acute chronic ischemia

8/3/2019 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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acute chronic ischemia

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