ARTERIAL PERIPHERAL VASCULAR ARTERIAL PERIPHERAL VASCULAR DISEASESDISEASESDISEASESDISEASES

ACUTE ARTERIAL OCCLUSION : SUDDEN INTERRUPTION ACUTE ARTERIAL OCCLUSION : SUDDEN INTERRUPTION OF THE BLOOD SUPPPLY RESULT IN A SPECTRUM OFOF THE BLOOD SUPPPLY RESULT IN A SPECTRUM OFOF THE BLOOD SUPPPLY RESULT IN A SPECTRUM OF OF THE BLOOD SUPPPLY RESULT IN A SPECTRUM OF SYMPTOMS AND SIGNS WHICH ARE DEPENDENT UPON THE SYMPTOMS AND SIGNS WHICH ARE DEPENDENT UPON THE LOCATION AND EXTENT OF THE OCCLUSION AND LOCATION AND EXTENT OF THE OCCLUSION AND EXISTING COLLATERAL CIRCULATIONEXISTING COLLATERAL CIRCULATION..THE MAJOR CAUSES ARE EMBOLISM THROMBOSIS AND INJURYTHE MAJOR CAUSES ARE EMBOLISM THROMBOSIS AND INJURYTHE MAJOR CAUSES ARE : EMBOLISM,THROMBOSIS,AND INJURYTHE MAJOR CAUSES ARE : EMBOLISM,THROMBOSIS,AND INJURYIN THE ARM,THE HEART IS THE SOURCE OF EMBOLI IN 95 % OF THE IN THE ARM,THE HEART IS THE SOURCE OF EMBOLI IN 95 % OF THE PATIENTS.PATIENTS.LESS COMMON CAUSES INCLUDE EMBOLI FROM ULCERATED PLAQUES IN LESS COMMON CAUSES INCLUDE EMBOLI FROM ULCERATED PLAQUES IN THE SUB CLAVIAN ARTERY,ANEURYSM OF THE ARCH VESSELS ANDTHE SUB CLAVIAN ARTERY,ANEURYSM OF THE ARCH VESSELS ANDTHE SUB CLAVIAN ARTERY,ANEURYSM OF THE ARCH VESSELS AND THE SUB CLAVIAN ARTERY,ANEURYSM OF THE ARCH VESSELS AND PARADOXICAL EMBOLI VIA APATENT FORAMEN OVALE.PARADOXICAL EMBOLI VIA APATENT FORAMEN OVALE.IN THE LEG ,THE HEART IS AGAIN THE MOST COMMON SOURCE EMBOLI IN THE LEG ,THE HEART IS AGAIN THE MOST COMMON SOURCE EMBOLI BUT THEY MAY ALSO ARISE FROM ULCERATED PLAQUES AND ANEURYSMS BUT THEY MAY ALSO ARISE FROM ULCERATED PLAQUES AND ANEURYSMS OF THE THORACIC,ABDOMINAL,FEMORAL,POPLITEAL ARTERRIES.OF THE THORACIC,ABDOMINAL,FEMORAL,POPLITEAL ARTERRIES.OVER HALF OF THE LARGE EMBOLI FROM THE HEART LODGE IN THEOVER HALF OF THE LARGE EMBOLI FROM THE HEART LODGE IN THEOVER HALF OF THE LARGE EMBOLI FROM THE HEART LODGE IN THE OVER HALF OF THE LARGE EMBOLI FROM THE HEART LODGE IN THE FEMORAL AND POPLITEAL ARTERIES.FEMORAL AND POPLITEAL ARTERIES.THE ILIAC ARTERIES ARE INVOLVED IN APPROXIMATELY ONETHE ILIAC ARTERIES ARE INVOLVED IN APPROXIMATELY ONE--FIFTHFIFTHTHE ABDOMINAL AORTA IN ONE THE ABDOMINAL AORTA IN ONE –– SIXTH SIXTH

