VASCULAR DISEASES AND SURGERY Khaled Daradka Faculty of Medicine / University of Jordan General Surgery Department 1

Peripheral Arterial Disease Definition: Also known as PVD. Occlusive disease of the arteries of the lower extremity. Most common cause: o Atherothrombosis o Others: arteritis, aneurysm + embolism. Has both ACUTE and CHRONIC Px

PAD 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.

4 Introduction Atherosclerotic changes Normal ArteryDiseased Artery

5 Introduction Disease evolution Claudication Rest pain Ulceration Gangrene Limb loss

6 Risk Factors Tobacco abuse Diabetes Hypercholesterolemia Hypertension Obesity Sedentary lifestyle

7 Diagnosis Patient history Physical examination Laboratory values Noninvasive vascular studies Angiography

8 Patient History Risk factors Exercise-induced symptoms Rest pain Ulceration

9 Patient History Historical clues to the diagnosis of intermittent claudication Variable Symptom Complex Symptoms in the legs that are provoked by walking and relieved by rest PainAchesTiredness TightnessSorenessWeaknessNumbness

10 Is it vascular limb pain? Patient History HistoricalVascularNeurogenic ClueEtiologyEtiology OnsetPredictableVariable Only with walking?YesNo Relief with stopping or YesVariable standing? Absent pedalVariableVariable pulses at rest

11 Patient History Differential diagnosis of PAD Intermittent claudication – Atherosclerosis – Non-atherosclerotic n Buerger’s n Vasculitis Neurogenic causes – Lumbar canal stenosis – Peripheral neuropathy Venous claudication Musculoskeletal causes – Arthritis – Bursitis – Tendonitis Pediatric causes – Plantar fasciitis

12 Physical Examination Pulses Bruits Ankle-Brachial Index (ABI)

13 Physical Examination Ankle-Brachial Index Simple, painless, accurate, highly reproducible examination Clinically useful – Identifies patients with PAD – Major indicator of premature MI, CVA, mortality Indications – Any patient with suspicion for PAD – Any patient at risk of PAD n Age 50 or greater with history of DM or tobacco use n Age 70 or greater regardless of risk factors

14 Right Arm Pressure: Left Arm Pressure: PT DP Pressure: PT DP Physical Examination Ankle-Brachial Index How to perform – Patient resting supine for 5-10 minutes – Continuous wave, hand-held Doppler – Measure systolic BP in both arms n Higher value is DENOMINATOR of ABI – Measure systolic BP in DP and PT n Higher value is NUMERATOR of ABI

15 Physical Examination ABI = Ankle Systolic Pressure Brachial Systolic Pressure >0.9=Normal > =Moderate disease <0.4=Severe disease

16 Above 0.90—Normal —Mild Obstruction —Moderate Obstruction —Severe Obstruction Physical Examination Interpretation and limitations of ABI ABI Interpretation Two Main Limitations Calcified ankle vessels result in artificially “normal” ABI (DM, RF) Normal ABI in patient with Aortoiliac Disease— only becomes abnormal with exercise testing

17 Noninvasive Vascular Studies Vascular ultrasound CT angiography Magnetic resonance angiography

18 Noninvasive Vascular Studies Post-intervention iliac imaging

19 Noninvasive Vascular Studies MRA in PAD

20 Right Fem-Pop BPG DSA (Pre-PTA) Left SFA Stenosis Noninvasive Vascular Studies CTA

21 NormalAbnormal Invasive Vascular Studies Diagnosis − angiography

22 Treatment Risk factor modification Medical management Minimally invasive techniques Surgical intervention

23 Goals Identify and treat systemic atherosclerosis Improve functional status and quality of life Preserve the limb Prevent progression of atherosclerosis PAD Therapeutic Goals

24 Risk Factor Modification Tobacco cessation Exercise Weight reduction Pharmacologic intervention – Hypercholesterolemia – Hypertension – Diabetes

25 Minimally Invasive Techniques Percutaneous transluminal angioplasty (PTA) Stenting Thrombolysis

26 Minimally Invasive Techniques Guidewire placement

27 Minimally Invasive Techniques Guidewire advanced past lesion

28 Balloon dilatation Percutaneous Transluminal Angioplasty Minimally Invasive Techniques

29 Minimally Invasive Techniques Stent expansion by a balloon catheter over a guidewire

30 Post-PTA/stent placement Minimally Invasive Techniques

31 Thrombolysis Post-thrombolytic infusion revealing stenosis Minimally Invasive Techniques

32 Case Study #1 Aorto/iliac disease

33 Case Study #1 Aorto/iliac disease pre-PTA stenting Aorto/iliac disease post-PTA stenting

34 Case Study #2 Pre-thrombolysis Post-thrombolysis

35 Case Study #2 Angioplasty post-thrombolysis

36 Surgical Intervention Bypass grafts Amputation

37 Surgical Intervention Bypass grafts

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

Venous Disease (CVI) Simple spider veins to complex dermal sclerosis and ulcer formations. 39

Venous Valves  Presence of valves prevent reflux  Pressure generated in deep veins by the calf muscles are prevented from transmission to superficial veins by the valves 40

Venous Pathology  Obstruction  Reflux and/or incompetence 41

Venous Obstruction  As a result of DVT or superficial phlebitis  As a result of extrinsic compression 42

Venous Reflux Spider VeinsVaricose Veins 43

Venous Reflux EdemaVenous Statis w/wo Ulcer 44

Venous History of Patient  Pain  Edema  Ulcers 45

Physical Exam of Patient  Supine and Standing  Objective findings of spider or varicose veins  Skin changes (hyperpigmentation to atrophic blanch)  Edema (typically pitting)  Ulcer formation 46

Diagnostic Testing Duplex Scan 47

Treatment Medical Management 1. Leg elevation 2. Compression therapy 3. Exercise 48

Interventional Therapy  Sclerotherapy  Endovenous Ablation  Surgical 49

Sclerotherapy 50

Similarities and Differences  Arterial symptoms produced by exercise and relieved by resting  Venous symptoms worsened by standing and improved by exercise and leg elevation 51

THANK YOU 52