an insight into arterial disorders

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ARTERIAL DISORDERS AN INSIGHT

2. ANATOMY
• ARTERIES OF UPPER LIMB
• ARTERIES OF LOWER LIMB
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LAYERS OF ARTERY
• TUNICA ADVENTITIA
• TUNICA MEDIA
• TUNICA INTIMA

7. ARTERIAL PULSES
PULSE WHERE? AGAINST?
DORSALIS PEDIS LATERAL TO EXTENSOR
HALLUCIS LONGUS TENDON
AT PROXIMAL END OF FIRST
WEB SPACE.
NAVICULAR AND MIDDLE
CUNEIFORM BONES
POSTERIOR TIBIAL ARTERY BEHIND MEDIAL MALLEOLUS
MIDWAY BETWEEN IT AND
ACHILLES TENDON
CALCANEUM
ANTERIOR TIBIAL ARTERY LATERAL TO EXTENSOR
HALLUCIS LONGUS TENDON,
ABOVE THE ANKLE JOINT,
BETWEEN BOTH MALLEOLI
LOWER END OF TIBIA
POPLITEAL ARTERY LOWER PART OF POPLITEAL
FOSSA
FLAT POSTERIOR SURFACE OF
UPPER END OF TIBIA
FEMORAL ARTERY JUST BELOW INGUINAL
LIGAMENT MIDWAY
BETWEEN ASIS AND PUBIC
SYMPHYSIS
UPPER END OF FEMUR
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PULSE WHERE? AGAINST?
RADIAL ARTERY LATERAL ASPECT OF WRIST LOWER END OF FRONT OF
RADIUS
ULNAR ARTERY MEDIAL ASPECT OF WRIST LOWER END OF FRONT OF
ULNA
BRACHIAL ARTERY FRONT OF ELBOW MEDIAL TO
BICEPS TENDON
LOWER END OF HUMERUS
AXILLARY ARTERY APEX OF AXILLA SHAFT OF HUMERUS
SUBCLAVIAN ARTERY JUST ABOVE THE MIDDLE OF
CLAVICLE
FIRST RIB
COMMON CAROTID ARTERY MEDIAL TO
STERNOCLEIDOMASTOID
MUSCLE AT THE LEVEL OF
THYROID CARTILAGE
CAROTID TUBERCLE OF
TRANSVERSE PROCESS OF C6
CERVICAL VERTEBRA
FACIAL ARTERY INSERTION OF MASSETER BODY OF MANDIBLE
SUPERFICIAL TEMPORAL
ARTERY
FRONT OF TRAGUS OF EAR ZYGOMATIC BONE
ARTERIAL PULSES

9. CLINICAL TESTS
1. HARVEY’S SIGN – DELAYED VENOUS REFILLING
2. FUCHSIG’S TEST – POPLITEALARTERY STENOSIS
3. DISAPPEARING PULSE SYNDROME
4. BUERGER’S POSTURAL TEST – ANGLE <30 INDICATES SEVERE
ISCHAEMIA
5. ADSON’S TEST- CERVICAL RIB / SCALENUS ANTICUS
SYNDROME
6. EAST – THORACIC OUTLET SYNDROME
7. ALLEN’s TEST- RADIAL & ULNAR ARTERIES
8. FALCONER’S TEST- SUBCLAVIAN ARTERY
9. HYPERABDUCTION MANOEURVE
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10. CASE SCENARIO 1
A 40 year old male, comes to the Emergency Department at 6 am with
complaints of pain, inability to use both lower limbs since morning. On
examination, cold, loss of peripheral pulses and loss of penile
tumescence. Loss of sensation below the level of inguinal ligament. The
patient is a known smoker for past 15 years.
DIAGNOSIS?
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11. CASE SCENARIO 2
A previously healthy 40 year old woman comes to OPD with complaints
of 6 month history of shortness of breath. Patient complaints of pulsatile
tinnitus. She has reduced her running from 40min to 20 min at a slower
pace.
O/E
BP – 130/60mm Hg, Pulse -96/min, RR- 16/min
Peripheral pulses are bounding. Bruit heard over the upper part of neck.
ECG- left ventricular hypertrophy.
DIAGNOSIS?
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12. A 42 year old male comes to Emergency Department with
C/O
Acute onset of shearing pain radiating to back while straining for stools.
H/O chest Pain.
On Examination
Pulse
UL - bounding.
LL – weekly felt.
DIAGNOSIS?
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CASE SCENARIO 3

