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 also happen when thrombosis occur on plaque preexisting atheroma.

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Causes
Embolism, thrombosis & vascular injury are the causes of acute lower limb ischemia. Emboli: The Sources of arterial emboli are : (Cardiac (90% (Arrhythmia (atrial fibrillation (Valvular heart diseaes. ( MS .Prosthetic heart valves .Hx of myocardial infarction .Atrial myxoma
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(Arterial source (9% Atherosclerotic aorta Aneurysm (Other (1% .Pardoxial Hx of medication (oral (contraceptives

 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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Clinical Features
The 6 Ps :
.Pain .Pallor .Pulselessness .Perishing cold .Paraesthesia .Paralysis
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Clinical differentiation between thrombosis & embolism

Embolism: obvious cardiac source No hx of cluadication Normal pulses in contralateral limb Angiogram: minimal atherosclerotic Few collateral 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 occlusion of 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 arteriography should 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 & the common femoral artery is opened. often the clot is found in the artery a Fogarty balloon catheter is passed in turn into the proximal & distal arteries the balloon is inflated & the catheter withdrawn removing the WWW.SMSO.NET clot.

Fogarty balloon catheter

Management
Thrombolytic therapy: Percutaneous intra-arterial thrombolytic therapy. Takes approximately 12-72 hours to dissolve the clot. Agents used: streptokinase, urokinase & tissue plasminogen activator. Mechanism: The convert plasminogen to plasmin which the active lytic agent.

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Complications
Compartment 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 with normal 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 supply to the tissues due to partial occlusion of arteries. Stenosis or occlusion produces symptoms & signs that are related to the organ supplies by the artery. The severity of symptoms is related to the size of the vessel 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 formation of focal obstructions or plaques in large & medium sized arteries. It is characterised by the presence of focal intimal thickening, these intimal elevations being made up of accumulations of cholesterol rich & a proliferation of connective tissue. An essential component of atherogenesis is inflammation involving monocytes / macrophages, T lymphocytes & mast cells. WWW.SMSO.NET

Risk factors
Smoking Hypertension Hyperlipidaemia (raised LDL) High fat diets Diabetes mellitus Elevated blood uric acid (gout) Hypothyroidism Renal disease Familial history of premature atherosclerosis Male sex & age High risk factors

Other risk factors

Sedentary life Obesity Anxiety

Factors having an uncertain role

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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 & medium size arteries, thrombophlebitis of superficial or deep veins & Raynauds syndrome. It occurrs in male patients with heavy smoking & usually under the age of 30 years.
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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 of finer 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 and calves, femoral and disal pulses absent,bruits, impotence Illiac Unilateral claudication of thigh, calf Unilateral absence of femoral and distal pulses

femoropop Unilateral claudication in calf , femoral liteal pulse palpable with absent unilateral distal pulses
Distal Femoral & popliteal pulses palpable, ankle pulses obstruction absent, 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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