2

2.1



1. acute chronic limb ischaemia

2. (comorbid condition)
3.
4.
5.
2.2
2.2.1 (chronic limb ischaemia)
Atherosclerosis

atherosclerosis

aortoiliac artery, superficial femoral artery
80%

Artherosclerotic plaque

Artherosclerotic plaque
2.2.2 (acute limb ischaemia)
2.2.2.1 Acute embolism
(solid mass)

(Rheumatic heart disease)
80% atrial fibrillation

 emboli
artery bifurcation

2.2.2.2 Acute thrombosis

thrombosis
atherosclerosis moderate/severe atherosclerotic stenosis
plaque rupture clotting factor
thrombosis superficial
femoral artery popliteal artery thrombosis

polycythaemia
2.3
5

1.
2.
3
4.
5.
2.3 1.

acute chronic ischemia
Acute ischaemia onset
onset sudden chronic
ischaemia
collateral vessel
thrombosis
atherosclerosis (acute occlusion on top chronic arterial occlusion)

 arterial embolism atherosclerosis

collateral vessel

embolism
(distal) collateral vessel
collateral vessel

2.3 1.1 acute ischaemia (5P)

Pain
Pallor
Pulselessness
Paralysis
Paresthesia
acute limb ischaemia
embolism thrombosis
Emboli
- Atheromatous emboli ()
-Amniotic fluid, bone marrow
-Foreign body catheter tip bullet
Atheromatous emboli thrombus
- Left ventricular walls myocardial infarction (MI)
- Left atrium atrial fibrilation
- Mitral aortic valve disorder
- Atheromatous disease aorto-iliac artery
acute limb ischaemia embolism
thrombosis embolism

 embolism atrial fibrillation MI

2.3 1.2
Intermittent claudication
Rest pain
Ulceration/gangrene
Chronic Ischaemia

atheromatous disease Popliteal aneurysm
collateral vessel
vessel

Rest pain at night

Ulcer chronic arterial occlusion

Digital gangrene arterial occlusion

2.3.2 (location of the occlusion)

acute ischaemia
proximal chronic ischaemia

aortic iliac occlusion

collateral circulation
calf vessel occlusion (crural
vessel) superficial femoral artery occlusion

onset
2.3.2.1 Aorto-iliac occlusive disease
aorta iliac segment
Buttock, thigh calf (claudication) chronic
disease atheromatous lesion collateral vessel
erectile
impotence Leriches syndrome
Rene Leriche
embolus thrombosis aortoiliac
segment aortic occlusion
buttock, perineum
2.3.2.2 Common femoral artery occlusive disease

femoral pulse
embolism femoral artery
bifurcation

2.3.2.3 Superficial femoral artery occlusive disease

superficial femoral artery (SFA)

adducator hiatus (Hunters canal)
SFA

collateral circulation profunda femoris artery
profunda femoris artery SFA
common femoral artery
2.3.2.4 Popliteal artery occlusive disease

popliteal artery genicular artery
collateral circulation profunda femoris artery popliteal artery

2.3.2.4 Crural artery occlusive disease

anterior tibial artery,
posterior tibial artery, peroneal artery

2.3.3.(Status of limb)


2.3.3.1 acute ischaemia
2.3.3.1.1. Thrombolysis
Thrombolysis
(revascularisation)
severe ischaemia thrombolysis

2.3.3.1.2.
revascularisatrion
toxic metabolite free radical
metabolic acidosis, acute renal failure, myoglobinuria MI
(primary amputation) severe
ischaemia irreversible limb ischaemia
2.3.3.1.3 (saving a
viable limb or primary amputation)

- pain (tenderness) anterior posterior

compartment advanced ischaemia
irreversible ischaemia
- paresthesia
(pins and needles) (numbness)
severe acute critical ischaemia
- pallor severe ischaemia
(mottling)
(fixed mottling)
(irreversible ischaemia)
- pulselessness

- paralysis

2.3.3.2
(intermittent claudication)
aortoiliac

occlusion buttock
1-2
oxygen


(shopping)
intermittent claudication

(rest pain)



gravity

gravity
(dependent oedema) microcirculation
gangrene
(ulcer)
(gangrene) wet gangrene dry
gangrene
- wet gangrene
sepsis

- dry gangrene dry

gangrene granulation tissue

(autoamputation)
2.3.4. (fitness of the patient)

 severe limb
ischaemia Bypass operation
revascularisation
severe MI severe limb iscahemia embolism
embolectomy reperfuse MI toxic metabolite free radical
co-existing disease

(overtreat)

renal
failure
2.3.4.1 Pre-event causes

Cardiac disease
Angina pectoralis, previous MI, cor pulmonale, left ventricular failure
Lung disease
Chronic obstructive pulmonary disease, asthma
Renal disease
Chronic renal failure
Metabolic disease
Diabetes mellitus, malignancy, cachexia

flexion contracture
2.3.4.2 Per-event causes

Dehydration
Acidosis
Uncontrolled diabetes
Organic psychosis

2.3.4.3 post-event causes

Myoglobinuria renal failure

Severe acidosis revascularisation
MI
thrombolysis
2.3.5 (investigation)




