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Surgery M4 part 1 > Chronic ischemia > Flashcards

Chronic ischemia Flashcards

1
Q

What is the main cause of chronic limb ischemia?

A

ATHEROSCLEROSIS

there is time for collaterals to develop

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2
Q

What are the non- atherosclerosis causes related to chronic limb ischemia?

A

BURGER’S DISEASE (thromboangitis obliterans)

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3
Q

What is the pathogenesis of atherosclerosis?

A

endothelial injury –> PDGF –> monocytes attach to injured endothelium –> migrate into subendothelial layer –> macrophages ingulf fat and become foam cells –> smooth muscle cells are stimulated to migrate into intimal layers –> fibrous plaques become part of fatty streaks

  • adventitia layer is completely normal
  • purely an arterial disease
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4
Q

What is the cause behind burger’s disease?

A

toxic spasm caused by SMOKING in a middle aged man

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5
Q

What is affected in Burger’s disease?

A

Neuro vascular bundle (small & medium arteries, veins, & nerves)

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6
Q

What is the pathology of thromboangitis obliterans?

A
  • spasm of vasa-vasorum affect arteries & veins in different patches of lengths (segmental)
  • thrombosis occurs in acute stage
  • aggregation of peripheral nerve vessels & micro abscesses

Chronic phase -> hypercellularity & frequent recanalization of vessel lumen

End stage —> organized thrombus & blood vessel fibrosis

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7
Q

fibrosis & round cell infiltration in the adventitia with perivascular fibrosis which welds artery & vein & nerve is characteristically seen in which disease?

A

Burger’s disease

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8
Q

What is the most common site affected by Burger’s?

A

bilateral but ASYMMETRICAL
small & medium sized arteries
POSTERIOR TIBIAL & POPLITEAL ARTERIES

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9
Q

What is the general clinical picture of chronic ischemia?

A
  • claudication pain (early)
  • rest pain (late except in Burger’s)
  • impotence (Le riche syndrome)
  • ischemic chest pain
  • post-cibal angina due to mesenteric ischemia

GENERAL EXAMINATION

  • calcification & cord-like radial artery
  • hypertension
  • murmurs
  • aneurysm
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10
Q

What are the findings on inspection of patient presenting with chronic ischemia?

A

INSPECTION
color changes
- (Burger’s angle): PALLOR with leg elevation then REACTIVE HYPEREMIA with hanging leg below bed
- Rubor (stagnation of blood)

venous filling

trophic changes

  • muscle wasting
  • thin scaly dry skin
  • hair fall
  • brittle nails
  • ulcerations over pressure areas

gangrene

ischemic ulcer

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11
Q

What will be felt upon palpation of patient presenting with chronic ischemia?

A
  • weak or absent pulse
  • decreased capillary flow
  • temperature (cold limb)
  • motor power (muscle wasting)
  • sensations (paresis)
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12
Q

What is heard on auscultation of ischemic limb?

A

ARTERIAL BRUIT

systolic murmur at site of narrowing

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13
Q

What are the general investigations that could be used in case of chronic ischemia?

A
  • Laboratory
  • plain x-ray (calcification of blood vessels)
  • ECG & echocardiography
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13
Q

What are the general investigations that could be used in case of chronic ischemia?

A
  • Laboratory
  • plain x-ray (calcification of blood vessels)
  • ECG & echocardiography
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14
Q

What is the doppler & duplex US used for?

A
  • detection of narrowing & occlusion
  • ANKLE BRACHIAL INDEX
    1 : 1.3 –> normal
    less than 0.9 –> claudication
    less than 0.5 –> rest pain
    less than 0.3 –> impending gangrene
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15
Q

Which method of investigation detects the presence of distal run-off?

A

Conventional angiography

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16
Q

What will be shown during investigation of Burger’s disease using angiography?

A
  • no distal run-off
  • segmental obliteration of arteries
  • tree-root or spider legs collateral circulation seen in chronic cases
  • corckscrew appearance due to recanalization of arteries (in small arteries)
17
Q

What will be seen on angiography in atherosclerosis?

A
  • distal run-off

- proximal large arteries affected

18
Q

What is the the diagnostic investigation for Burger’s disease?

A

BIOPSY

inflammatory changes in the walls of arteries & veins leading to thrombosis & micro abscesses

19
Q

What is the diagnostic criteria of critical limb ischemia?

A

1- rest pain
2- resistant ulcer
3- gangrene
4- ABI less than 0.3

angiography & surgical intervention should be done

20
Q

chronic obstruction at aorto-bi-iliac level will lead to?

A

Leriche syndrome

21
Q

What is the diagnostic criteria for Leriche syndrome?

A
  • bilateral claudication pain reaching glutei
  • bilateral absent femoral pulse
  • erectile dysfunction
22
Q

What non-operative treatment is usually done for chronic limb ischemia?

A

General Measures

  • reduce risk factors
  • stop smoking
  • control DM & hypertension
  • lipid control

Exercise Rehabilitation

  • increase flow through collaterals
  • daily walking & stop before claudication pain

Foot Care

Pharmacotherapy

  • Vasodilators
  • Anti-platelets
  • Anticoagulants (if there’s thrombosis)
  • Vitamin A & E
23
Q

What are the indications for operative treatment?