ARTERIAL PERIPHERAL VASCULAR ARTERIAL PERIPHERAL VASCULAR DISEASESDISEASESDISEASESDISEASES

SOURCE EMBOLI (mural thrombi ) FROM THE HEART :

-LEFT ATRIUM

MURAL THROMBI ARISE SEQONDARY :

- ATRIAL FIBRILATION

-LEFT VENTRICLE

-AORTIC VALVE

-MYOCARDIAL INFARCTION

- AORTIC AND MITRAL PROSTHETIC VALVE-MITRAL VALVEPROSTHETIC VALVE

ARTERIAL THROMBOSIS OCCURS SEQONDARY TO INJURY,ARTERIOSCLEROSIS OBLITERANS,FEMORAL AND POPLITEAL ANEURYSM,COLLAGEN VASCULAR DISEASES ,MYELOPROLIFERATIVE DISORDERS ,DIC,DYSPROTEINEMIAS.

SYMTOMS AND SIGNSYMTOMS AND SIGNSYMTOMS AND SIGNSYMTOMS AND SIGN

RELATED TO THE SITE OF INVOLVEMENT AND RELATED TO THE SITE OF INVOLVEMENT AND IMMEDIATELY AVAILABLE COOLATERAL CIRCULATIONIMMEDIATELY AVAILABLE COOLATERAL CIRCULATIONIMMEDIATELY AVAILABLE COOLATERAL CIRCULATIONIMMEDIATELY AVAILABLE COOLATERAL CIRCULATIONIF THE PRESSURE DISTAL TO OBSTRUCTION FALLS TO IF THE PRESSURE DISTAL TO OBSTRUCTION FALLS TO BELOW 40 mmHg, THE CLINICAL PICTURE WILL BE BELOW 40 mmHg, THE CLINICAL PICTURE WILL BE DRAMATIC.DRAMATIC.THE INITIAL COMPLAINT IS PAIN IS THE MOST DISTAL THE INITIAL COMPLAINT IS PAIN IS THE MOST DISTAL PART OF THE LIMBPART OF THE LIMBPALLORPALLORCOLDNESSCOLDNESSCOLDNESSCOLDNESSSENSATION OF NUMBNESS,CUTANEUS SENSATION IS LOST SENSATION OF NUMBNESS,CUTANEUS SENSATION IS LOST WITHIN THE FIRST HOURWITHIN THE FIRST HOURWITHIN 6 HOUR ISCHAEMIC MUSCULAR CONTRACTURE WITHIN 6 HOUR ISCHAEMIC MUSCULAR CONTRACTURE DEVELOPS ASSOCIATED WITH SUB CUTANEUS DEVELOPS ASSOCIATED WITH SUB CUTANEUS HEMORRHAGE AND FOCAL AREA OF GANGRENHEMORRHAGE AND FOCAL AREA OF GANGRENFIXED STAINING OF THE SKIN IS THE MOST CERTAIN SIGN FIXED STAINING OF THE SKIN IS THE MOST CERTAIN SIGN OF IRREVERSIBLE TISSUE DEATHOF IRREVERSIBLE TISSUE DEATHOF IRREVERSIBLE TISSUE DEATH.OF IRREVERSIBLE TISSUE DEATH.

