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Arterial Disorders

Introduction:
Arterial disease includes:
Acute arterial occlusion
Chronic arterial occlusion
Aneurysms

Chronic Arterial Occlusion:

Causes: atherosclerosis

Risk factors:

• Hyperlipidemia
• Hypertension
• Diabetes melitus
• Obesity and decrease physical activity
• Smoking
• Male sex
• Advanced age

Pathogenesis:

Clinical presentation:
• Intermittent claudication
• Rest pain
• Coldness and color changes
• Ulceration and gangrene
• Reduced sensation, numbness, parasthesia
• Motor weakness
• Absent or diminished pulses
• Arterial briut
• Beurger’s angle

Investigations:

• Doppler ultrasound
• Duplex ultrasound.
• Angiography (gold standard)
• CT angiography and MRA.

Non-surgical treatment:

• Stop smoking
• Control of blood sugar
• Reduce blood lipid
• Reduce weight
• Regular exercise to the limit of claudication
• Drugs:
• Antiplatelets e.g.; aspirin, clopidogrel.
• Vasodilators e.g.; tolazoline, calcium canal blockers, pentoxifylline,

Percutaneous transluminal angioplasty:

Advantages:
simple procedure
under local anesthesia
less cost,
Shorter hospital stay
Lower mortality rate
Complications:
Hematoma
Arterial dissection
Aneurysm
Renal failure
Allergic manifestations

Surgical treatment:

• Bypass surgery
• Surgical endarterectomy
• Sympathectomy
• Endovascular procedures
• Amputation

Surgical bypass:

Endarterectomy:

Beurger's disease (ThromboangitisObliterans):

Progressive inflammatory segmental disease of small & medium sized arteries.


Upper and lower limb arteries and veins

Treatment:

Pain relieve
Abstinence from smoking
Drugs: steroids, anticoagulants and vasodilators
Surgery.

Aneurysms:

Classification of aneurysms:
• Wall:
• True aneurysms
• False aneurysms
• Morphology:
• Fusiform
• Saccular
• Dissecting
• Etiology:
• Atherosclerotic
• Mycotic
• Collagen vascular disease
• Traumatic
• Post stenotic


Clinical presentation:
Asymtomatic
Symptomatic
Pressure on nearby structures
Aneurysm thrombosis leading to ischemia
Aneurysm embolization
Aneurysm rupture.
O/E: palpable, expansile mass

Treatment:

• Aneurysm excision with graft interposition
• Aneurysm repair
• Aneurysm excision with resection of supplying tissue
• Aneurysm excision without arterial reconstruction
• Endovascular aneurysm repair







Graft interposition
Endovascular repair

Acute arterial occlusion:

Causes:
Embolism
Thrombosis of an atheromatous plague
Arterial trauma.

Embolic arterial occlusion:

What is an embolus?

What is the most common source of an embolus?

What does an embolus cause?

Clinical presentation:

Depending on the site of obstruction:
Limbs: (6P); pain, pallor, paresis, purchasing cold, pulselessness , and paraesthesia.
Brain: stroke
Retina: amaurosis fugax
Intestine: gangrene of corresponding loop of bowel
Spleen: splenic infarction and left hypochondrial pain
Kidney: loin pain and hematuria

Diagnosis & treatment:

• Diagnosed clinically
• Heparin
• Relieve pain
• Emergency embolectomy

Acute arterial thrombosis:

Sudden occlusion of an already diseased artery
Acute on chronic ischemia
Similar presentation to emboli but less severe. Why?
Arterial mapping mandatory
Embolectomy may be not enough


Arterial Trauma
Causes:
Penetrating injury
Blunt injury
Deceleration injury

Patterns of injury:

Clinical presentation:

Signs of arterial injury include:
• Pulsatile bleeding or pulsatile or expanding hematoma
• Bruit or thrill
• End organ ischemia
Suggestive signs include:
• Unexplained shock
• Trauma near a known course of a major artery
• A stable hematoma
• Injury to a nerve known to share a common course with a major artery
• History of pulsatile bleeding from a wound


Treatment:
• ABC
• Control of hemorrhage
• Operative treatment

Complications of vascular trauma:

• Anastomosis dehiscence
• Anastomosis site thrombosis
• Pseudoaneurysm formation
• Traumatic arterio-venous fistula formation
• Compartment syndrome
• Reperfusion injury

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