• Bi-...
Thrombotic –vs- Embolic
• Embolic
– History
• Cardiac events
• Acute onset
• Hx of emboli
– Physical
• Normal contralatera...
Treatment Options
• Multiple options available
– Conventional surgery
• embolectomy
• endarterectomy
• revascularization
–...
Treatment Fundamentals
• Early recognition and anti-coagulation
– Minimizes distal propagation and recurrent emboli
• Moda...
Embolectomy
• Fogarty embolectomy catheter
– Intoduced 1961
• Thru-lumen catheter
– Selecti ve placement over wire
– Admin...
Embolectomy
Surgical Therapy
• Iliac and femoral embolectomy
– Common femoral approach
– Transverse arteriotomy proximal p...
Embolectomy
• Popliteal embolectomy
– 49% success rate from femoral approach
– Blind passage selects peroneal 90%
– may ex...
Embolectomy
• Completion angiography
– 35% incdence of retained thrombus
• Failure requires
– Thrombolytic thearpy
– revas...
Thrombolytic Therapy
• Advantages
• Opens collaterals & microcirculation
• Avoids sudden reperfusion
• Reveals underlying ...
Indications for Thrombolysis
• Category 1-2a limbs should be considered
– Class 2b : Two schools of thought
1)“Delay in de...
Technique of Thrombolysis
• Guide Wire Traversal Test (GTT)
– Abilty to traverse lesion best predictor of
success
– Use 0....
Technique of Thrombolysis
• Catheter directed delivery
1) Lace clot via catheter with side holes
2) Pulse-Spray technique ...
Mechanical Thrombectomy
• Percutaneous aspiration embolectomy
– Viable alternative in selected patents
– Varity of devises...
Reperfusion Syndrome
Local: endothelial damage, capillary permeability,
Transudative swelling, cellular damage
• Compartme...
SUMMARY
• Thrombotic and embolic occlusions are
separate processes with different
presentations and treatments
• Treatment...
Thanks
sumeryadav2004@gmail.com
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Peripheral vascular disease and Clinical features of acute and chronic arterial stenosis and occlusion

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Peripheral vascular disease and Clinical features of acute and chronic arterial stenosis and occlusion

  1. 1. Clinical features of acute and chronic arterial stenosis and occlusion Dr Sumer Yadav MCh – Plastic and Reconstructive Surgery Dr Sumer Yadav MCh – Plastic and Reconstructive Surgery sumeryadav2004@gmail.com
  2. 2. What is PVD? Definition: • Also known as PAD or PAOD. • Occlusive disease of the arteries of the lower extremity. • Most common cause: o Atherothrombosis o Others: arteritis, aneurysm + embolism. • Has both ACUTE and CHRONIC Pathophysiology: • Arterial narrowing  Decreased blood flow = Pain • Pain results from an imbalance between supply and demand of blood flow that fails to satisfy ongoing metabolic requirements. sumeryadav2004@gmail.com
  3. 3. The Facts: 1. The prevalence: >55 years is 10%–25% 2. 70%–80% of affected individuals are asymptomatic 3. Pt’s with PVD alone have the same relative risk of death from cardiovascular causes as those CAD or CVD 1. PVD pt’s = 4X more likely to die within 10 years than pt’s without the disease. 2. The ankle–brachial pressure index (ABPI) is a simple, non-invasive bedside tool for diagnosing PAD — an ABPI <0.9 = diagnostic for PAD 1. Patients with PAD require medical management to prevent future coronary and cerebral vascular events. 1. Prognosis at 1 yr in patient’s with Critical Limb Ischemia (rest pain): • Alive with two limbs — 50% • Amputation — 25% • Cardiovascular mortality 25% sumeryadav2004@gmail.com