DIAGNOSISDIAGNOSIS

HISTORY OF THE SUDDEN ONSET OF HISTORY OF THE SUDDEN ONSET OF PAIN,COLDNES,NUMBNESSPAIN,COLDNES,NUMBNESSDETECTION OF A BRUIT IS COMMON WHEN AN ARTERIAL DETECTION OF A BRUIT IS COMMON WHEN AN ARTERIAL PLAQUE OR ANEURYSM IS THE SOURCE OF THE EMBOLUS.PLAQUE OR ANEURYSM IS THE SOURCE OF THE EMBOLUS.HISTORY OF INTERMITTEN CLAUDICATIONHISTORY OF INTERMITTEN CLAUDICATIONHISTORY OF INTERMITTEN CLAUDICATIONHISTORY OF INTERMITTEN CLAUDICATIONISCHEMIC REST PAIN OF THE FEETISCHEMIC REST PAIN OF THE FEETIF THE SOURCE OF EMBOLI ORIGINATE FROM THE IF THE SOURCE OF EMBOLI ORIGINATE FROM THE THORASIC AORTA,ABDOMINAL PAIN AND HEMATURIA MAY THORASIC AORTA,ABDOMINAL PAIN AND HEMATURIA MAY ALSO OCCURALSO OCCURTHE DIAGNOSIS MAYBE SUSPECTED BY PHYSICAL THE DIAGNOSIS MAYBE SUSPECTED BY PHYSICAL EXAMINATION AND VERIFIED BY B MODE ULTRA SOUNDEXAMINATION AND VERIFIED BY B MODE ULTRA SOUNDARTERIOGRAPHYARTERIOGRAPHYARTERIOGRAPHYARTERIOGRAPHY

TREATMENTTREATMENT

IMMEDIATE OPERATION IS REQUIRED FOR OCCLUSION OF IMMEDIATE OPERATION IS REQUIRED FOR OCCLUSION OF THE MAJOR ARTERIESTHE MAJOR ARTERIESTHE MAJOR ARTERIES.THE MAJOR ARTERIES.HEPARIN SHOULD BE GIVEN IMMEDIATELYHEPARIN SHOULD BE GIVEN IMMEDIATELYTHE OCCLUSION MAY USUALLY BEREMOVED UNDER THE OCCLUSION MAY USUALLY BEREMOVED UNDER LOCAL ANESTHESIA,BUT IN SOME INSTANCES IT MAYBE LOCAL ANESTHESIA,BUT IN SOME INSTANCES IT MAYBE ,,NECESSARY TO BYPASS THE OBSTRUCTED AREA.NECESSARY TO BYPASS THE OBSTRUCTED AREA.STREPTOKINASE OR UROKINASE LOW DOSES DIRECTLY STREPTOKINASE OR UROKINASE LOW DOSES DIRECTLY INTO THE THROMBOSIS VIA AN ARTERIAL CATHETER INTO THE THROMBOSIS VIA AN ARTERIAL CATHETER TRANSLUMINAL ANGIOPLASTY OR BY PASS GRAFTINGTRANSLUMINAL ANGIOPLASTY OR BY PASS GRAFTINGTRANSLUMINAL ANGIOPLASTY,OR BY PASS GRAFTING TRANSLUMINAL ANGIOPLASTY,OR BY PASS GRAFTING AFTER LYSIS OF THE THROMBUS.AFTER LYSIS OF THE THROMBUS.IF THE CAUSE OF THE PROBLEM IS EMBOLIC LONGTERM IF THE CAUSE OF THE PROBLEM IS EMBOLIC LONGTERM ANTICOAGULATION WITH WARFARIN OR COUMADIN ANTICOAGULATION WITH WARFARIN OR COUMADIN S O OS O OSHOULD BE EMPLOYEDSHOULD BE EMPLOYEDMICRO EMBOLI SHOULD BE EXPECTANTLY WITH ASPIRINMICRO EMBOLI SHOULD BE EXPECTANTLY WITH ASPIRIN

ARTERIOSCLEROSIS OBLITERANSARTERIOSCLEROSIS OBLITERANS

THE PRIMARY LESION OF ATERIOSCLEROSISTHE PRIMARY LESION OF ATERIOSCLEROSISTHE PRIMARY LESION OF ATERIOSCLEROSIS THE PRIMARY LESION OF ATERIOSCLEROSIS IN THE INTIMAL PALQUE ,WICH IN THE INTIMAL PALQUE ,WICH PROGRESSIVELY NARROWS AND MANY PROGRESSIVELY NARROWS AND MANY INSTANCES,LEAD TO COMPLETE OCCLUSION INSTANCES,LEAD TO COMPLETE OCCLUSION OF THE LARGE AND MEDIUM SIZED OF THE LARGE AND MEDIUM SIZED ARTERIESARTERIESARTERIES.ARTERIES.INCIDENCE : AORTA ABDOMINAL,ILIAC INCIDENCE : AORTA ABDOMINAL,ILIAC ARTERIES POPLITEAL ARTERIES POSTERIORARTERIES POPLITEAL ARTERIES POSTERIORARTERIES,POPLITEAL ARTERIES ,POSTERIOR ARTERIES,POPLITEAL ARTERIES ,POSTERIOR TIBIAL ARTERIES,ANTERIOR TIBIAL TIBIAL ARTERIES,ANTERIOR TIBIAL ARTERIES,ARTERIES,ARTERIES, ARTERIES,

