‫‪Acute Vascular Disorders‬‬

‫مت تفريغ كالم الدكتور‬

‫علي الكايد على احملاضرة‬
‫باللون األخضر‬
‫كل الشكر للطالبة ‪:‬‬
‫أبرار الصرايرة على‬
‫جمهودها‬
 Acute Lower Limb Ischemia
• Def: sudden occlusion of a previously
patent artery supplying the lower
limbs which posses a potential threat
to the viability of the limbs.

• Causes:
Causes The most common cause is
embolization.
• The heart is the source of embolus in
80-90% of episodes. Due to atrial
fibrillation
• 5-10% of emboli of unknown origin
called cryptogenic emboli.
• if adequate collateral circulation not
present, irreversible changes may appear
as early as 4-6hs after onset.
So, priority must be given to restore the
blood flow within this period.
• Once the occlusive process has begun,
vasospasm & propagation of thrombus
distal to the site of initial occlusion can
contribute to further ischemia.
• Virchow's traid ( injury , stasis ,
hypercoagulopathy )

• Infarction or ischemia cause sever pain

not progressive
*The Characteristic S&S are the 6Ps:
1. Pain first sign of vascular disease .
2. Pallor.
3. Pulselessness.
4. Poikilothermia. the affected limb take the
temperature of the surrounding atmosphere
5. Paresthesia. The earliest sign in tissue loss or
necrosis ( not vascular insufficiency )
6. Paralysis.
• Paresthesia:
Paresthesia is an essential finding. The
earliest sign of tissue loss:
• is the loss of:
• light touch, 2 point discrimination,
vibratory perception, & propreoception
esp. in the 1st web space of the foot ( not
pain, pressure or temperature BCZ:- the
larger fibers serving these functions are
relatively less susceptible to hypoxia).
• Paralysis:
Paralysis the onset of motor paralysis is an indication of
advanced limb threatening ischemia & impending
gangrene If changes persist beyond 12hs. Tense
swelling with acute tenderness of a muscle belly occur.
( common in gastrocnemious muscle after superficial
femoral artery occlusion). The extent of paralysis must
be determined.
• Skin & subcutaneous tissue have greater resistance to
hypxia than nerves & muscles.
• Peripheral pulses:
pulses in earlier stages the pulse at site of
occlusion can be palpable but absent distally,
because the fresh clot, is soft, semilquid consistency
& allow the pulse transmission to the site of
occlusion,
when becomes organized & densely compacted the pulse
lost at site of occlusion.
 Arteriography
* the gold standard for diagnosis.
* it should not be performed if
doing so would keep a critically
ischemic limb from receiving
prompt surgical therapy.
* should be reserved for patients
with viable limbs who can tolerate
the additional delay before
revascularization.
 Diagnostic testing
• CBC, platelets count, Blood chemistry,
coagulation profile.
• CXR, AXR (look for calcifications), ECG,
transesophageal echocardiogram.
• Doppler segmental pressure is useful to localize
the involved arterial segment and as a
quantitative index to gauge the severity of the
problem.
 Management
• If physical examination demonstrates clear evidence of
embolization, the definitive therapy should not be
delayed.
• Immediate heparin i.v bolus of 80units/kg, followed by
i.v. infusion of 18units/kg/h, & PTT should be
maintained between
60-80sec.
Heparin prevents proximal and distal propagation of
thrombus, maintains patency of collateral vessels, and
in addition can have a beneficial effect by reducing the
extent of ischemic injury

25-50% of DVT patients is asymptomatic because the embolus is attached

to the intima of the endothelium
 Surgical therapy
• Embolectomy: common femoral ( lower limb )
• Brachial >> ( upper )
- under local or general anesthesia.
- Fogarty catheter used.
- intraoperative thrombolysis When residual thrombus
exists.
- intraoperative arteriogramis necessary to define the
position of the clots so that the catheter can be placed as
close to the clot as possible.and When the viability of the
extremity is threatened or when there are poor Doppler
signals in the distal extremity .
- Bypass grafting.
***Heparin is reinstituted 6 to 12 hours after surgery
because of a significant incidence of recurrent embolism.
***Amputation (usually after 12hs the limb is paralysed
due to irreversible damage).
catheter embolectomy
is done through the
common femoral
artery. Most aortic,
iliac, superficial
femoral, and
popliteal artery
occlusions can be
managed successfully
.through this vessel
• Color changes in ischemic limb :
Pale > blue > dusky > black
• Thrombolytic therapy
Useful in patients with clearly viable extremity in
whom thrombosis is the likely underlying cause of their
acute ischemia.
In general the fresher the thrombus the more
successful the thrombolysis.
Urokinase is the agent of choice

• Percutaneous aspiration
thromboembolectomy
Useful as an adjunct to thrombolysis to reduce the
clot volume
 Complications
1.Reperfusion injury:
reestablishment of blood flow leads to further tissue death.
* results from formation of oxygen-free radicals.
*cause direct tissue damage & accumulation of WBCs &
sequestration in the microvascular system,
* it prolongs the ischemia despite restoration of axial blood flow.
* currently no proved therapy limits the injury.

