Arterial diseases

Arterial diseases

1. ARTERIAL DISEASES DR. MD. SHERAJUL ISLAM FCPS (Surgery), FACS(USA),FMAS(INDIA) Assistant Professor, Surgery Sheikh Sayera Khatun Medical College

2. Anatomy of arteries The arterial wall is composed of three layers: The adventitia O utermost layer C omposed of connective tissue, neural fibres and small capillaries I t is the main site for the nutrition and innervation of the vessel The media Thickest layer of the vessel wall C omposed of smooth muscle cells and connective tissue bundles P rovide its strength and elasticity

3. Anatomy of arteries T he intima I nnermost layer L ined with an endothelial cell layer that functions both as an interface between the circulating blood and the arterial wall A source of vasoactive products that prevent thrombosis and regulate the vascular tone by inducing vasoconstriction and vasodilation

4. DISEASES OF THE ARTERIES Atherosclerosis Thromboangiitis obliterans (Buerger’s disease) Raynaud’s disease Conditions causing Raynaud’s phenomenon: S cleroderma R heumatoid arthritis SLE G ranulomatosis Vasculitis of other causes

5. DISEASES OF THE ARTERIES Embolus Aneurysms Other causes: Fibromuscular dysplasia R adiation Takayasu’s arteritis

6. ATHEROSCLEROSIS Atherosclerosis is a systemic disease of the large and medium sized arteries in which lipid and fibrous material accumulate between the intima and media of the vessel, eventually causing narrowing of the lumen

7. ATHEROSCLEROSIS It is a degenerative process triggered by endothelial cell dysfunction followed by the adhesion and infiltration of inflammatory cells (macrophages and T lymphocytes), which leads to the formation of fibrocellular plaques As these plaques continue to grow, they cause an inflammatory reaction that triggers smooth muscle proliferation in the affected area, resulting in luminal narrowing and a reduction of blood flow through the vessel

8. Composition of Atherosclerotic Plaque

9. ATHEROSCLEROSIS R isk factors for the development of atherosclerosis include Smoking H ypertension D islipidaemia D iabetes mellitus Coagulation disorders

10. ATHEROSCLEROSIS This process start as early as childhood, with endothelial fat streaks being the first manifestations This chronicity and gradual stenosis allows for the formation of collateral arterial channels to the affected organ T he ischaemic symptoms vary depending on the vessel involved the degree of narrowing the presence or absence of collaterals Examples Angina pectoris with diseased coronary arteries Intermittent claudication with diseased arteries in the extremities Renovascular hypertension with affected renal arteries

11. ATHEROSCLEROSIS Another complication of this inflammatory process is the ulceration and acute rupture of an unstable plaque, leading to either acute occlusion of the artery (thrombosis) or a distal showering of the plaque material (embolism) Acute occlusion does not allow for the development of collaterals and therefore leads to symptoms of acute ischaemia Some manifestations of this process include acute myocardial infarctions, strokes and acute limb ischaemia

12. ATHEROSCLEROSIS Despite the fact that atherosclerosis is a systemic disease, the plaques tend to occur more in specific areas, mainly those with high turbulence, low shear stress and flow stagnation As such, regions of arterial bifurcation are the most susceptible to the development of atherosclerotic disease The most common site for these plaques are the coronary arteries, carotid bifurcation, aortic bifurcation and proximal iliac arteries, as well as the lower extremity arteries at the site of the adductor canal

13. INTERMITTENT CLAUDICATION Claudio means “I limp” a Latin word It is a crampy pain in the mus cle seen in the limbs Due to arterial occlusion, metabolites like lactic acid and substance P accumulate in the muscle and cause pain The site of pain depends on site of arterial occlusion The most common site is calf muscles Pain in foot is due to block in lower tibial and plantar vessels Pain in the calf is due to block in femoropopliteal segment Pain in the thigh is due to block in the superficial femoral artery

14. INTERMITTENT CLAUDICATION Pain in the buttock is due to block in the common iliac or aortoiliac segment, often associated with impotence and is called as Leriche’s syndrome Pain commonly develops when the muscles are exercising Cause for pain is accumulation of substance P and metabolites During exercise increased perfusion and increased opening of collaterals wash the metabolites

15. Boyd’s classification of claudication Grade I: Patient complains of pain after walking, and distance in which pain develops is called as ‘claudication distance’ If patient continues to walk, due to increased blood flow in muscle and opening of collaterals metabolites causing pain are washed away and pain subsides Grade II: Pain still persists on continuing walk; but can walk with effort Grade III: Patient has to take rest to relieve the pain