  4. 4. Risk Factors: Typical Patient: • Smoker (2.5-3x) • Diabetic (3-4x) • Hypertension • Hx of Hypercholesterolemia/AF/IHD/CVA • Age ≥ 70 years. • Age 50 - 69 years with a history of smoking or diabetes. • Age 40 - 49 with diabetes and at least one other risk factor for atherosclerosis. • Leg symptoms suggestive of claudication with exertion or ischemic pain at rest. • Abnormal lower extremity pulse examination.sumeryadav2004@gmail.com
  5. 5. Chronic PVD History: 3. Critical Stenosis = >60%, impending acute ischemic limb: - rest pain - ischemic ulceration - gangrene 2. Other Symptom/Signs: • A burning or aching pain in the feet (especially at night) • Cold skin/feet • Increased occurrence of infection • Non-healing Ulcers • Asymptomatic 1. INTERMITTENT CLAUDICATION • Derived from the Latin word ‘to limp’ • “Reproducible pain on exercise which is relieved by rest” • Pain can also be reproduced by elevating the leg • “my legs get sore at night and feel better when I hang them over the edge of the bed” sumeryadav2004@gmail.com
  6. 6. Thigh Claudication 60% Upper 2/3 Calf Claudication Lower 1/3 Calf Claudication Foot Claudication 30% Buttock & Hip Claudication ±Impotence – Leriche’s Syndrome sumeryadav2004@gmail.com
  7. 7. DDx of Leg Pain 1. Vascular a) DVT (as for risk factors) b) PVD (claudication) 1. Neurospinal a) Disc Disease b) Spinal Stenosis (Pseudoclaudication) 1. Neuropathic a) Diabetes 1. Musculoskeletal a) OA (variation with weather + time of day) b) Chronic compartment syndrome sumeryadav2004@gmail.com
  8. 8. Physical Examination: Examination: What do to: Inspection Expose the skin and look for: • Thick Shiny Skin • Hair Loss • Brittle Nails • Colour Changes (pallor) • Ulcers • Muscle Wasting Palpation • Temperature (cool, bilateral/unilateral) • Pulses: ?Regular, ?AAA • Capillary Refill • Sensation/Movement Auscultation • Femoral Bruits Ankle Brachial Index (ABI) = Systolic BP in ankle Systolic BP in brachial artery Buerger’s Test • Elevate the leg to 45° - and look for pallor • Place the leg in a dependent position 90°& look for a red flushed foot before returning to normal • Pallor at <20° = severe PAD. sumeryadav2004@gmail.com
  9. 9. Pictures: sumeryadav2004@gmail.com
  10. 10. What does the ABI mean? ABI Clinical Correlation >0.9 Normal Limb 0.5-0.9 Intermittent Claudication <0.4 Rest Pain <0.15 Gangrene CAUTION: Patient’s with Diabetes + Renal Failure: They have calcified arterial walls which can falsely elevate their ABI. sumeryadav2004@gmail.com
  11. 11. Investigations: NON INVASIVE: Duplex Ultrasound  normal is triphasic  biphasic  monophasic  absent BLOOD TESTS: 1. Coagulation Studies 2. Fasting Lipids and Fasting Glucose 3. HBA1C WHEN TO IMAGE: 1. To image = to intervene 2. Pt’s with disabling symptoms where revascularisation is considered 3. To accurately depict anatomy of stenosis and plan for PCI or Surgery sumeryadav2004@gmail.com
  12. 12. ANGIOGRAPHY: Non-invasive: • CT Angiogram • MR Angiogram Invasive: • Digital Subtraction Angiography  Gold Standard  Intervention at the same time sumeryadav2004@gmail.com
  13. 13. sumeryadav2004@gmail.com
  14. 14. Tardus et parvus = small amplitude + slow rising pulse sumeryadav2004@gmail.com
  15. 15. CT Angiography Digital Subtraction Angiography Value of angiographyValue of angiography Localizes the obstruction Visualize the arterial tree & distal run-off Can diagnose an embolus:sumeryadav2004@gmail.com