13. ARTERIAL DISORDERS
1. STENOSIS
2. DILATATIONS (ANEURYSMS)
3. ARTERITIS
4. SMALL VESSEL ABNORMALITIES
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14. ARTERIAL STENOSIS
INTERMITTENT CLAUDICATION
REST PAIN
LIMB ISCHEAMIA
PRE-GANGRENE
GANGRENE
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15. Boyd’s classification of Claudication
Grade I – pain after walking, if continued walking pain subsides.
Grade II – Pain still persists on continuing walking, but can walk with
effort.
Grade III – Takes rest to relieve pain.
CAUSES
1. Arterial
2. Neurogenic
3. Venous
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16. GANGRENE
1. Dry gangrene
2. Wet gangrene
3. Gas Gangrene
Organs in which gangrene may
develop – Appendix, Bowel, Gall
Bladder, Testis, Pancreas.
Specific types:
1. Diabetic Gangrene
2. Bedsores
3. Frostbite
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17. Ankle brachial pressure Index
Ratio of systolic pressure in ankle to systolic pressure in arm. Highest
value is taken.
Normal – 1.0
<0.9 – claudication
<0.5 – rest pain
<0.3 – imminent necrosis.
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18. THROMBOANGIITIS OBLITERANS
• Non-atherosclerotic
inflammatory disorder
• Medium sized, distal vessels
• Cell mediated sensitivity to T-I &
T-III collagen.
• Involvement of ARTERY, VEIN
and NERVE.
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19. Vasospasm
Intimal hyperplasia
Thrombosis
Panarteritis
Obliteration
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THROMBOANGIITIS OBLITERANS

20. THROMBOANGIITIS OBLITERANS
Smoking index
No of cigars/day x no of years
(>300 high risk )
Pack year index
no of years of smoking x no of cigar packets per day
( >40 HIGH RISK )
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21. TAKAYASU ARTERITIS
• Pulseless disease
• Involves aortic arch
• Incidence - 2.6 cases/million/year
• Features
• Upper limb claudication
• Absent pulses
• Thrill/bruit along major arteries
• Optic nerve atrophy
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22. RAYNAUD’S PHENOMENON
• Episodic vasospasm
• Primary and secondary types
• Raynauds syndrome
Local syncope
Local asphyxia
Local recovery
Local gangrene
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23. • Bilateral
• Females
• Recurrence
• Peripheral pulses felt
• Medial 4 digits involved; thumb is
spared.
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RAYNAUD’S PHENOMENON

24. C- calcinosis cutis
R- raynaud’s PHENOMENON
E- esophageal defects
S- sclerodactyly
T- telangiectasia
Vibration white finger
Collagen vascular diseases
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RAYNAUD’S PHENOMENON

25. Investigations
• Angiogram
• X-ray hand, anti-nuclear
antibody assay
• Segmental blood pressure
gradient
• Cold recovery time
• Routine investigations
Treatment
• Treat cause
• Avoid precipitants
• LOW DOSE ASPIRIN 75mg
• NIFEDIPINE 20mg
• Steroids
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RAYNAUD’S PHENOMENON

26. ANEURYSM
• Abnormal permanent dilatation of a localized segment
• True/false
• Fusiform / saccular / dissecting
• Etiology:
• Degenerative/ traumatic/infective/ collagen disease
• Berry aneurysm / congenital AV fistula
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ANEURYSM

28. • Clinical features
• Pulsatile swelling
• Smooth/warm/compressible/thrill/bruit
• Distal edema
• Altered sensation
• Embolus
Classification
I - infrarenal/suprarenal
II- asymptomatic / symptomatic/symptomatic ruptured
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ANEURYSM

29. Complications
Rupture, infection
Thrombosis, embolism
Distal ischaemia, gangrene
Fistula
Erosion of vertebra
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ANEURYSM

30. Rupture
1. Early diagnosis
2. Immediate resuscitation
3. Permissive hypotension
4. Urinary catheter
5. Cross match 6 units blood
6. Rapid transfer to operating room.
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ANEURYSM

31. Operative procedure for aneurysm
• Open surgical procedure
• Endovascular aneurysm repair
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ANEURYSM

32. ARTERIOVENOUS FISTULA
• Communication between artery and vein.
• Congenital / acquired
• Structural effect
• Physiological effect
Clinically:-
• Pulsatile swelling
• Thrill/ bruit
Investigations:
Duplex scan / angiography
Management - Embolisation
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33. CASE SCENARIO 1
A 40 year old male, comes to the Emergency Department at 6 am with
complaints of pain, inability to use both lower limbs since morning. On
examination, cold, loss of peripheral pulses and loss of penile
tumescence. Loss of sensation below the level of inguinal ligament. The
patient is a known smoker for past 15 years.
DIAGNOSIS?
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34. LERICHE SYNDROME
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35. CASE SCENARIO 2
A previously healthy 40 year old woman comes to OPD with complaints
of 6 month history of shortness of breath. Patient complaints of pulsatile
tinnitus. She has reduced her running from 40min to 20 min at a slower
pace.
O/E
BP – 130/60mm Hg, Pulse -96/min, RR- 16/min
Peripheral pulses are bounding. Bruit heard over the upper part of neck.
ECG- left ventricular hypertrophy.
DIAGNOSIS?
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36. ARTERIOVENOUS FISTULA
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37. A 42 year old male comes to Emergency Department with
C/O
Acute onset of shearing pain radiating to back while straining for stools.
H/O chest Pain.
On Examination
Pulse
UL - bounding.
LL – weekly felt.
DIAGNOSIS?
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CASE SCENARIO 3

38. DISSECTING AORTIC ANEURYSM
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39. REFERENCES
• BAILEY AND LOVE SHORT PRACTICE OF SURGERY 26TH
EDITION
• DAS -MANUAL OF CLINICAL SURGERY
• INTERNET FOR PICTURES.
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40. THANK YOU
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