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Lerning objectives
Aneurysm
Introdution
Causes and risk factors
Symptoms and signs
Physical exam
Lab and radiological
exam
Option of treatment
Background
Peripheral artery disease (PAD) is a nearly
pandemic condition that has the potential to
cause loss of limb or even loss of life.
Peripheral artery disease manifests as
insufficient tissue perfusion caused by existing
atherosclerosis that may be acutely
compounded by either emboli or thrombi.
Pathophysiology
Pathophysiology of
Atherosclerosis
Unstable Angina
Plaque
Rupture
Platelet
Adhesion,
Activation, and
Aggregation
MI
Thrombus
Formation
PAD
Atherosclerosis
Critical leg
ischemia
Intermitent
claudication
CV death
Stable angina/
Intermittent claudication
Adapted from Libby P. Circulation. 2001;104:365-372.
Unstable
Few
SMCs
Thin
fibrous cap
Eroded
endothelium
Inflammatory
cells
More
SMCs
Thick
fibrous cap
Lack of
inflammatory
cells
Intact
endothelium
Activated
macrophages
Foam cells
Plaque Rupture
Over age 70
Over age 50 who smoke or have DM
Obvious associated risk of stroke, MI, cardiovascular death
Impaired QoL
Limb Loss
Premature Mortality
Increased
Smoking
Diabetes
Hypertension
Hypercholesterolemia
Hyperhomocysteinemia
Fibrinogen
C- Reactive Protein
Alcohol
Relative Risk
.5
Intermittent claudication
Rest pain
Coldness,numbness,paraesthesia,and colour
change
Ulceration and gangrene
Temperature sensation and movement
Arterial pulsations
Arterial bruits
Venous refilling
Intermittent Claudication
Aorticiliac
Iliac
Femoropopliteal
Distal obstruction
Ankle pulses absent
Location of obstruction
Claudication in bothbuttocks,thighs
and calves;femoral and distal
pulse(-)
Unilateral claudication in thigh and
calf and sometimes buttock
Unilateral claudication in
calf,femoral pulse palpable with
absent unilateral distal pulse
Femoral and popliteal pulses
palpable
Claudication in calf and foot
Location of claudication
Rest pain
Rest pain
Physical Exam
Trophic Signs
Pulse exam
Colour change
Blanched on elevation
Red speckle
Purple discolouration
Vascular exam
Diminution
stenosis/occluded
Expansile arterial
pulsationdilation/aneurysm
Arterial bruites
Systolic bruitestenosis/occluded
Continuous murmur-AVF
Arterial pulsations
Radial arteries
Carotid arteries
Abdominal aorta
Femoral arteries
Popliteal arteries
Posterior tibial arteries
Dorsalis pedis arteries
Artereis to be examed
Examination of pules
0, absent
1, diminished
2, normal
3, bounding
Use of a
standard
examination
should
facilitate
clinical
communication
Physicla exam
Venous refilling
Elevat limb for 30 seconds----laid flat on bed
Normal refilling within seconds
Reduced refilling-severe arterial insufficiency
Increased refilling -AVF
Color Return(s)
Venous Filling(s)
Normal
10
10-15
Adequate
Collaterals
15-25
15-30
Severe Ischemia
>35
>40
General investigation
PAD
The ankle-brachial index is 95% sensitive and 99% specific for PAD
Establishes the PAD diagnosis
Identifies a population at high risk of CV ischemic events
Population at risk can be clinically & epidemiologically defined:
ABI algorithem
2.Segmental Pressures
Calibrated air
plethysmographic
wave form recording
system
Helps localize site of
obstruction
Placement of cuffs at
levels of proximal and
distal thigh, calf and
ankle
3.Duplex Doppler
Is this enough?
20-40 cc
Automated Scan delay
MRI
Limitations of MRI
Uncooperative patient
Claustrophobia(fear of closed place)
Metal artifact
Pacemakers/ICDs
Lack of visualization of calcium
(maganetic field)
CTA of PVD
Multidetector CT scanner
necessary (4+)
80-150 cc
Automated Scan Delay
CTA of PVD
CTA of PVD
Maximum Intensity
Projection -MIP (most
common)
Shaded surface display
3D Volume rendering
CT Limitations
Exercise ABI
Duplex ultrasound
Diagnostic algorithem
CLASSIFICATION
Stage of severity(Fontain stages)
>Stage:asymptomatic
>Stagea:mild claudication
>Stageb: moderate to severe claudication
>Stage :ischemic rest pain
>Stage :ulceration or gangrene.
