1. Arterial ischemia – acute and chronic.
Principles of Surgery lecture series
20 October 2009
Barry Rubin MD
Vascular Surgery
UHN

2. Causes of acute leg ischemia.
How to differentiate causes of acute leg ischemia.
Natural history of the disease.
Therapy.
Chronic ischemia.
Differential diagnosis of leg ulcers.

3. Acute ischemia
Embolism in situ thrombosis
History
Risk factors
Embolic source
Atherosclerosis
Contra-lateral pulses
Murmur
Time for collaterals
to develop
Natural history

4. Iliac stenosis

5. Severe aorto-iliac disease

6. Aortic occlusion

7. Progression to
in situ thrombosis –
takes time

8. in situ thrombosis
Plaque rupture

9. Multi-level peripheral vascular disease
External iliac Superficial femoral Tibial

10. Risk factors for atherosclerosis
Smoking
Hypertension
Dyslipidemia
Diabetes
Chronic renal failure

11. in situ thrombosis History of claudication Risk factors Yes
Embolic source
Atherosclerosis
Contra-lateral pulses
Murmur
Time for collaterals
to develop
Natural history – better
Or worse with time
Yes No
Unlikely
Better

12. Arterial embolus – artery blocked in seconds.
Sources of arterial emboli?

13. Myocardial infarction and mural thrombosis

14. Thrombus in left atrium

15. Clot on bicuspid aortic valve

16. Bacterial endocarditis

17. Cardiac sources
of emboli

18. Arterial to arterial embolization

19. Popliteal embolus
Natural history of this lesion?

20. in situ thrombosis embolus
History of
claudication
Risk factors
Embolic source
Atherosclerosis
Contra-lateral pulses
Murmur
Time for collaterals
to develop
Natural history – better
Or worse with time
Yes No
Unlikely
Better No
Yes
Possibly
Worse

21. Chronic ischemia

22. Iliac stenosis
Therapeutic options?

23. Therapeutic options. Do nothing (i.e. do no harm).
Angioplasty (+/- stent).
Bypass surgery.

24. Iliac stenosis - angioplasty

25. Iliac stenosis – post angioplasty and stent

26. Severe aorto-iliac disease - therapeutic options?

27. Aorto-bifemoral bypass

28. Types of foot ulcers
Arterial
Venous
Neuropathic