ACUTE ARTERIAL OCCLUSION

• Usually caused by an embolus.

• May also happen when thrombosis occurs on

an atherosclerotic plaque.

• Trauma.
 Embolic occlusion
• An embolus is a body that is foreign to the bloodstream and
which may become lodged in a vessel and cause
obstruction.
• Often a thrombus that has become detached from the
heart or a more proximal vessel.
• Sources ;
 left atrium in atrial fibrillation,
 left ventricular mural thrombus following myocardial
infarction;
 vegetations on heart valves in infective endocarditis,
 thrombi in aneurysms and on atheroscerotic plaques.
Arm and leg: (5Ps)
• Pain
• Pallor
• Paralysis
• Pulselessness
• Paraesthesia

 Differs from occlusion due to thrombosis on

preexisting atheroma.
• Brain. The middle cerebral artery (or its
branches) is mostcommonly affected, resulting
in major or minor (TIA) stroke.
• Retina- Amaurosis fugax is fleeting blindness
caused by a minute thrombus emanating from
an atheromatous plaque in the carotid artery
passing into the central retinal artery. Lasting
obstruction causes permanent blindness.
• Mesenteric vessels- Gangrene of the
correspondingloop of intestine.
• Limb vessels- Acute limb ischemia.
 Acute limb ischaemia
 Emergency that requires immediate treatment.
 Ischaemia beyond 6 hours is usually irreversible and
results in limb loss.
 The limb is cold and the toes cannot be moved (v/s
venous occlusion when muscle function is not affected)
 no history of claudication,
 has a source of emboli,
 suddenly develops severe pain or numbness of the
limb, which becomes cold and mottled.
 5Ps
• Treatment
• The immediate administration of 5000 U of
heparin intravenously can reduce extension
and maintain patency of the surrounding.
• The relief of pain is essential.
• Embolectomy and thrombolysis
Embolectomy
• Local or general anaesthesia.
• The artery (usually the femoral), bulging with clot,
is exposed.
• longitudinal or transverse incision.
• Clot is removed with help of Fogarty balloon
catheter.
• An angiogram may be performed in the operating
theatre at the end.
• Postoperatively, heparin therapy is continued.
• long-term anticoagulation with warfarin
Compartment syndrome
• Sudden ischaemia followed by
revascularisation.
• Muscles swell within fixed fascial
compartments.
• Ischaemia.
• Renal failure secondary to the liberation of
muscle breakdown products.
• The treatment is urgent fasciotomy to release
the compression.
• Intra-arterial thrombolysis
• If ischaemia is not so severe.
• usually via the common femoral artery.
• Tissue plasminogen activator (TPA) is infused
through the catheter.
• Regular arteriograms are taken.
• Contraindications-recent stroke, bleeding
diathesis and pregnancy,
• Acute mesenteric ischaemia
• Thrombotic (following atheromatous narrowing)
or embolic.
• severe abdominal pain, with bowel emptying
(vomiting and diarrhoea)
• Diagnosis is often only made at laparotomy with
widespread infarction.
• resection of the dead bowel and embolectomy of
the superior mesenteric artery, or bypass surgery
• Other forms of emboli
• Infective emboli-bacteria or an infected clot -
mycotic aneurysms, septicaemia or infected
infarcts.
• Parasitic emboli
• Tumour cells.
• Fat embolism - major bony fractures.
• Air embolism -IV catheters, head and neck
surgery or a cut throat,Fallopian tube
insufflation orillegal abortion,
• Air embolism –
• IV catheters, head and neck surgery or a cut
throat,Fallopian tube insufflation orillegal abortion,
• Treatment
• Put the patient in a headdown (Trendelenburg)
position.
• The patient should also be placed on the left side
• In extreme cases- air may be aspirated from the
heart
 THROMBOANGIITIS OBLITERANS (TAO)or
Buerger’s Disease
• commonly seen in young and middle aged males
• seen only in smokers and tobacco users
• Almost always starts in lower limb, may start on one
side and later on the other side. Upper limb
involvement occurs only after lower limb is diseased.
Only upper limb involvemnt can occur (not
uncommon) but it is rare.
• It is nonatherosclerotic inflammatory disorder
involving medium sized and distal vessels with cell
mediated sensitivity to type I and type III collagen.
• 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.
 Pathology
• 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
 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.
 Investigations
• Hb%. Blood sugar.
• Arterial Doppler and Duplex scan (Doppler + B
mode U/S).
• Transfemoral retrograde angiogram through
Seldinger technique
• Transbrachial angiogram
• Ultrasound abdomen to see abdominal aorta for
block/aneurysm.
• Vein, artery, nerve biopsy
 Treatment
• Stop smoking.
• Drugs
• Pentoxiphylline increases the flexibility of RBC’s and helps
them reach the microcirculation in a
• 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).
• Analgesics, often sedatives, antilipid drugs better way.
• Care of the Limbs
• Buerger’s position and exercise
• Care of feet