Rutherford categories
Grade 0,category0:asymptomatic
Grade,category1:mild claudication
Grade,category2:moderate claudication
Grade,category3:sever claudication
Grade,category4:ischemic rest pain
Grade , category5:minor tissue loss
Grade ,category6:major tissue loss
General treatment
Lipid-lowering therapy
Smoking cessation
Glucose control
Weight control
Antiplatelet therapy
Supervised exercise
Endovascular revasculariztion
Recommended for
1.Aortoiliac stenosis<10cm,chronic
occlusion<5cm
2.Femoropopliteal discrete stensis
<10cm,calcified stenosis <5cm
3.Infrapopliteal ensovascular Tx limited to
threatened limb loss
Balloon catcheter
Self-expanding Stent
Baloon-expanding stent
PTA
Stenting after or before
Stenting spontaneusly
PTA+Stenting
Surgical revasculariztion
Recommended for
1.Aortoilac: stenosis >10cm,chronic
occlusion>5cm,heavily calcified
lesion,associated with aortic aneurysm
2. Common femoral artery:lesion>10cm,heavily
calcified lesion >5cm,ostium of superficial F
involved,popliteal involved
CASE 1
69yr/male
MI 10Yr ago
Right foot pain 1mon
Right ABI 0.36
Run-in reconstruction
bypass
Case 2
73yr old/female
DM
Right claudication 100m
No pulse dorsalis/pt
Right ABI 0.4
Femoral-tibia bypass
Combined PTFE+auto
vein graftpopliteal
anastomosis
Femoral anastomosis
Case 3 Endarterectomy
Common femoral
artery endarteretomy
Embolus source:
Cardiac
atrial fibrillation
myocardial infarction
Artery
atheromatous plaque
ameurysm
Sites of Embolization
Bifurcations
Femoral - 40%
Aortic - 10-15%
Iliac - 15%
Popliteal - 10%
Upper extremities - 10%
Cerebral - 10-15%
Mesenteric/visceral - 5%
History
Previous revascularization
Risk factors for atherosclerotic heart disease
5ps
Pain
Pallor
Pulselessness
Paresthesia
Paraparesis
Poikilothermia(changing temperature 6th p)
Femoral
Popliteal
Pedal
Aortoiliac segment
Femoral segment
++
Menagment
Arteriography
Surgery- Embolectomy
Percutaneous Thrombectomy
Embolectomy
Fogarty catheter
Embolectomy
Fogarty catheter
Catheter thrombolysis
Right iliac thrombosis
Ilia stent
Iliac artery
Patency
recovered
classification
The answer is
B. Reperfusion injury
Reperfusion injury
Local effects
Systemic effects
Hydration
Alkalinization of urine
Mannitol
UO 100cc/hr
Insulin/glucose
Fasciotomy
Question
Regarding compartment syndrome, which of the
following is correct?
A. The leg is divided into two compartments--anterior and
posterior
B. The most commonly affected compartment is the
posterior
C. The earliest manifestation of acute compartment
syndrome is pain
D. Patients with compartment pressures greater than 15
mm Hg should undergo fasciotomy
Compartment of leg
4 compartments:
Anterior
Lateral (Peroneal)
Deep Posterior
Superficial Posterior
Pathophysiology
CELL INJURY
TRANSUDATION
OF FLUID
CELL SWELLING
INTRACOMPARTMENT
PRESSURE
VENULAR
PRESSURE
CAPILLARY
TRANSUDATE
NO NUTRIENT FLOW
TISSUE PRES. =
CAP. HYDR. PRES.
ISCHEMIA
Fasciotomy
Aneurysm
ANEURYSM
Pathology
True aneurysm
Pseudoaneurysm
PSEUDOANEURYSM
Brachial artery
Pseudoaneurysm with
Axillary fat
blood clot
Axilla Pseudoaneurysm, stab wound severed brachial artery
SHAPES OF ANEURYSMS
Saccular
Fusiform
Atherosclerotic Aneurysm
Atherosclerosis is the most common
cause of aortic aneurysm
Most frequently occur in males, >50
years of age
Most occur in abdominal aorta, below the
renal arteries
Complications include thrombosis,
embolism, and rupture
Syphilitic Aneurysm
Mycotic Aneurysm
Berry Aneurysm
Dissecting Aneurysm
Symtoms
Expansion
Thrombosis
Emboli
rupture
Clinic features
Edema-veins
Altered sensation-nerves
Obstrcuction of trachea/esophgus
Atherosclerosis
Marfans, Ehlers-Danlos
Infection (Syphilis, salmonella, others)
AAA Epidemiology
AAA symptom
AAA Diagnosis
AAA
Emphysema , smoking,
hypertension increase liklihood of rupture
(Cronenwett 1985)
Law of LaPlace
T = Pr/2
Larger Aneurysm more likely to rupture
<4cm: 2% rupture over 5 years
>5 cm 25-41% rupture over 5 years
6 cm rupture rate ? 50% in 5 years
Surgical repair
Endovascular repair
Ruptured AAA