MANIFESTATIONS OF VASCULAR DISEASES Prof. Hasan Ali Al Zahrani, FRCS Professor of Surgery, Consultant Vascular Surgeon King Abdulaziz University, Jeddah (

Arterial Problems 1. Aneurysms : - AAA - peripheral 2. Limb ischaemia : - acute - chronic 3. Vasculitis : - Types - Thromboangitis obliterans 4. Carotid artery disease : 5. D.M. foot :

Venous Problems 6.Varicose veins 7.D.V.T. & postphlebitic limb 8.Leg ulcers

Others 9.Vascular malformations 10.Angioaccess 11.Thoracic Outlet Syndrome 12.Vascular Trauma

Aneurysms Definition : Localized dilatation of an artery or vein The commonest is AAA Rare in veins Usually due to ATO

Symptoms : Most are asymptomatic Intermittent claudication (if there is occlusive disease) Trash foot or blue toes syndrome (if embolizing) Severe abdominal and/or back pain (if leaking) Shock (if ruptures)

Signs : Pulsating epigastric mass – AAA Pulsating iliac mass - ? Iliac Examine other arteries 5-10% associated aneurysms Abd. tenderness Shock

Acute Limb Ischaemia Sudden cessation of blood flow to lower or less frequently upper limb which is usually due to embolism or trauma and less frequently due to thrombosis.

A.L.I. Causes : 1.Embolism : a. Cardiac : very common - A.F. - M.I. in I.H.D. - Rh. H. D - Others b. Non-cardiac : - atheromatous plaques - aneurysm - trauma

A.L.I. 2.Thrombosis : a. Acute or chronic (? I.C.) b. Aneurysms c. Severe D.V.T. (P.C.D.)

A.L.I. Symptoms & Signs : The 5 P’s Coldness Poor capillary refilling Rigor (late signs) Examine other pulses Heart examination

A.L.I. Investigation : C.W. Doppler Duplex scan Arteriography (in selected cases) ECG, CXR, Echo

A.L.I. Management : Aim to minimize the time lag to less than 8 hours Establish the underlying cause Heparin infusion Surgical embolectomy Fibrinolytic therapy ? Primary amputation

Chronic Limb Ischaemia (C.L.I.) Affects usually the lower limbs Usually due to atherosclerosis Common in D.M. patients Symptoms and signs depend on the site of occlusion.

Chronic Limb Ischaemia (C.L.I.) Symptoms : Intermittent claudication :- cramping pain affecting usually the calf muscles which comes with exercise and relieved by rest. (? Distance, radiation) Rest pain:- severe burning pain affecting the forefoot, coming at rest and relieved by hanging the leg beside the bed Impotence :- Leriche’s Syndrome

Chronic Limb Ischaemia (C.L.I.) Signs : Ulceration :- painful, no bleeding Pallor, Buerger’s test, rubor or dependency, capillary re-perfusion Cyanosis, coldness, trophic changes Examination of pulses Listen for bruits

(C.L.I.) Investigations : General including :- R.B.S., lipids, CXR, ECG Specific:- –A/B index, toe pressure –Duplex scan –MRA, C.T. angio,. –Angiogram

(C.L.I.) Indications for surgery : Disabling I.C. Critical ischaemia:- I.R.P., ulcer Impotence ? Progressive disease

(C.L.I.) Medical:- Anti-platelets Control D.M., hyperlip., high B.P. Stop smoking Reduce weight and diet ? Pentoxyfylline Endovascular and surgical :- P.T.A.  stenting bypass endartrectomy amputation

Vasculitis Definition : A group of vascular inflammatory disorders sharing immune-mediated reactions but with distinctive clinical picture, e.g. Thromboangitis obliterans P.A.N., G.C.A., …etc.

Buerger’s Disease (T.A.O.) : - Vasculitis of small and medium-sized veins and arteries affecting mainly young and middle-aged males who smoke heavily. Its aetiology in unknown.

Buerger’s Disease (cont) : - Management : Diagnosis (including diff. Diag.) Stop smoking Vasodilators Sympathectomy Bypass Amputation

Carotid Artery Disease (CAD) Symptoms : TIA PRIND Amurosis fugax Stroke Blindness Signs : Carotid bruit Neurological deficits

C A D Diagnosis : Duplex scan MRA CT Carotid angio

C A D Management : 1.Medical : - Antiplatelets - Anticoagulants - Control risk factors 2.Carotid Endartrectomy 3. ?? Angioplasty

D M F High incidence of D.M. in S.A. The most common indication for amputation Factors : –Ischaemia :40% –Neuropathy :60% –Infection :90%

D M F Diagnosis :- For Infection :- - CBC, culture, x-ray of foot For Ischaemia :- - Toe pressure, Duplex scan, Angio For Neuropathy:- - EMG

D M F Prevention :- Management : - 1.Medical : - control of D.M. & hyperlipidaemia - antibiotics - Antiplatelets 2. Surgical : - Debridement + drainage - Vascular reconstructive procedure - Skin grafting - Amputation

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