2.3.5.1. Clinical examination

pulse

2.3.5.2.
- BUN. Creatinine Electrolyte
aorta
(major operation)
renal artery disease
- Full Blood Count, plasma viscosity polycythaemia,
thrombocytosis, hyperviscosity syndrome
- Coagulation study anticoagulant coagulation
liver disease baseline
- EKG chest X-ray

2.3.5.3. Fixed wave Doppler examination

Doppler probe
probe

Ankle Brachial index

2.3.5.4. Treatmill testing
Chronic ischaemia
arterial occlusion .
10
3 /
Chronic lung disease, Angina pectoralis
percutaneous angioplasty
bypass surgery

2.3.5.5.Duplex scan
2 ultrasound (B-mode)
abdominal (aorta/iliac) popliteal aneurysm rare
aneuysm femoral aneurysm Doppler scan
(occlusive disease) wave flow
(degree of stenosis) duplex
scan non-invasive test

Duplex scan
2.3.5.6. Contrast arteriography
contrast media x-ray lumen
(conventional arteriography)
arteriography (resolution-clearity) Digital
subtraction arteriography (DSA)
Digital angiogram

Angiogram = Road map for surgery

2.3.5.7. Computerised Tomographic Angiography
Helical Computerised Tomography(CT)
CT scan
CT
scan contrast Computer
Carotid Body Tumor
Carotid Artery

2.3.5.8. Magnetic Resonance Arteriography (MRA)

Magnetic

(Angiogram)

 Angiogram

Angiogram Iodine Iodine
MRA
X ray


Angiogram

MRA

2.4
2.4.1

2.4.1.1. (life style altenation)

(Secondary Smoking)

Collateral Vessel



60%
2.4.1.2. Angioplasty
Angioplasty
balloon
superficial femoral artery
fluroscopy
balloon balloon


Angioplasty aorta iliac artery
anterior tibial artery posterior tibial artery

 Angioplasty
2.4.1.3. Bypass Surgery

(conduit)
Bypass surgery
1. intermittent claudication

2. critical limb ischaemia rest pain, gangrene chronic

ulcer
(conduit) Bypass Surgery
long saphenous vein
bypass surgery long saphenous vein
Bypass
phebitis
varicose vein (arm vein)

 vein graft
bypass surgery
bypass surgery Bypass
Surgery 2
1. polytetrafluoroethylene (PTFE)
2. polyethylene terephthallate (dacron)
PTFE dacron
PTFE
(Thrombosis dacron)
inguinal ligament ( flow
) PTFE dacron
aorta iliac artery

Dacron graft

 Axillofemoral bypass

axillofemoral bypass

Femorofemoral bypass

 Femorotibial bypass vein graft

(Amputation)
(amputation)

outflow
amputation

2.4.1.4 amputation

1. Digital amputation Ray
amputation
2. Transmetatarsal amputation metatarsal

3.Below knee amputation

4. Gritti stoke amputation Knee joint

femur

5. Above knee amputation

Below knee amputation

Below knee amputation long posterior flap

Stroke MI
intermittent claudication critical limb ischaemia
(gangrene, ulcer) 2% critical limb ischaemia
50% 5
Bypass Surgery
(distal anastomosis)

 femoropopliteal bypass
(patency) femoroperoneal bypass

synthetic materials bypass femoral artery
posterior tibial artery 5 bypass
50% PTFE bypass 25%
2.4.2
2.4.2.1. Heparin
heparin
heparin
(stasis)
Collateral Vessel Collateral Vessel

heparin 5,000
(IU) 500
1,000 / Actvated Partical Thromboplastin Time
(APTT) 2 3 .. heparin Actvated
Partial Thromboplastin Time 2 3 Control
2.4.2.2. Thrombolysis
Thrombolysis


Coronary acute arterial thrombosis
angiogram


1 2 streptokinase,
urokinase, tissue thromboplastin


(Thrombolysis)
Angiogram

thrombosis

Angioplasty bypass operation
2.4.2.3. Embolectomy
Embolism
Forgarty balloon catherter catherter
Embolism (arteriotomy)
balloon
embolus (
) arteriotomy



MI atrial myxoma
2.5





5
, ,
,


1. Lamont PM, Shearman CP, Scott DJA. Lower limb arterial disease. In: Lamont PM,
Shearman CP, Scott DJA, editors. Vascular Surgery. Oxford: Oxford University
Press; 1998. p. 75-87.
2. Tennant WG. Limb ischaemia. In: Macintyre IM, Smith RC, editors. The RCSE
SELECT Program. Dundee: Dundee University Press; 2000. p. 1-25.
3. Walker AJ. Vascular Trauma. In: Davies AH, Beard JD, Wyatt MG, editors.
Essential Vascular Surgery. London: W.B.Saunders; 1999. p. 304-15.