16. Claudication Arterial —typically develops after walking for certain distance and resolves rapidly within 5 minutes once walking is stopped N eurogenic —pain develops in standing or walking and disappears immediately after stopping walk; normal feeling pulses without ischaemic changes are present It is usually due to narrow lumbar canal (spinal canal stenosis) Venous —it is rare but definitely occurs. It is observed in chronic pelvic venous obstruction as a mechanical high venous pressure It is usually due to iliac vein thrombosis Peripheral pulses are normal

17. Claudication Beta blockers may aggravate claudication Claudication is not that common in upper limb but can occur during writing or any upper limb exercise

18. REST PAIN It is continuous aching in calf or feet and toes or in the region even a t rest depending on site of obstruction It is ‘ cry of dying nerves’ due to ischaemia of the somatic nerves It signifies severe decompensated ischaemia Pain gets aggravated by elevation and is relieved in dependent position of the limb Pain is more in the distal part like toes and feet It gets aggravated with movements and pressure .

19. REST PAIN Hyperaesthesia is common association with rest pain Rest pain is increased in lying down and elevation of foot; it may be reduced on hanging the foot down Rest pain is worst at night and so patient is sleepless at night Rest pain is apparently reduced by holding the foot with hand, probably due to suppression of transmission of pain sensation

20. THROMBOANGIITIS OBLITERANS (TAO) Synonym: Buerger’s Disease

21. Buerger’s Disease Very commonly seen in young and middle aged males S een only in smokers and tobacco users Not usually seen in females due to genetic reasons Almost always starts in lower limb, may start on one side and later on the other side

22. Buerger’s Disease Upper limb involvement occurs only after lower limb is diseased Only upper limb involvement can occur but it is rare A non atherosclerotic inflammatory disorder involving medium sized and distal vessels with cell mediated sensitivity to type I and type III collagen

23. Buerger’s Disease It is common in Jewish people; it is rare even in female smokers Hormonal influence, familial nature, hypersensitivity to cigarette, altered autonomic functions are probable different causes Lower socioeconomic group, recurrent minor feet injuries, poor hygiene are other factors It is segmental, progressive, occlusive, inflammatory disease of small and medium sized vessels with superficial thrombophlebitis often may present as Raynaud’s phenomenon with micro abscesses, along with neutrophil and giant cell infiltration, with skip lesions

24. Pathogenesis Smoke contains carbon monoxide and nicotinic acid  Carboxyhaemoglobin Causes initially vasospasm and hyperplasia of intima  Thrombosis and so obliteration of vessels occur, commonly medium sized vessels are involved  Panarteritis is common Usually involvement is segmental

25. Pathogenesis Eventually artery, vein and nerve are together involved  Nerve involvement causes rest pain  Patient presents with features of ischaemia in the limb  Once blockage occurs, plenty of collaterals open up depending on the site of blockage either around knee joint or around buttock Once collaterals open up, through these collaterals, blood supply is maintained to the ischaemic area

26. Pathogenesis It is called as compensatory peripheral vascular disease  If patient continues to smoke, disease progresses into the collaterals, blocking them eventually, leading to severe ischaemia and is called as decompensatory peripheral vascular disease It is presently called as critical limb ischaemia It causes rest pain, ulceration, gangrene

27. Buerger’s Disease • There is vasospasm → intimal hyperplasia → thrombosis → panarteritis→ obliteration; tender, cord like veins with superficial migratory thrombophlebitis (30%); with nerve involvement due to vasa nervorum block/spasm. Arterial lumen is blocked but not thickened like atherosclerosis • In 10% disease is bilateral; 10% females may get the disease (but rare); 10% seen in upper limbs • Large arteries are not involved by TAO

28. I ndexes Smoking index (SI) = Number of cigarettes Number of years smoked per day of smoking SI > 300 is a risk factor Pack Years Index (PYI ) = Number of years Number of packets of of smoking cigarettes per day PYI > 40 is a risk factor

29. Shianoya’s criteria for Buerger’s disease Tobacco use. Only in males Disease starts before 45 years Distal extremity involved first without embolic or atherosclerotic features Absence of diabetes mellitus or hyperlipidaemia With or without thrombophlebitis