2. Compartment syndrome:
* prolonged ischemia cause cell membrane damage & leak of fluid to
interstitium.
* edema increased intracompartmental pressure, when exceeds CPP,
further muscle & nerves necrosis occur.
* Fasciotomy should be done if ischemia>6h
* 2 incisions, one antrolateral, one posteromedial.
* skin lift open, to be closed either secondarily or by graft later on.
Compartment syndrome:.
ο Indications for fasciotomy:
♦ 4–6 hour delay after vessel injury.
♦ Combined vein and artery injury.
♦ Concomitant fracture/crush, severe soft-tissue injury,
muscle edema or patchy necrosis.
♦ Tense compartment/compartment pressures exceeding
40 mm Hg.
♦ Prophylactic for patients with prolonged transport
times
or long periods without observation (no surgical care
available).
3. Myo-nephropathic syndrome:
* products of ischemic muscles as K, lactic acid,
myoglobin, Cr phosphokinase released to the
circulation after reperfusion.
leads to arrhythmias & renal failure.
failure
* aggressive:
hydration,
diuresis as mannitol,
mannitol intravenous
sodium bicarbonate sufficient to alkalinize the urine.
urine
Alkalinization of the urine reduces the extent of
myoglobin precipitation in the renal tubules.
Insulin and glucose given intravenously may be
necessary for extreme or sudden elevations in serum
potassium levels.
4. Catheter related complications:
complications
* early:
early from arterial wall trauma includes
perforation, rupture, intimal dissection,
pseudoaneurysm formation.
* late: development of accelerated atherosclerosis in

the embolectomized vessel.

 Vascular injury
Epidemiology
• Peripheral vascular trauma typically occurs in young
men between the ages of 20 and 40 years.
• many vascular injuries of the head, neck are
immediately fatal.
• High risk areas:
areas
• Upper extremity: axilla, deltopectoral groove, anticubital fossa.
wound distal to the bifurcation of brachial artery: no serious
limb ischemia.
• Lower extremity: top of the leg till the mid calf.
 Types of Injuries

A. Penetrating Trauma
1. Stab wounds,
2. bullet wounds.
3. iatrogenic injuries from Percutaneous
catheterization, and intra-arterial injection of
drugs
4. high-velocity missiles & Shotgun blasts may
produce arterial thrombosis due to disrupted
intima even when the artery has not been
directly hit.
B. Blunt Trauma
• Motor vehicle accidents.
• Multiple injuries include fractures and dislocations;
dislocations and
while direct vascular injury may occur, in most instances
the damage is indirect due to fractures. This is especially
likely to occur with fractures near joints,
joints where vessels
are relatively fixed and vulnerable to shear forces. For
example, the Popliteal artery and vein are frequently injured
in association with posterior dislocation of the knee.
Fractures of large heavy bones such as the femur or tibia.
• Contusions or crush injuries may result in complete or
partial disruption of arteries, producing intimal flaps or
intramural hematomas that impede blood flow.
 Clinical Findings

A. Hemorrhage
• When pulsatile external hemorrhage is present, the
diagnosis of arterial injury is obvious, but when blood
accumulates in deep tissues of the extremity, the thorax, abdomen, or
retroperitoneum, the only manifestation may be shock.
• The presence of arterial pulses distal to a penetrating wound does
not preclude arterial injury, either because the vessel has not
thrombosed or because pulse waves are transmitted through soft clot.
Conversely, the absence of a palpable pulse in an adequately
resuscitated patient is a sensitive indicator of arterial injury.
B. Ischemia.
C. Arteriovenous Fistula
• With simultaneous injury of an adjacent artery and vein, a
fistula may form that allows blood from the artery to enter
the vein.
• Because venous pressure is lower than arterial pressure,
flow through an arteriovenous fistula is continuous;
accentuation of the bruit and thrill can be detected over
the fistula during systole.
• Traumatic arteriovenous fistulas may occur as operative
complications.
• Long-standing large arteriovenous fistulas may result in
cardiac failure.
• spontaneous resolution of acute arteriovenous fistulas
usually occurs.
• The time interval between injury &
evaluation must be considered.
- after more than 6hs of warm ischemia at
body temperature ( without cooling the
extremity) results in irreversible nerve &
muscle damage in 10% of patients.
 Diagnosis

