1. Arterial ischemia – acute and chronic. Principles of Surgery lecture series 18 October 2011 Barry Rubin MD PhD FRCSC Vascular Surgery UHN

2. 1.Causes of acute leg ischemia. 2.How to differentiate causes of acute leg ischemia. 3.Natural history of the disease. 4.Therapy.

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

4. Embolus in the aorta Clot breaks off from another location and travels in arteries. Risk factors? Symptoms? Treatment? Outcome?

5. Embolism – angiographic picture. Get better or worse with time?

6. Cardiac sources of emboli – 90% of all arterial emboli.

7. Myocardial infarction and mural thrombosis

8. Thrombus in left atrium

9. Clot on bicuspid aortic valve

10. Bacterial endocarditis

11. Arterial to arterial embolization 10% of all arterial emboli.

12. In situ thrombosis Atherosclerotic Plaque Clot Clot forms in a previously diseased artery. Risk factors? Symptoms? Treatment? Outcome?

13. In situ thrombosis - aortic occlusion Get better or worse with time? Risk factors? Symptoms? Treatment? Outcome?

14. Iliac stenosis

15. angioplasty

16. Iliac stenosis – post angioplasty and stent

17. Severe aorto-iliac disease

18. Severe internal carotid stenosis

19. Aortic occlusion

20. Aorto-bifemoral bypass

21. How do arteries go from being narrowed to being totally blocked: ►progression to in situ thrombosis.

22. in situ thrombosis Plaque rupture

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

25. Embolism in situ thrombosis no claudication claudication yes no no yes yes no maybe no no yes gets worse gets better with time History Embolic source Risk factors for atherosclerosis Contra-lateral pulses Murmur Time for collaterals to develop Natural history

26. Arterial Venous Neuropathic Chronic ischemia and types of foot ulcers

27. Arterial VenousNeuropathic DistalMedial Pressure malleoluspoint YesNoNo NoYesYes (maybe) NoYesNo MaybeNoYes Location Arterial disease and risk factors for atherosclerosis Contra-lateral pulses Skin changes of venous HTN Neuropathy Leg ulcers

28. Location Arterial disease and risk factors for atherosclerosis Contra-lateral pulses Skin changes of venous HTN Neuropathy