30. Classification of TAO Type I: Upper limb TAO—rare Type II: Involving leg/s and feet crural/infrapopliteal Type III: Femoropopliteal Type IV: Aortoiliofemoral Type V: Generalised

31. Clinical Features Common in male smokers between the 20-40 years of age group It is a smoker’s disease Intermittent claudication in foot and calf progressing to rest pain, ulceration, gangrene Recurrent migratory superficial thrombophlebitis Absence/Feeble pulses distal to proximal; dorsalis pedis, posterior tibial, popliteal, femoral arteries May present as Raynaud’s phenomenon

32. Investigations Hb% Blood sugar Arterial Doppler and Duplex scan (Doppler + B mode U/S)

33. Investigations Transfemoral retrograde angiogram through Seldinger technique Shows blockage—sites, extent, and severity Cork screw appearance of the vessel due to dilatation of vasa vasorum Inverted tree/spider leg collaterals Severe vasospasm causing corrugated/rippled artery Distal run off is amount of dye filling in the main vessel distal to the obstruction through collaterals If distal run off is good then ischaemia is compensated If distal run off is poor then ischaemia is decompensated

34. Investigations T ransbrachial angiogram (through left side brachial artery—left subclavian artery—and so to descending aorta) should be done Ultrasound abdomen to see abdominal aorta for block/ aneurysm Vein, artery, nerve biopsy

35. Treatment Stop smoking. “Opt for either cigarette or limb, but not both.”

36. Treatment Drugs: Pentoxiphylline increases the flexibility of RBC’s and helps them reach the microcirculation in a better way so as to increase the oxygenation Its efficacy is more in venous ulcer than arterial diseases

37. Treatment Low dose of aspirin 75 mg once a day—antithrombin activity Prostacyclins, ticlopidine, praxilene, carnitine Clopidogrel 75 mg; atorvastatin 10 mg; parvostatin 40 mg; cilostazole 100 mg bid—is a phosphodiesterase inhibitor which improves circulation (ideal drug). All drugs act at the collateral level than on the diseased vessel

38. Treatment Analgesics, often sedatives, antilipid drugs like atorvastatin may be needed However, graded injection of xanthine nocotinate 3000 mg from day 1 to 9000 mg on day 5 is often practiced to promote ulcer healing, helps to increase claudication distance as a temporary basis Low molecular dextran may be also used Naftidofuryl is useful in intermittent claudication; it alters the tissue metabolism.

39. Treatment Vasodilators and anticoagulants are of no use in TAO.

40. Treatment Care of the Limbs: Buerger’s position and exercise—regular graded exercises up to the point of claudication improves the collateral circulation In Buerger’s position, head end of bed is raised; foot end of bed is lowered to improve circulation In Buerger’s exercise leg is elevated and lowered alternatively, each for 2 minutes for several times at time

41. Treatment Care of feet (Chiropady): Exposure of feet to more cold and warm temperature should be avoided; trauma even minor like nail paring or pressure at pressure points in feet should be avoided Dryness of feet and legs should be avoided by applying oil to the feet and legs Footwea r should be selected carefully It is better to wear socks with footwear Heel raise by raising the heels of shoes by 2 cm decreases the calf muscle work to improve claudication.

42. Treatment Chemical Sympathectomy Sympathetic chain is blocked to achieve vasodilatation by injecting local anaesthetic agent (xylocaine 1%) paravertebrally beside bodies of L 2, 3 and 4 vertebrae in front of lumbar fascia, to achieve temporary benefit Long time efficacy can be achieved by using 5 ml phenol in water. It is done under C-Arm guidance Feet will become warm immediately after injection Problems are —possible risk of injecting phenol into IVC/aorta, spinal cord ischaemia.

43. Treatment Surgery: Omentoplasty to revascularise the affected limb Profundaplasty is done for blockage in profunda femoris artery so as to open more collaterals across the knee joint(It often makes better perfusion to the knee joint and flap of below-knee amputation) Lumbar sympathectomy to increase the cutaneous perfusion so as to promote ulcer healing But it may divert blood from muscles towards skin causing muscle more ischaemic

44. Treatment Amputations are done at different levels depending on site, severity and extent of vessel occlusion Usually either below-knee or above-knee amputations done Ilzarov method of bone lengthening helps in improving the rest pain and claudication by creating neo-osteogenesis and improving the overall blood supply to the limb

45. Treatment Gene Therapy Intramuscular injection of vascular endothelial growth factor (VEGF) which is an endothelial cell mitogen that promotes angiogenesis