aortic iliac.pdf........................

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1. Aortic bifurcation (most common site)
Infrarenal abdominal aorta

Iliac arteries

2. f
|
| Type |

>

Distal aorta and
common iliac
arteries

A

I
Type II | |
|
|

L Y
Widespread abdominal
aorta and iliac arteries

Multiple level disease—
abdominal, iliac,
infrainguinal arteries

y

3. 5th and 6th decades.
> Some degree of atherosclerosis is almost always

seen.

The process may be atherosclerosis with intimal |:
thickening and fibrosis.

> The thrombus often propagates upto the level

of the renal arteries, occluding one renal artery 3

and extending upto near the origin of the
superior mesenteric artery.

Concomitant coronary or cerebral
atherosclerosis occurs in 30 to 50% of patients

4. INTERMITTENT CLAUDICATION- BOTH BUTTOCKS THIGHS AND
CALVES
SYMMETRIC OR ASYMMETRIC
IMPOTENCE-CHARACERISTIC IN MALES
LERICHE’S SYNDROME
REST PAIN AND ULCERATION-PARTICULARLY IN DIABETICS

5. Y” Diminution or absence of femoral pulses.
v Absence of popliteal pulses.

Y” Pulsation of the abdominal aorta may be palpable but
may be absent if the abdominal aorta is occluded upto
the renal arteries.

5 it is often audible over the aorta or iliac
arteries confirming the presence of atherosclerosis.

6. + This depends very much on the symptom and the
profession of the individual.

For example, mild claudication in a 45 year old patient
whose occupation necessitates frequent walking is a
strong indication for operation.

Whereas a retired patient of 70 with angina

pectoris and claudication does not

require operation.

7. 1.Dail ( to the point of claudication. This may not only

increase the walking tolerance, but also may enhance

collateral circulation. If walking is not feasible similar exercise

maybe ES indoors.
i in any form is mandatory.

y with vasodilators have very limited result.

5.Attempt must Le made to |: [ ipid concentr by diet
na Que

6. icylic acid in small doses strikingly alters platelet
sagregation and may thereby prevent intravascular thrombosis.

8. Mainly preferred when the occluded segment is short i.e; Involving the terminal
5 cm of the aorta and the proximal part of the common iliac arteries.
When the disease is more extensive than this, by-pass graft procedure should be
the operation of choice.
DVANTAGES- AVOIDS PROSTHETIC GRAFT AND IT’S
COMPLICATIONS
NTAGES- REOCCLUSION AND RESTENOSIS

Extent of disease

aorta
E

Operation

aortoiliac
endarterectomy

common iliac

9. Gold Standard For Type | & II
Woven Dacron Graft Used

aorta

Bleeding +
Thrombosis EA
Embolization
Graft Blockage
Graft Failure
Graft Infection
Graft Leak
Aortovenacaval/Aortoduodenal Fistula
Mesenteric Ischemia

Impotence

external iliac

7

aortotemoral
Dacron bypass

10. Suitable for short segmental stenosis
Rupture of vessel

Retroperitoneal hemorrhage
Total occlusion of previously stenotic vessel

11. NDICATIONS Indicated in patients with trophic changes in the
feet not amenable to arterial reconstruction
operations.

Unpredictable benefit.

Increases blood flow to skin and subcutaneous tissue

Doesn't increase blood flow to leg muscles

12. FEMORO POPLITEAL OCCLUSION

Q The most common site for atherosclerotic occlusion in the lower
extremity is the distal superficial femoral artery within the
adductor canal almost near the adductor foramen.

Q From here occlusion extends proximally in the superficial femoral
artery till the opening of a large collateral branch or may extend
upto its origin from the common femoral.

Q If occlusion affects the popliteal artery or its branches, more

serious circulatory insufficiency appears and ulceration and

gangrene of the feet may start. This is more common in,diabetics.

13. ~ Intermittent claudication of the calf muscles with moderate
exercise is the main symptom.

Normal femoral pulse but absent popliteal and dorsalis

pedis pulses.
Sometimes dorsalis pedis pulse may be felt at rest, but disappears

with exercise, which is known as the

The nutrition of the foot is usually normal.
But if occlusive disease is present distally, it may be associated with

rest pain and trophic changes in the foot.

