CHRONIC LIMB ISCHEMIA

DR SHAKIR RAHMAN PGT SURGERY

Peripheral Arterial Occlusive Disorders

Involves narrowing of arterial lumens or
damage to the lining Blood flow can be partially obstructed or completely occluded Chronic disease differs from acute Found more in men over 50 yrs Legs most frequently affected

Risk Factors For Arterial Occlusive Disease

HTN Hyperlipidemia Diabetes Nicotine use Inflammation Autoimmune disorders Obesity Trauma

Classification
1. Aortoiliac occlusive disease 2. Femoropopliteal occlusive disease 3. Tibial-peroneal disease

Clinical Features

Intermittent claudication Rest pain Coldness, Numbness, Paraesthesia and colour changes Ulceration and gangrene Temperature as that of the suroundings Sensations decreased Movements lost or diminished Arterial pulsation decreased or absent Arterial Bruit Decreased Venous refilling

Relationship of clinical findings to site of disease

Aortoiliac Obstruction-------- Claudication in both buttocks, thighs and calves.
Femoral and distal pulses absent in both limbs. Bruit over the aortoiliac region. Impotence common (Leriche)

Ilial Obstruction

--------- Unilateral Claudication in thigh and calf and sometimes in buttock. Bruit over iliac region. Unilateral absence of femoral and distal pulses --------- Unilateral claudication in calf. Femoral pulse palpable with absent unilateral distal pulses. --------- Femoral and popliteal pulses papable

Femoropopliteal
Obstruction

Distal Obstruction

General Investigations

Blood CP with ESR PT,APTT,INR Urine RE LFTs RFTs ECG Echo CXR

Specific Investigations
Doppler Ultrasound Duplex Imaging Angiography MRA

Diagnostic Findings With Arterial Occlusive Disease

Decreased Ankle-Brachial Index (ABI)
0.50 to 0.95 indicates mild to moderate insufficiency. 0.25 or less severe
Ankle pressure = ABI (normally 1.0) Brachial pressure

Management of Chronic Arterial Occlusive Disease

Smoking cessation Exercise program Weight reduction

Medical Managment
Risk factors modification Co-morbid conditions (coronary artery disease or

CVA) Drugs 1. Statins 2. Antihypertensives such as beta blocker and ACE inhibitors 3. Aspirin 4. Clopidogrel

Preoperative care
Complete arterial evaluation Treat the underlying

cardiac,pulmonary,cerebrovascular and renal diseases Screening for carotid disease should be performed (H/O TIA and Stroke)

Surgical Treatment
(1) Aortoilial occlusive disease
a.

open surgical therapy

Aortobifemoral grafting

is the tratment of choice(in low risk pt) may be performed transperitoneal or retoperitoneal appoach distal endarterectomy may be performed to improve outflow b.Femorofemoral,ilioiliac,or iliofemoral bypasses are alternative in high risk patient with unilateral iliac disease

continued
c- Axillobifemoral bypass alternative for high risk patients avoids intra-abdominal procedure and no need for cross-clamping the aorta d- aortoiliac endarterectomy for patients who have disease localized to distal aorta and common iliac vessels

(2) Femoral,popliteal,and tibial occlusive disease a- Above knee occlusionan above knee femoral-popliteal bypass may be constructed b- Below knee occlusion.a distal bypass to the below knee popliteal,posterior tibial,anterior tibial or peroneal arteries may be constructed

Types of grafts
(1) Autologous graft
Great sephenous vein is the vein of choice,Lesser sephenous or arm veins can also be used can be used in situ or reversed

(2) Synthetic graft a-polytetrafluoroethylene(PTFE)grafts

PTFE grafts have a good patency rate above knee and there is a substantial decrease in patency rate below knee b-Dacron prosthetic material is favoured for aortoiliac segment

 Endarterectomy
may have a role in patients with limited vein availability or in the presence of an infected field

Amputation
Reserved for patients with gangrene or
LEVEL OF AMPUTATION
Is determined clinically
A general principle is to preserves as much length of the extremity as safely possible because it improves the patients opportunity for rehabilitation persistent painful ischemia not amenable to vascular reconstruction

continued
(1) DIGITAL AMPUTATION
done in diabetic patients who develop osteomylitis or severe foot infection

(2) TRANSMETATARSAL AMPUTATION done when several toes are involved in ischemic process or after previous singledigit amputation

(3) SYME AMPUTATION - involve the entire foot and calcaneus while preserving the entire tibia (4) BELOW KNEE AMPUTATION(BKA) -Most common type of amputation performed for patient with severe occlusive disease (5) ABOVE KNEE AMPUTATION(AKA) -Heals more easily than BKA useful in old patients who do not ambulate (6) HIP DISARTICULATION -Rarely performed

INTRAOPERATIVE ANTICOAGULATION

Unfractionated heparin(100 to 150

units/kg) is administered intravenously shortly before cross-clamping aorta and supplemented as necessary until the cross-clamps are removed

Post-operative care
Check pulses of affected extremity frequently Monitor pain, color, sensation, motor function,

capillary refill frequently Monitor for swelling Leg crossing and prolonged dependency of extremity is to be avoided Keep leg extended Hips flexion greater than 60 degrees should be avoided for first 72 hrs

POST-OPERATIVE ANTITHROBOTIC THERAPY

(1)ASPIRIN(75-325 mg/day) if sensitive to

Aspirin then Clopidogrel(75 mg/day) (2) Warfarin (INR 2-3) is given to patients who are at high risk for thrombosis (3)Dextran 40 (0.5ml/kg/hr i/v) is administered for up to 72 hrs postoperatively in high risk grafts

LONG TERM FOLLOW UP

For Distal bypass grafts
-Arterial Doppler examination every 3 months for the first 18 months,then every 6 months for a year,and then yearly -For Aortoiliac bypass grafts less frequent folllow up is necessary

COMPLICATION
Early complication frequently related to
preoperative comorbid disease such as MI,CCF,Pulmonary insufficiency,and renal insufficiency Early complications include hemorrhage,embolization or thrombosis of distal arterial tree,microembolization,ischemic colitis,ureteral injuries,impotence,paraplegia and wound infection

 Late complication include anastomotic

pseudoaneurysm or graft dilatation,graft limb occlusion,aortoenteric erosion or fistula,and graft infection

ENDOVASCULAR OPTIONS
Balloon angioplasty and intravascular stent
placement produce excellent results Indicated for symptomatic stenotic lesions Short-segment stenoses (<3 cm length)of the common iliac or external iliac artery display excellent long-term patency rates when treated with angioplasty alone or with stent placement

complications
Arterial wall dissection Vessel occlusion(either from thrombosis or
dissection) Arterial rupture Distal embolization