• Arterial injury must be considered in any injured

patient. Patients who present in shock following
penetrating injury or blunt trauma should be assumed to
have vascular injury until proved otherwise.
• Any injury near a major artery should arouse suspicion.
• A plain film may be helpful in demonstrating a fracture
whose
fragments could affect an adjacent vessel or a bullet
fragment that could have passed near to a major vessel.
Before the x-ray is taken, entrance and exit wounds should
be marked with radiopaque objects such as safety pins.
 Hard signs
• the presence of hard signs has a 92-95%
sensitivity for injuries requiring intervention
1. Bruit or thrill is present in 45% of patients with
an AV fistula.
2. Active or pulsatile hemorrhage.
hemorrhage
3. Pulsatile or expanding hematoma.
hematoma
4. Signs of limb ischemia 6Ps.
5. Diminished or absent pulses:
pulses not a sensitive
prognostic sign, as up to 25% of patients
requiring repair have normal pulses distal to the
injury.
 Soft signs
• Much less useful in predicting or excluding
major peripheral vascular injuries.
• The vast majority of these lesions do not
require emergent repair.
1. Hypotension or shock.
shock
2. Neurologic deficit due to primary nerve injury
occurs immediately after injury, in contrast,
ischemic neuropathy is delayed in onset
(minutes to hrs).
3. Stable non- pulsatile or small hematoma.
4. The proximity of the wound to major
vascular structure.
• Doppler flow.
flow
• An ankle brachial index (ABI),
(ABI determined by
dividing the systolic pressure in the injured limb
by the systolic pressure in an uninjured arm, is
highly reliable for excluding arterial injury after
both blunt and penetrating trauma. An ABI < 0.9
has sensitivity of 95%, specificity of 97%, for
determining the presence of clinically significant
arterial injury. Thus, only patients with "soft"
signs and an ABI of < 0,9 require arteriography.
• Color flow duplex ultrasonography.
ultrasonography This technology
can provide images of vessels and velocity spectral
analysis. *Color flow duplex scanning of an area of injury
is noninvasive, painless, portable, and easily repeated
for follow-up examinations.
*duplex ultrasound identifies nearly all major injuries that
require treatment. In addition to screening for arterial
trauma, duplex scanning has been used to detect
pseudoaneurysms, arteriovenous fistulas, and intimal
flaps.
*The technology is sophisticated and requires skill in
operation and interpretation, which is not always
immediately available.
• Arteriography is the most accurate diagnostic
procedure for identifying vascular injuries.
• Arteriography is also valuable when arterial injuries
may have occurred at multiple sites to localize an
injury. Complications of arteriography include :
• groin hematomas, iatrogenic pseudoaneurysms,
arteriovenous fistulas, embolic occlusions, and
delays in diagnosis that may lead to irreversible
ischemia in marginally perfused limbs.
• Arteriography may be particularly useful in
differentiating arterial injury from spasm.
• In general, it is risky to attribute abnormal
physical findings in an injured patient to arterial
spasm; an arteriogram is indicated in such
patients.
• MRA lacks sufficient resolution to detect
significant arterial abnormalities.
• CT scans may reveal intra-abdominal or
thoracic hematomas or organ displacement,
suggesting the presence of a hematoma. This
suggests the need for arteriography or
immediate surgery.
 Management Aspects

• Initial management.
ο Control external bleeding immediately! Direct pressure
to the bleeding wound is; temporary tourniquet (BP cuff)
placed proximal to the injury site and inflated above
systolic blood pressure may be useful.
ο Administer IV antibiotics, tetanus toxoid, and
analgesia.
ο In most long-bone fractures, resuscitation and fracture
alignment will restore distal flow.
ο Indications for operation for a suspected vascular
injury:
♦ Hard signs.
♦ Soft signs confirmed by duplex US and/or angiography.
 .Operative management

**Preparation of injured extremity as well as contralateral

uninjured lower or upper extremity in case repair requires
autogenous vein graft.
**Longitudinal incisions usually directly over injured vessel
followed by proximal and distal control.
Once control is obtained, perform the following steps:
♦ Debride injured vessels to macroscopically normal
wall.
♦ Pass balloon catheters proximal and distal to remove
any residual thrombus.
♦ Flush both directions with heparinized saline.
saline
 Type of repair
will depend on the extent of injury.
ο Lateral suture repair: Required for minimal injuries that,
when repaired, will not compromise the lumen nor decrease pulse
or
Doppler signal.
ο End-to-end anastomosis: Excise extensively damaged
segments and perform anastomosis if able to mobilize ends
(generally, < 2 cm gap) without tension. An oblique anastomosis is
less likely to stenose.
Interposition graft: Required if the vessel cannot be primarily repaired
without undue tension.
♦ Autogenous vein grafts preferred, usually the contralateral greater
saphenous vein (GSV).
♦ Prosthetic grafts may be required when autogenous vein is
inadequate or unavailable.
◊ Polytetrafluoroethylene (PTFE) grafts