14. It is almost similar to that described in aorto-iliac
occlusion.

Only one point requires mention that a good exercise
program of walking daily has resulted in marked
improvement in claudication in at least 50% of patients
within 6 to12 months.

15. Open endarterectomy is preferred
The whole length of the occluded portion of the artery is exposed bya
longitudinal incision, atherosclerotic core is removed and the
arteriotomy is closed by suturing with a vein patch to prevent constriction.
Endarterectomy has not proved satisfactory in femoro-popliteal occlusive
disease. That is why it

is only advocated when a suitable vein is not available for by-pass surgery.

tem
endarterectomy

superticial
femoral

16. 1" à RAFI

By-pass operation with autologous saphenous vein is the standard
technique.

In determining the choice of operative procedure, venous by-pass is
always favoured if the saphenous vein is at least 4 mm in external

diameter. | Extent of disease Operation

superficial femoropopliteal
temoral vein bypass

17. Profundaplasty is aimed at removal of atheromatous
stenosis from the origin of the profunda and then to
widen the endarterectomised segment by insertion of a
vein patch.

superticial

deep temoral profundaplasty
*

ror leal (vein patch)
popliteal

18. When claudication is the only symptom, this operation should not
be performed.

This operation is only indicated when trophic changes are . present
and direct arterial reconstruction is not possible.

i) a limb salvage procedure
ii) an adjunct to reconstructive arterial procedure

19. PU
In certain cases when there is definite ischaemic
change in the distal limb with ulceration and
gangrene, there is probably no way out but to
amputate the distal portion

of the limb.

20. ACUTE ARTERIAL OCCLUSION

It’s a condition of acute lack of tissue perfusion
due to sudden cessation of circulation.

21. ACUTE ARTERIAL OCCLUSION

ATRIAL FIBRILLATION
MITRAL STENOSIS
MYOCARDIAL INFARCTION
BACTERIAL ENDOCARDITIS
ATRIAL MYXOMA

TES:-BIFURCATION OF COMMON FEMORAL ARTERY

BIFURCATION OF POPLITEAL ARTERY
BIFURCATION OF COMMON ILIAC ARTERY
BIFURCATION OF AORTA

22. ACUTE ARTERIAL OCCLUSION

Arises from atherosclerotic plaques

PENETRATING INJURIES
LACERATIONS
TRANSECTIONS
ARTERIAL CONTUSION WITH THROMBOSIS
COMPARTMENT SYNDROME

23. Paralysis

Paraesthesia
Pallor
absent Pulses.

24. PHYSICAL EXAMINATION

SPECTIO!
Pale with collapsed peripheral vein.

Local temperature is cold below the site of lodgement of
embolus
Site of obstruction
Level of occlusion
Level of ischaemia
Cardiac examination

25. SPECIAL INVESTIGATIONS

"SHOULD BE. DONE IN GOLDEN PERIOD 1.E; 4-6 HRS

ALTERNATIVE
USEFUL WHEN SITE OF EMBOLUS IS NOT CERTAIN

26. TREATMENT

A. FOR EMBOLUS
ARTERIAL EMBOLECTOMY
TREATMENT OF CHOICE

SHOULD BE PERFORMED AS SOON AS
POSSIBLE

ATLEAST 4-6 HRS BEFORE TO
PREVENT MUSCLE NECROSIS

27. TREATMENT

LYS! >
- STREPTOKINASE
UROKINASE
TISSUE PLASMINOGEN ACTIVATOR (TPA)

RECENT STROKE
BLEEDING DIATHESIS
PREGNANCY

28. TREATMENT

OPERATION

DEPENDS UPON TYPE OF INJURY TO ARTERY

PORTION OF ARTERI MALL IS [ 3ED- REPAIRED WITH VEIN
PATCH

-D- END TO END
ANASTOMOSIS
ERY Is NTUSED/LACERATED- SEGMENT
REMOVED END TO ANASTOMOSIS
CM- AUTOGENOUS VEIN GRAFT (REVERSED
LONG SAPHENOUS VEIN)