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Seminar PVD Y5B2
Seminar PVD Y5B2
DISEASE:
ARTERIAL & VENOUS DISEASE
SUPERVISOR : ASST. PROF DR AHMAD FAIDZAL OTHMAN
Peripheral arterial disease
DEFINITION
A sudden decrease in limb perfusion that threatens limb viability which occurs within 14 days after symptom onset
CLINICAL FEATURES
6 P : Pain (sudden onset), Pulselessness, Perishing cold, Pallor, Paraesthesia (nerve ischaemia), Paralysis (muscle ischaemia)
Symptoms Signs
Pain - sudden onset and continuous, usually in one Limb appearance : pallor or bluish discoloration,
periphery mottled skin (fixed vs blanching), skin blistering
Temperature : cold
Perishing cold - sudden onset and continuous,
Pulses (via palpation and confirm with Doppler) :
usually in one periphery absent
Paraesthesia or numbness - sudden onset, usually in Sensation loss
one periphery Progressive paralysis and foot drop
ETIOLOGY
Thrombosis
Trauma
INVESTIGATION
IMMEDIATE
1. Early anticoagulation with IV Heparin 5000 U bolus followed by IV Heparin infusion at 1000U/hour -to prevent
propagation of thrombus proximal and distal to occlusion
2. Improve existing perfusion : keep foot dependent, avoid heel pressure, 100% oxygen supplementation, correct hypotension
3. Revascularization - surgical or endovascular
Embolectomy Thrombolysis
Thrombectomy Angioplasty
Bypass grafting Stenting
Fasciotomy (in profoundly ischaemic limb to prevent
compartment syndrome) *risk of severe complications such as stroke and bleeding within
Amputation 30 days of treatment
*Currently, hybrid intervention is being practiced whereby endovascular surgery under intraoperative angiography is being simultaneously
performed following surgical thromboembolectomy.
Chronic limb ischemia
Defined as:
(1) recurrent foot pain at rest that requires regular use of analgesics with
ankle systolic pressure <50mmHg or toe systolic pressure <30mmHg
(2) a nonhealing wound or gangrene of the foot or toes,
Physical findings
CT Angiography, MR
Angiography
Management of CLTI
- Lifelong follow-up
- Rehabilitation
- Nutritional status
- Patency of bypass graft after revascularization
- Close follow-up of coronary artery and cerebrovascular disease
Reperfusion Injury
- Reperfusion exacerbating the cellular damage already
caused by ischemia
- Can present as
- Acute heart failure
- Cerebral dysfunction
- SIRS
- Multi-organ failure
- Can be attenuated by reducing the extent and duration of
tissue hypoperfusion
Aneurysm
Dilatation of all three layers of vessel Dilatation artery not involving all 3 layers
(intima, media, adventitia ) Eg: collection of blood or hematoma that
has leaked out of the artery but is then
confined by the surrounding tissue.
Abdominal aortic aneurysm
● The most common type of large vessel aneurysm and is found
in 2% of the population at autopsy
● Small (3cm to 4.4cm across)
Risk factor
- Hypertension
- Hyperlipidemia
- COPD
- Family history of AAA
- Cardiovascular disease or history of stroke
- smoking
Principle of management
INDICATIONS OF AAA SURGERY INVESTIGATIONS
- Periodic monitoring ultrasonography
• Size of aneurysms of 5-5.5 cm diameter or more - CT scan ( elective operation is planned)
• Aneurysm expand more than 0.5 cm per year
1. Typically presented with palpable pulsatile abdominal mass with pain and
has transient collapse (hypotension)
2.If happened to rupture in the vena cava, there will be large arteriovenous
fistulae. Symptoms include tachycardia, congestive heart failure (CHF), leg
swelling, abdominal thrill, machinery-type abdominal bruit, renal failure, and
peripheral ischemia.
3. if rupture into the fourth portion of the duodenum- patient will present with
symptoms of UGIB & massive haemorrhage
Management
DVT
PE
● CTPA
● D-dimers test (-ve predictive value)
VTE - Prophylaxis
MECHANICAL PHARMACOLOGICAL
1. Start LMWH (enoxaparin or tinzaparin) or fondaparinux as soon as possible and continue for at least 5
days or until the INR is 2 or above for 2 consecutive days
● Enoxaparin dose is 1 mg/kg twice daily
● Tinzaparin dose is 175 IU/kg once daily
● Fondaparinux dose is 7.5 mg daily
2. Start warfarin at 5 mg daily within 24 hours of diagnosis and continue for 3 months
3. For severe renal impairment: Intravenous unfractionated heparin with dose adjustment based on APTT
4. For patients with PE and haemodynamic instability: offer IV UFH and consider thrombolytic therapy
5. Rivaroxaban: 15 mg twice daily for the first 21 days followed by 20 mg once daily for continued treatment
and prevention of recurrence
VTE - Thrombolytic Mx Mechanical Intervention
1. DVT 1. Compression Stocking
● Venous thrombectomy
● Thrombolytic therapy: Catheter
directed thrombolysis
2. PE 2. Vena cava filters
● Thrombolytic therapy a. To prevent PE secondary to DVT
● Pulmonary embolectomy b. Small device to stop blood clots
○ Emergency procedure from going to the lungs
following failed conservative
c. INdication:
measures
○ Recently, percutaneous i. When pt is contraindicated
catheter directed for anticoagulants
embolectomy devices had ii. When pt have large free
been developed floating iliocaval thrombus
1. Colour duplex
Gold Standard
3. Contrast Venography
5. MR Venography
Suspect congenital vascular
malformation- assess extent of lesion
and arterial component.
MANAGEMENT
Etiology
Secondary : due to DVT which triggers an inflammatory response subsequently injuring the vein
wall.
Investigation
Management
Location area between the lower Pressure points, toes Plantar aspect of
calf and the medial and feet, lateral foot, tip of the toe,
malleolus malleolus, and tibial lateral to fifth
areas metatarsal
Ulcer
characteristic
shallow and flag margin, Punched out and deep, Deep, surrounded by
moderate-to-heavy exudate, irregular shape, callus, insensate
slough at base with unhealthy wound bed,
granulation tissue presence of necrotic
tissue, minimal exudate,
unless infected