CLINICAL FEATURESCLINICAL FEATURES

INTERMITTEN CLAUDICATION : THE PAIN THAT OCCURS INTERMITTEN CLAUDICATION : THE PAIN THAT OCCURS IN A MUSCLE WITH INADEQUATE BLOOD SUPPLY THAT ISIN A MUSCLE WITH INADEQUATE BLOOD SUPPLY THAT ISIN A MUSCLE WITH INADEQUATE BLOOD SUPPLY THAT IS IN A MUSCLE WITH INADEQUATE BLOOD SUPPLY THAT IS STRESSED BY EXERCISE.STRESSED BY EXERCISE.DISCOMFORT AS ACRAMP WITH DISAPPEARS WITHIN 1 OR 2 DISCOMFORT AS ACRAMP WITH DISAPPEARS WITHIN 1 OR 2 MIN AFTER THE STOPING THE EXERCISEMIN AFTER THE STOPING THE EXERCISEPARASTHESIAPARASTHESIANUMBNESSNUMBNESSGANGRENE OF THE TOES AND DISTAL FOOT WHEN THE GANGRENE OF THE TOES AND DISTAL FOOT WHEN THE DISEASES REACHES THIS ADVANCED STAGEDISEASES REACHES THIS ADVANCED STAGEDISEASES REACHES THIS ADVANCED STAGEDISEASES REACHES THIS ADVANCED STAGEULCERSULCERSTROPHIC NAIL CHANGESTROPHIC NAIL CHANGESTHE LOSS OF PULSES DISTAL TO THE MOST PROXIMALTHE LOSS OF PULSES DISTAL TO THE MOST PROXIMALTHE LOSS OF PULSES DISTAL TO THE MOST PROXIMAL THE LOSS OF PULSES DISTAL TO THE MOST PROXIMAL LEVEL OF THE DISEASESLEVEL OF THE DISEASESBRUITS BRUITS

DIAGNOSTICDIAGNOSTIC

ASSESSED SIMPLY BY MEASURING THE ANKLE SYSTOLIC ASSESSED SIMPLY BY MEASURING THE ANKLE SYSTOLIC BLOOD PRESURE AT REST AND FOLLOWING EXERCISE TOBLOOD PRESURE AT REST AND FOLLOWING EXERCISE TOBLOOD PRESURE AT REST AND FOLLOWING EXERCISE TO BLOOD PRESURE AT REST AND FOLLOWING EXERCISE TO THE POINT OF CLAUDICATION.THE POINT OF CLAUDICATION.PLETHYSMOGRAPH PLETHYSMOGRAPH ULTRASONIC VELOCITY DETECTORULTRASONIC VELOCITY DETECTORIN GENERAL,IF THE SYSTOLIC RESSURE AT THE ANKLE IS IN GENERAL,IF THE SYSTOLIC RESSURE AT THE ANKLE IS GREATER THAN ONE GREATER THAN ONE ––HALF THAT RECORDER FROM THE HALF THAT RECORDER FROM THE ARM,OCCLUSION ONE SEGMEN IS MOST LIKELY.ARM,OCCLUSION ONE SEGMEN IS MOST LIKELY.ANKLE PRESSURE LESS THAN ONE HALF OF THE ARMANKLE PRESSURE LESS THAN ONE HALF OF THE ARMANKLE PRESSURE LESS THAN ONE HALF OF THE ARM ANKLE PRESSURE LESS THAN ONE HALF OF THE ARM SYSTOLIC PRESSURE ARE MOST OFTEN OBSERVED WITH SYSTOLIC PRESSURE ARE MOST OFTEN OBSERVED WITH MULTIPLE LEVEL OF DISEASE.MULTIPLE LEVEL OF DISEASE.ARTERIOGRAPHYARTERIOGRAPHYULTRASONIC DUPLEX SCANNINGULTRASONIC DUPLEX SCANNING