A
  • Critical limb ischemia
  • claudication interfering with life & job
  • rest pain
  • ischemic ulcer resistant to medical treatment
24
Q

How should the type of surgical procedure be chosen?

A

according to distal run-off

GOOD DISTAL RUN-OFF: reconstructive procedures
long distance run-off –> OPEN
endovascular

NO DISTAL RUN-OFF: non-reconstructive procedures
sympathectomy
amputation

25
Q

What are the types of reconstructive procedures?

A 
OPEN SURGERY
- by-pass surgery (grafting)
    -anatomical 
    -extra-anatomical 
types of grafts 
- biological: from saphenous vein
- extra-anatomical: PTFE (teflon)

ENDOVASCULAR

  • balloon angioplasty: isolated short segment stenosis or graft stenosis with symptoms
  • intravascular stents: stent inserted after balloon to prevent elastic recoil
26
Q

What are the types of non-reconstructive surgery?

A

SYMPATHECTOMY

  • recurrence within 5 years
  • has vasodilator effect on collaterals
  • could lead to denervation hypersensitivity -> recurrence
  • has little value in claudicating patient

AMPUTATION

  • for gangrene
  • failure of sympathectomy
27
Q

What are the differences between atherosclerosis & Burger’s?

A

ATHEROSCLEROSIS BURGER’S

  • caused by age, gender, hyperlipidemia - SMOKING
  • subintimal atheromatous plaque - all 3 layers of medium sized arteries & veins & nerves
  • old age - middle age
  • progressive - fluctuant
  • proximal (large arteries) - distal (smaller arteries)
  • symmetrical - asymmetrical
  • rest pain comes later - earlier rest pain
  • IHD, stroke - DVT & neuropathy
  • distal run off - no distal run-off
  • conservative or constructive - conservative or non-constructive
28
Q

What is the difference between claudication & rest pain?

A

CLAUDICATION REST

  • PAD - Critical limb ischemia
  • anaerobic metabolism of muscle (lactic acid) - ischemic neuritis
  • at site of obstruction - foot
  • crampy - severe bursting
  • due to walking & exercise - due to warming & elevation
  • relieved by rest - by exposure & dependency
  • use duplex - use angiography
  • medical first - immediate intervention
29
Q

What is the sequence of Raynaud’s disease?

A

1- blanching (pallor)
2- dusky cyanosis
3- red engorgement

accompanied by pain

30
Q

What is the cause of Raynaud’s disease?

A

vasoconstriction of small arteries in response to sympathetic overactivity or exposure to cold

31
Q

What is the clinical picture of Raynaud’s disease?

A
  • occurs in young women (20-40)
  • affects upper extremity more than lower
  • peripheral pulses are normal
  • bilateral & symmetrical
32
Q

How should Raynaud’s disease be managed?

A

CONSERVATIVE

  • avoid exposure to cold, emotional stress, & smoking
  • electrically heated gloves in winter
  • avoidance of pulp & nail beed infection

PHARMA

  • calcium antagonists (nifedipine)
  • guanethidine: block peripheral a & B adrenergic activity
  • nitroglycerine

SURGICAL
- sympathectomy
only if severe disabling recurrent attacks or there is an ischemic ulcer resistant to healing

33
Q

What is the difference between Raynaud’s disease & syndrome?

A

DISEASE SYNDROME

  • young age - any age
  • females - both
  • exposure to cold or stress - Burger’s disease
  • only upper limb - can affect lower limb
  • bilateral & symmetrical - unilateral or bilateral & asymmetrical
  • present radial pulse - may be absent
  • no complications - can lead to complications
  • conservative management - target management at underlying cause
34
Q

What is acrocyanosis?

A

vasospastic disease in response to cold like Raynaud’s but the difference is:

  • painless
  • not paroxysmal
  • marked cyanosis
  • affects upper & lower limb
35
Q

What is the cause of frost bite & what does it lead to?

A
  • due to exposure to severe coldness
  • causes damage of vessel walls (not only spasm)
  • complicates into blister formation & gangrene
    TREAT by urgent warming by immersion of affect part in warm water
36
Q

When is amputation indicated?

A

when limb is:
DEAD (gangrene)
DEADLY (sarcoma, gas gangrene, crush syndrome)
DEAD LOSS (mangled limb, severe rest pain, massive lymphedema)

37
Q

What is the most important difference between lower limb & upper limb amputations?

A

LOWER LIMB: respect levels of amputation

  • below knee
  • above knee

UPPER LIMB: preserve as much as you can of the limb

38
Q

What are the early complications of amputation?

A
  • infection, hemorrhage, ..
  • ischemia of flap
  • wound dehiscence
39
Q

What are the late complications of amputation?

A
  • skin: ulcerations & adherent scar
  • excess muscle that prevents proper use of prosthesis
  • progressive ischemia of stump
  • phantom limb or stump neuroma
  • stiffness of joint above stump
  • osteomyelitis, projecting bone

Surgery M4 part 1 (47 decks)

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