Upload
michafute
View
224
Download
0
Embed Size (px)
Citation preview
8/12/2019 Vascular Disorders Specific to the Upper Limb
http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 1/15
8/12/2019 Vascular Disorders Specific to the Upper Limb
http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 2/15
ACUTE UPPER LIMB ISCHEMIA
Embolism.Heart (arrythmia, myocardial infarct).Proximal aneurysm
.Subclavian thrombus related to thoracicoutlet syndrome. Trauma
.Forced extension/traction injury
.Supracondylar fracture
.Antecubital fossa laceration Acute –on-Chronic Ischemia
8/12/2019 Vascular Disorders Specific to the Upper Limb
http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 3/15
Management AULI
Traumatic Intimal Flap/Dissection.High index of suspicion from history of injury
.Do not relay on appearance of hand
.If pulse absent, assume mayor injury
.Low threshold for angiography.
Embolectomy Iatrogenic injurie.
.Access for angiography/ endovascular intervention.
8/12/2019 Vascular Disorders Specific to the Upper Limb
http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 4/15
CHRONIC UPPER LIMB ISCHEMIA
Aetiology
.Occlusive atherosclerosis.
.Previous radiotherapy
.Arteritis.
History
.Excertional pain/heaviness of arm.
.Symptoms of subclavian steal.
.Manifestations of atherosclerosis.
.Previous radiotherapy.
.Evidence of connective tissue dis.
.Previous fracture/soft tissue trauma.
8/12/2019 Vascular Disorders Specific to the Upper Limb
http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 5/15
CHRONIC UPPER LIMB ISCHEMIA
Examination
.Presence of palpable pulse unreliable
.Measure brachial blood pressure
.Repeat after exercise.
Investigation
.Non-invasive blood pressure measurement, exercise
.Segmental pressure
.Finger pressure
.Duplex ultrasound scanning
.Intra –arterial DSA
8/12/2019 Vascular Disorders Specific to the Upper Limb
http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 6/15
ManagementBrachiocephalic Artery
Mild to Moderate Stenosis withHemispheric TIAs: Antiplatelet therapy.
Severe Bc Dis causing TIA+/- ULI.
.Endarterectomy/bypass .
.Operative mortality 5%.
.Possible role for angioplasty+ stent
8/12/2019 Vascular Disorders Specific to the Upper Limb
http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 7/15
ManagementSubclavian/ Axillary artery
Short proximal stenoses/occlusion besttreatment is ballon angioplasty=/ - stent.
Surgical options:Subclavian transposition
Carotid-to-Subclavian bypass
Axillo-axillary bypass.
8/12/2019 Vascular Disorders Specific to the Upper Limb
http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 8/15
Algorithm for Investigation of Painon Walking
Calf/Thigh PainClaudication
Resting ABPIReduced Normal
AppropriateHistory
InappropriateHistory
AppropriateHistory
InappropriateHistory
EXERCISETEST
8/12/2019 Vascular Disorders Specific to the Upper Limb
http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 9/15
Algorithm for Investigation of Painon Walking
EXERCISETEST
Fall inPressure
Not Fall inPressure
VASCULARClaudication
NOT VASCULAR
8/12/2019 Vascular Disorders Specific to the Upper Limb
http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 10/15
Algorithm for Treatment ofClaudication
CLAUDICATION
Non –Invasive Assessment
Risk FactorModification
InterventionNOT Indicated
InterventionINDICATED
8/12/2019 Vascular Disorders Specific to the Upper Limb
http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 11/15
Algorithm for Treatment ofClaudication
StructuredExerciseProgram
SymptomDeterioration
Duplex/IADSA
StableImprovement Angioplasty
/Stenting
Endarterectomy
/Bypass
8/12/2019 Vascular Disorders Specific to the Upper Limb
http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 12/15
Confirmed Peripheral
Arterial Occlusive Disease
(ABI<0.95)
Cardiovascular
Risk Assessment
Aggressive Risk
Factor Modification
and
Antiplatelet
Therapy
Diabetes
-HbA1c and/or
-Fasting and postprandial glucose
.Smoking history
-Current and former
.Hyperlipidemia
-Lipid profile
-LP(a?)
Hypertension
-Blood presure measurement
Homocysteine
-Fasting homocysteine level?
Fibrinogen-Fibrinogen level
Hypercoagulable and arterial
thrombosis
-Coagulation screen
.Diabetes treatment
Normalize HbA1c
.Smoking cessation
-Behavior modification
-Nicotine replacementBupropion
Lipid goals
-LDL cholesterol<100 mg/dl
-Reduce triglycerides
-Raises HDL cholesterol
Hypertension treatment
-Control blood pressure
Homocysteine elevation-Folat/vit B12,B6
Hypercoagulable state
Anticoagulate
.Antiplatelet therapy
-Clopidogrelor
-Aspirin
Confirmed Peripheral
Arterial Occlusive Disease
(ABI<0.95)
Cardiovascular
Risk Assessment
Aggressive Risk
Factor Modification
and
Antiplatelet
Therapy
Diabetes
-HbA1c and/or
-Fasting and postprandial glucose
.Smoking history
-Current and former
.Hyperlipidemia
-Lipid profile
-LP(a?)
Hypertension
-Blood presure measurement
Homocysteine
-Fasting homocysteine level?
Fibrinogen-Fibrinogen level
Hypercoagulable and arterial
thrombosis
-Coagulation screen
.Diabetes treatment
Normalize HbA1c
.Smoking cessation
-Behavior modification
-Nicotine replacementBupropion
Lipid goals
-LDL cholesterol<100 mg/dl
-Reduce triglycerides
-Raises HDL cholesterol
Hypertension treatment
-Control blood pressure
Homocysteine elevation-Folat/vit B12,B6
Hypercoagulable state
Anticoagulate
.Antiplatelet therapy
-Clopidogrelor
-Aspirin
Abd i l P i d A t i l
8/12/2019 Vascular Disorders Specific to the Upper Limb
http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 13/15
Abdominal Pain and ArterialDisease .
Differential Diagnosis Mesenteric ischemia: often too late!
Suspect inpatient with other symptoms or
signs of vascular disease (angina pectoris,intermittent claudication, stroke) whocomplains of abdominal pain, weight loss,
fear of food, post prandial diarrhoea. Abdominal Aortic Aneurysm.
8/12/2019 Vascular Disorders Specific to the Upper Limb
http://slidepdf.com/reader/full/vascular-disorders-specific-to-the-upper-limb 14/15
Differential Diagnosis
Perforated DU
Acute pancreatitis
Renal Colic Lumbar osteoarthritis