  16. 16. Treatment: 1. RISK FACTOR MODIFICATION: a) Smoking Cessation b) Rigorous BSL control c) BP reduction d) Lipid Lowering Therapy 3. MEDICAL MANAGEMENT: a) Antiplatelet therapy e.g. Aspirin/Clopidogrel b) Phosphodiesterase Inhibitor e.g. Cilostazol c) Foot Care 2. EXERCISE: a) Claudication exercise rehabilitation program b) 45-60mins 3x weekly for 12 weeks c) 6 months later +6.5mins walking time (before pain) sumeryadav2004@gmail.com
  17. 17. PCI/Surgery: Indications/Considerations: •Poor response to exercise rehabilitation + pharmacologic therapy. •Significantly disabled by claudication, poor QOL •The patient is able to benefit from an improvement in claudication •The individual’s anticipated natural hx and prognosis •Morphology of the lesion (low risk + high probabilty of operation success) PCI: •Angioplasty and Stenting •Should be offered first to patients with significant comorbidities who are not expected to live more than 1-2 years Bypass Surgery: •Reverse the saphenous vein for femoro-popliteal bypass •Synthetic prosthesis for aorto-iliac or ilio-femoral bypass •Others = iliac endarterectomy & thrombolysis •Current Cochrane review = not enough evidence for Bypass>PCI sumeryadav2004@gmail.com
  18. 18. Some Bypass Options: sumeryadav2004@gmail.com
  19. 19. Mr. X presents with an acutely painful leg: You have had a busy day in the ED and the next patient to see is: Mr. X – a 60 yr old gentleman with a very painful leg. He tells you that he woke up this morning with an excruciating pain in his left leg and has never felt this pain before. ? Embolism (AF/Recent Infarct/Anuerysm) ? Thrombosis of native vessel or graft MUST RULE OUT ACUTE LIMB ISCHEMIA sumeryadav2004@gmail.com
  20. 20. What are the features of an acute ischemic limb? REMEMBER THE 6 P’S: 1. PAIN 1. PALLOR 1. PULSELESNESS 1. PERISHING COLD (POIKILOTHERMIA) 1. PARASTHESIAS 1. PARALYSIS Fixed mottling & cyanosis sumeryadav2004@gmail.com
  21. 21. History & Exam Findings Further Hx: • Smokes 20cigs/day for 30 years • 4 months of ‘leg cramps’ in BOTH legs • 2-3 weeks of intermittent chest palpitations Examination: • Inspection: : below the knee is pale/cool • Palpation: o Irregularly irregular pulse Capillary return is sluggish o No pulses palpable below L femoral artery o All pulses palpable but appear reduced in R leg o Normal Sensation + Movement bilaterally Impression? 60yo male with a L Acute Ischemic limb on the background of heavy smoking, untreated AF and symptomatic PVD.sumeryadav2004@gmail.com
  22. 22. What will you do now? 1. CALL THE VASCULAR REGISTRAR 2. ORDER INVESTIGATIONS a) FBE b) Coagulation Studies c) Group and Hold d) 12 Lead ECG e) Chest XR 3. INITATE ACUTE MANAGEMENT: a) Analgesia b) Commence IV heparin c) Call Radiology for Angiography if limb still viable d) Discuss with registrar: i) Thrombotic cause  ?cathetar induced thrombolysis ii) Embolic cause  ?embolectomy iii) All other measures not possible  Bypass/Amputation Simple measures to improve existing perfusion: • Keep the foot dependant • Avoid pressure over the heel • Avoid extremes of temperature (cold induces vasospasm) • Maximum tissue oxygenation (oxygen inhalation) • Correct hypotension sumeryadav2004@gmail.com
  23. 23. Mr. X’s Complication - Angiogram is done in radiology - Shows acute thrombosis of L popliteal artery - Cathetar induced urokinase and heparin infusion is started …. 3-4 hours later -Severe calf pain in the reperfused limb -All pulses are present -Leg is swollen, tense and +++ tender REPERFUSION INJURY! -Restored blood flow can lead to unwanted local + systemic effects 1) Washout = oMetabolic Acidosis oHyperkalemia oARF (myoglobinuria) oNon-cardiac APO 2) Compartment Syndrome = oMay need fasciotomy sumeryadav2004@gmail.com