THERAPHYTHERAPHY

MILD AND MODERATE INTERMITENTMILD AND MODERATE INTERMITENTMILD AND MODERATE INTERMITENT MILD AND MODERATE INTERMITENT CLAUDICATION MAY BENEFIT FROM A CLAUDICATION MAY BENEFIT FROM A RIGOUS,DAILY EXERCISE TRAINING RIGOUS,DAILY EXERCISE TRAINING PROGRAMPROGRAMPENTOXYFILLINEPENTOXYFILLINEWEIGHT REDUCTIONWEIGHT REDUCTIONSTOP SMOKINGSTOP SMOKINGSTOP SMOKINGSTOP SMOKINGDIRECT ARTERIAL SURGERYDIRECT ARTERIAL SURGERYTRANSLUMINAL ANGIOPLASTYTRANSLUMINAL ANGIOPLASTYTRANSLUMINAL ANGIOPLASTY TRANSLUMINAL ANGIOPLASTY

THROMBOANGITIS OBLITERANS ( BUERGER’S THROMBOANGITIS OBLITERANS ( BUERGER’S DISEASE )DISEASE )DISEASE )DISEASE )

NON ATHEROMATOUS LESION INVOLVING NON ATHEROMATOUS LESION INVOLVING ARTERIES VEIN NERVESARTERIES VEIN NERVESARTERIES,VEIN,NERVESARTERIES,VEIN,NERVESOCCURING IN YOUNG MALES AND FREQUENTLY LEADING OCCURING IN YOUNG MALES AND FREQUENTLY LEADING TO NON HEALING ULCERS AND GANGRENETO NON HEALING ULCERS AND GANGRENETHE EXACT PATHOGENESIS IS OBSCURETHE EXACT PATHOGENESIS IS OBSCURERELATIONSHIP WITH TOBACO SMOKING AND CHEWINGRELATIONSHIP WITH TOBACO SMOKING AND CHEWINGABNORMAL CELLULER AND HUMORAL IMMUNE ABNORMAL CELLULER AND HUMORAL IMMUNE RESPONSES TO TYPE I AND III COLLAGENRESPONSES TO TYPE I AND III COLLAGEN

T T TT T TSMALL ARTERIES OF THE HAND AND FEETSMALL ARTERIES OF THE HAND AND FEETINTENSE INFLAMMATORY COMPONENT,FIBROUS INTENSE INFLAMMATORY COMPONENT,FIBROUS ENCASEMENT OF THE ENTERIC NEURO VASCULAR ENCASEMENT OF THE ENTERIC NEURO VASCULAR BUNDLE BUNDLE

Clinical featuresClinical featuresClinical featuresClinical features

SUSPECT THE DIAGNOSIS MALESUSPECT THE DIAGNOSIS MALESUSPECT THE DIAGNOSIS MALE SUSPECT THE DIAGNOSIS MALE PATIENT 20 PATIENT 20 –– 40 YEARS AGE40 YEARS AGEHISTORY : SUPERFICIAL MIGRATORYHISTORY : SUPERFICIAL MIGRATORYHISTORY : SUPERFICIAL MIGRATORY HISTORY : SUPERFICIAL MIGRATORY PHLEBELITISPHLEBELITISCOLD SENSITIVITYCOLD SENSITIVITYCOLD SENSITIVITYCOLD SENSITIVITYTRIPHASIC COLOURS RESPONSTRIPHASIC COLOURS RESPONSINSTEP CLAUDICATIONINSTEP CLAUDICATION