• Chemical Sympathectomy
• Surgery
• Omentoplasty to revascularise the affected
limb.
• Lumbar sympathectomy to increase the
cutaneous perfusion
• so as to promote ulcer healing.
• Amputations are done at different levels
depending on site, severity and extent of vessel
occlusion.
 RAYNAUD’S PHENOMENON
• It is an episodic vasospasm, i.e. arteriolar spasm. It
leads to sequence of clinical features called as
Raynaud’s syndrome.
• Raynaud’s syndrome
• Sequence of clinical features due to arteriolar spasm.
• ™Local syncope
• ™Local asphyxia
• Local recovery
• Local gangrene
 Causes
• Raynaud’s disease:
• It is seen in females, usually bilateral.
• It occurs in upper limb with normal peripheral pulses.
• It is due to upper limb (hand) arteriolar spasm as a
result of abnormal sensitivity to cold. Patient develops
blanching, cyanosis and later flushing as in Raynaud’s
syndrome. Occasionally, if spasm persists it results in
gangrene.
• Symptoms can be precipitated and observed by placing
hands in cold water.
• Working with vibrating tools
• Collagen vascular diseases: Like scleroderma,
rheumatoid diseases causing vasculitis (all
autoimmune diseases).
• Other causes: Cervical rib, Buerger’s disease,
Scalene syndrome.
• It is often associated with CREST syndrome
(Calcinosis cutis, Raynaud’s phenomenon,
Esophageal defects, Sclerodactyly, Telangiectasia).
 Features (of Raynaud’s disease)
• Commonly bilateral.
• Common in young females.
• Raynaud’s disease is common in western white women.
• Usually medial four digits and palm are involved. Thumb is
spared.
• Features of pallor/blanching (syncope), dusky cyanosis (asphyxia),
rubor/painful red engorgement (recovery) are the presentation.
• Occasionally, if vasospasm becomes longer, gangrene or
ischaemic ulceration supervenes along the tips of the fingers.
• Peripheral pulses (radial/ulnar) are normally felt. These pulses will
be absent in upper limb TAO.
• Repeated attacks are common.
 Investigation
• Type is identified by angiogram of hand
(DSA/MR angiogram), arterial Doppler/Duplex
scan.
• Other investigations required are X-ray of the
part, antinuclear antibody (ANA assay)
• Other routine investigations for arterial
diseases like blood sugar/ lipid
profile/hypercoagulability status.
 Treatment
• Treat the cause.
• Avoid precipitating factors—protect from cold/proper dress/ hand
warmer electrical or chemical/hand gloves.
• Avoid smoking even though it is not direct etiological cause (other than
upper limb TAO), but it may possibly aggravate the disease. Avoid
vibrating tools.
• Vasodilators/pentoxiphylline/low dose aspirin (75–100 mg per/day).
Calcium antagonist (nifedipine 20 mg)is useful. Steroids may be useful.
• ACE inhibitors, nitrates,
• Antiplatelet drug
• Misoprostol
• Cervical sympathectomy—is used for nonhealing digital ulceration. Not
very beneficial to Raynaud’s syndrome.
Thank you