  24. 24. Learning Outcomes 1. Risk factors for PVD 2. Recognise signs and symptoms of chronic ischemia of the lower limbs 3. Differential diagnosis for leg pain 4. Examine a chronic ischemic limb 5. Understand medical/surgical of management of PVD 6. Recognise an acute ischemic limb 7. Know it is important to call the vascular registrar ASAP 8. Know what investigations to order in the ED sumeryadav2004@gmail.com
  25. 25. ACUTE ARTERIAL OCCLUSION • “ The operation was a success but the patient died” • High Morbidity and Mortality – Emergent operations in high risk patients – 20% mortality reported (Dale, JVS 1984) – Endovascular approaches may lower peri- procedural mortality while preserving outcomes sumeryadav2004@gmail.com
  26. 26. Evolution of Atherosclerosis • Areas of low wall shear stress • Increased endothelial permeability • Sub-endothelial lipid and macrophage accumulation • Foam cells • Formation of Fatty Streak • Fibrin deposition and stabilizing fibrous cap sumeryadav2004@gmail.com
  27. 27. Evolution of Atherosclerosis • Rupture of Fibrous Cap • • Pro-thrombotic core Exposed to lumen • • Acute thrombosis • • Embolization of plaque materials and thrombus sumeryadav2004@gmail.com
  28. 28. Thromboembolism • Embolus- greek “embolos” means projectile • Mortality of 10-25% • Mean age increasing – 70 years – Rhumatic disease to atherosclerotic disease • Classified by size or content – Macroemboli and microemboli – Thrombus, fibrinoplatelet clumps, cholesterol sumeryadav2004@gmail.com
  29. 29. Macroemboli • Cardiac Emboli – Heart source 80-90% of thrombus macroemboli – MI, A.fib, Mitral valve, Valvular prost hesis – Multiple emboli 10% cases – TEE • Views left atrial appendage, valves, aortic root • not highly sensitive sumeryadav2004@gmail.com
  30. 30. Thromboembolism • 75% of emboli involve axial limb vasculature • Femoral and Polilteal – >50% of emboli • Branch sites • Areas of stenosis sumeryadav2004@gmail.com
  31. 31. Thromboembolism Thromboembolism Non-cardiac sources • Aneurysmal (popliteal > abdominal) • Paradoxical – Follows PE with PFO • Thoracic outlet syndrome • Cryptogenic –5-10% • Atheroemboli (artery to artery) sumeryadav2004@gmail.com
  32. 32. Atheromatous Embolization • Shaggy Aorta – Thoracic or abdominal • Spontaneous • Iatrogenic – 45% of all atheroemboli • “Blue toe syndrome” – Sudden – Painful – cyanotic – palpable pulses • livedo reticularis sumeryadav2004@gmail.com
  33. 33. Atheromatous Embolization • Risk factors: PVD, HTN, elderly, CAD, recent arterial manipulation • Emboli consist of thrombus, platelet fibrin material or cholesterol crystals • Lodge in arteries 100 –200 micron diameter sumeryadav2004@gmail.com
  34. 34. Atheromatous Embolization • Affect variety of end organs – extremities, pelvis ,GI, kidney, brain • Work-up: – TEE ascending aorta, CT Angio, Angiography • Laboratory: CRP elevated, eosinophilia • Warfarin may destablize fibrin cap and trigger emboli. sumeryadav2004@gmail.com
  35. 35. Atheromatous Embolization • Reported incidence of 0.5-1.5% following catherter manipulation – Advance/remove catheters over guidewire – Brachial access? – controversial • Limited Sx– Anti-coagulation/ observation • Temporal delay up to 8 weeks before renal symptoms sumeryadav2004@gmail.com
