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

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

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

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

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

8. 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)

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

11. 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.

12. 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

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

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

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

16. 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

18. 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.

19. 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

20. 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

21. (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

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

23. (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

26. 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.

27. 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.

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

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

31. C A D Diagnosis : Duplex scan MRA CT Carotid angio

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

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

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

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

39. Thank You !!!