Practical Thinking in Suspected

Cases of Vascular Compromise

in Non Trauma Setting

SAHAL FATAH
TORACIC, CARDIAC and
1 VASCULAR SURGEON
 Peripheral Vascular Disease :

• Arterial : PAD, CLI, ALI

• Venous : CVI, DVT

Discrepancies & Similarities

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 Peripheral Arterial Disease (PAD)

• Disorders of the circulatory system to the

extremities

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 Introduction
Atherosclerotic changes

Normal Artery Diseased Artery

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 Introduction
Disease evolution  Sign & Symptomp
• Claudication
• Rest pain
• Ulceration
• Gangrene
• Limb loss

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 Prevalence
Outcomes in Patients with
Intermittent Claudication

Limb Outcomes
Peripheral Vascular Outcomes

Population >55 Worsening Lower Extremity Major

yr Claudication Bypass Surgery Amputation
16% 7% 4%

Other Cardiovascular

Reduce CV Risk
Intermittent Morbidity/Total Mortality
Claudication
5% Nonfatal 5-yr Mortality
Cardiovascular Event 30%
(MI/Stroke, 5-yr Rate)
20% Cardiovascular Cause
75%
6 Adapted from Weitz JI, et al. Circulation. 1996;94:3026-3049.
 Risk Factors
• Diabetes
• Hypercholesterolemia
• Hypertension
• Obesity
• Tobacco abuse
• Lifestyle

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 Diagnosis
• Patient history
• Physical examination
• Laboratory values
• Noninvasive vascular studies
• Angiography

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 Patient History
Historical clues to the diagnosis of
intermittent claudication

Variable Symptom Complex

Symptoms in the legs that are provoked
by walking and relieved by rest

Pain Aches Tiredness

Tightness Soreness Weakness Numbness

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 Physical Examination
• Pulses
• Bruits
• Ankle-Brachial Index (ABI)

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 Physical Examination
Ankle-Brachial Index
• Simple, painless, accurate, highly
reproducible examination
• Clinically useful
– Identifies patients with PAD
– Major indicator of premature MI, CVA, mortality
• Indications
– Any patient with suspicion for PAD
– Any patient at risk of PAD
 Age 50 or greater with history of DM or tobacco use
 Age 70 or greater regardless of risk factors

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 Physical Examination
Ankle-Brachial Index
• How to perform
Right Arm Left Arm
– Patient resting supine Pressure: Pressure:
for 5-10 minutes
– Continuous wave,
hand-held Doppler
– Measure systolic BP in
both arms
 Higher value is
DENOMINATOR of ABI
– Measure systolic BP in Pressure: Pressure:
DP and PT PT PT
 Higher value is DP DP

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NUMERATOR of ABI
 Physical Examination

ABI = Ankle Systolic Pressure

Brachial Systolic Pressure

>0.9 = Normal
>0.4-0.9 = Moderate disease
<0.4 = Severe disease

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 Physical Examination
Interpretation and limitations of ABI

ABI Interpretation Two Main Limitations

Above 0.90 — Normal Calcified ankle vessels
0.71-0.90 — Mild result in artificially
Obstruction “normal” ABI (DM, RF)

0.41-0.70 — Moderate Normal ABI in patient

Obstruction with Aortoiliac Disease—
0.00-0.40 — Severe only becomes abnormal
Obstruction with exercise testing

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 Noninvasive Vascular Studies
• Vascular ultrasound
• CT angiography
• Magnetic resonance angiography

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 Treatment
• Goals
• Risk factor modification
• Medical management
• Minimally invasive techniques
• Case studies
• Surgical intervention
• Follow-up care

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 Risk Factor Modification
• Tobacco cessation
• Exercise
• Weight reduction
• Pharmacologic intervention
– Hypercholesterolemia
– Hypertension
– Diabetes

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 Minimally Invasive Techniques
• Percutaneous transluminal angioplasty (PTA)
• Stenting
• Thrombolysis

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 Minimally Invasive Techniques

Guidewire placement
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 Minimally Invasive Techniques

Guidewire advanced past lesion

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 Minimally Invasive Techniques

Balloon dilatation
Percutaneous Transluminal Angioplasty
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 Minimally Invasive Techniques

Stent expansion by a balloon

catheter over a guidewire
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 Minimally Invasive Techniques

Post-PTA/stent placement
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 Minimally Invasive Techniques

Thrombolysis
Post-thrombolytic infusion
revealing stenosis
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 Surgical Intervention
• Bypass grafts
• Amputation

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 Surgical Intervention
• Bypass grafts

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 Venous Disease (CVI)

Simple spider veins to complex

dermal sclerosis and ulcer
formations.

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 Venous Anatomy

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 Hemodynamics
The leg muscle pumps, of which the
calf pump is the most important,
generate high pressure during
muscle contraction, which propels
venous blood toward the heart.
During relaxation, valves close and
blood is prevented from refluxing
down the leg and breaking up the
hydrostatic pressure column

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 Calf Pump

The calf muscle pump includes the soleal

and gastrocnemius muscles, their
intramuscular venous sinusoids, and the
superficial and deep veins. The soleal and
gastrocnemius muscle sinusoids
constitute the major “bellows” of the calf
pump. Even in the standing position,
contraction of the calf muscles produces
enough pressure to eject blood and
propel it toward the heart. Intramuscular
veins are also affected because of the
30 strong fascia investing the muscles.
 Venous Valves

 Presence of
valves prevent
reflux
 Pressure
generated in
deep veins by
the calf muscles
are prevented
from
transmission to
superficial veins
by the valves

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 Venous Pathology

Obstruction
Reflux and/or incompetence

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 Venous Reflux
Spider Veins Varicose Veins

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 Venous Reflux
Edema Venous Statis w/wo Ulcer

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 Venous History of Patient

Pain
Edema
Ulcers

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 Diagnostic Testing
Duplex Scan

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 Treatment

Medical Management
1. Leg elevation
2. Compression therapy
3. Exercise

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 Interventional Therapy

Sclerotherapy
Endovenous Ablation
Surgical

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 Sclerotherapy

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 Endovenous Ablation

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 Surgical

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 Similarities and Differences

Arterial symptoms produced by

exercise and relieved by resting even
standing
Venous symptoms worsened by
standing and improved by exercise and
leg elevation

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 Venous Claudication

Pain produced by prolonged exercise

in the legs secondary to iliac vein
obstruction and relieved by rest
Symptoms present with normal arterial
findings
Exception:::: to venous symptoms

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 Treatment Differences

In the arterial system, treatment is

aimed at opening and restoring
blood flow
In the venous system, treatment is
aimed at obstructing and
eliminating dysfunctional blood
vessels

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