  36. 36. Atheromatous Embolization Therapy • Prevention and supportive care – Statins, prostacyclin analogs (iloprost) • Elimination of embolic source and reestablishing blood flow to heal lesions • Surgical options: endaterectomy or resection and graft placement – Abdominal Aorta – Aorta-bi-fem bypass – Ligation of external iliac and extra-anatomic bypass if high risk • Endovascular therapy – Angioplasty & stenting - higher rate of recurrence – Athrectomy – no datasumeryadav2004@gmail.com
  37. 37. Acute Thrombosis • Graft thrombosis (80%) – intimal hyperlasia at distal anastamosis (prosthetic) – Retained valve cusp – Stenosis at previous site of injury • Native artery • Intra-plaque hemmorhage • Hypovolemia • Cardiac failure • hypercoagable state • Trauma • Arteritis, popliteal entrapment, adventitial cystic disease sumeryadav2004@gmail.com
  38. 38. Acute Thrombosis Heparin Induced Thrombosis • White Clot Syndrome • Heparin dependent IgG anti-body against platelet factor 4 • 3-10 days following heparin contact • Dx: thrombosis with > 50% decrease in Platelet count • Tx: Direct throbin inhibiors: Agartroban & Hirudin – Avoid all heparin products • Morbity and Mortality: 7.4-61% and 1.1-23%sumeryadav2004@gmail.com
  39. 39. Other causes of Thrombosis – Anti-thrombin III Defiency – Protein C & S Defiency – Factor V Leiden – Prothrombin 20210 Polymorphism – Hyper-homocystinemia – Lupus Anti-coagulant (anti phospho-lipid syndrome) sumeryadav2004@gmail.com
  40. 40. “The Cold Leg” • Clinical Diagnosis – Avoid Delay – Anti-coagulate immediately – Pulse exam – 6 P’s (pain, pallor, pulselessness, parathesias, paralysis,poiklothermia) • Acute –vs- Acute on chronic – Collateral circulation preserves tissue sumeryadav2004@gmail.com
  41. 41. Diagnostic Evaluation • SVS/ISCVS Classification • – “Rutherford Criteria” • • Class I: Viable – Pain, No paralysis or sensory loss • • Class 2: Threatened but salvageable • • 2A: some sensory loss, No paralysis >No immediate threat • • 2B: Sensory and Motor loss > needs immediate treatment • • Class 3: Non-viable – Profound neurologic deficit, absent capillary flow,skin marbling, absent arterial& venous signal sumeryadav2004@gmail.com
  42. 42. Therapeutic Options – Class 1 or 2A • Anti-coagulation, angiography and elective revascularzation – Class 2B • Early angiographic evaluation and intervention • Exception: suspected common femoral emboli – Class3 sumeryadav2004@gmail.com
  43. 43. Diagnostic Evaluation • Modalities – Non-invasive: • Waveforms • CTA / MRA : avoid nephrotoxity – Contrast Angiography • Gold Standard sumeryadav2004@gmail.com
  44. 44. Thrombotic –vs- Embolic • Thrombotic – History • Claudication, PVD • Bypass graft – Physical • Hair loss, shiny skin • Bi-lateral Disease – Angiographic • Diffuse disease • mid vessel occlusion – PVD confuses diagnosis sumeryadav2004@gmail.com
  45. 45. Thrombotic –vs- Embolic • Embolic – History • Cardiac events • Acute onset • Hx of emboli – Physical • Normal contralateral exam – Angiographic • meniscus Cut-off in normal vessel • Bifurcations affected Determination of etiology possible in 85% of cases sumeryadav2004@gmail.com
  46. 46. Treatment Options • Multiple options available – Conventional surgery • embolectomy • endarterectomy • revascularization – Thrombolytic therapy – Percutanious mechanical thrombectomy • Native vessel thrombosis often require more elaborate operations sumeryadav2004@gmail.com
  47. 47. Treatment Fundamentals • Early recognition and anti-coagulation – Minimizes distal propagation and recurrent emboli • Modality of Tx depends on: – Presumed etiology – Location/morphology of lesion – Viability of extremity – Physiologic state of patient – Available vein conduit for bypass grafting sumeryadav2004@gmail.com
  48. 48. Embolectomy • Fogarty embolectomy catheter – Intoduced 1961 • Thru-lumen catheter – Selecti ve placement over wire – Administer: lytics, contrast sumeryadav2004@gmail.com
  49. 49. Embolectomy Surgical Therapy • Iliac and femoral embolectomy – Common femoral approach – Transverse arteriotomy proximal profunda origin – Collateral circulation may increase backbleeding – Examine thrombus sumeryadav2004@gmail.com
  50. 50. Embolectomy • Popliteal embolectomy – 49% success rate from femoral approach – Blind passage selects peroneal 90% – may expose tibialperoneal trunk & guide catheter – Idrectly cannulate distal vessels • Distal embolectomy – Retrograde/antegrade via ankle incisions – Frequent Rethrombosis – Thrombolytic Tx viable alternative sumeryadav2004@gmail.com
  51. 51. Embolectomy • Completion angiography – 35% incdence of retained thrombus • Failure requires – Thrombolytic thearpy – revascularization sumeryadav2004@gmail.com
  52. 52. Thrombolytic Therapy • Advantages • Opens collaterals & microcirculation • Avoids sudden reperfusion • Reveals underlying stenosis • Prevent endothelial damage from balloons Risks • Hemmorhage • Stroke • Renal failure • Distal emboli transiently worsen ischemia sumeryadav2004@gmail.com
  53. 53. Indications for Thrombolysis • Category 1-2a limbs should be considered – Class 2b : Two schools of thought 1)“Delay in definitive Tx” 2)“Thrombolytics extend window of opportunity” • Clots <14days most responsive – But even chronic thrombus can be lysed • Large clot burden – Better response to lytic tx than surgery – Requires longer duration of thrombolytics sumeryadav2004@gmail.com
  54. 54. Technique of Thrombolysis • Guide Wire Traversal Test (GTT) – Abilty to traverse lesion best predictor of success – Use 0.035 in angled glide wire – “knuckling-over” indicates sub-intimal plane – Attempt pro-grade, Anti-grade, lytic bolus sumeryadav2004@gmail.com
  55. 55. Technique of Thrombolysis • Catheter directed delivery 1) Lace clot via catheter with side holes 2) Pulse-Spray technique (mechanical component) • Urokinase and TPA equally effective • 4 hr treatment followed by angiogram – 4000IU/min x4hr, 2000Iu/M=min x 48h – r-UK (TOPAS Trial) – no improvement after 4hr >> surgery – Continue Heparin tt – Fibrinogen levels sumeryadav2004@gmail.com
  56. 56. Mechanical Thrombectomy • Percutaneous aspiration embolectomy – Viable alternative in selected patents – Varity of devises – Combines diagnostic and therapeutic procedure – Removes non-lysable debris – Effective in distal vessels – Risk distal embolization • Combine with lytic T x sumeryadav2004@gmail.com
  57. 57. Reperfusion Syndrome Local: endothelial damage, capillary permeability, Transudative swelling, cellular damage • Compartment Syndrome • Tx: Fasciotomy Systemic: Lactic Acidosis, Hyperkalemia, Myoglobin, Inflammatory Cytokines • Cardiopulmonary complications Renal Tubular necrosis • Myoglobin precipitates • Tx: Volume, Urinary alklinizationsumeryadav2004@gmail.com
  58. 58. SUMMARY • Thrombotic and embolic occlusions are separate processes with different presentations and treatments • Treatment pathways in AAO are complex and vary depending on clinical situation • Catheter-based treatments preserve outcomes with less overall morbidity sumeryadav2004@gmail.com
  59. 59. Thanks sumeryadav2004@gmail.com
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Peripheral vascular disease and Clinical features of acute and chronic arterial stenosis and occlusion

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