SOURCE EMBOLI (mural thrombi ) FROM THE HEART : -LEFT ATRIUM -LEFT VENTRICLE -AORTIC VALVE -MITRAL VALVE

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1 ARTERIAL PERIPHERAL VASCULAR DISEASES ACUTE ARTERIAL OCCLUSION : SUDDEN INTERRUPTION OF THE BLOOD SUPPPLY RESULT IN A SPECTRUM OF SYMPTOMS AND SIGNS WHICH ARE DEPENDENT UPON THE LOCATION AND EXTENT OF THE OCCLUSION AND EXISTING COLLATERAL CIRCULATION. THE MAJOR CAUSES ARE : EMBOLISM,THROMBOSIS,AND INJURY IN THE ARM,THE HEART IS THE SOURCE OF EMBOLI IN 95 % OF THE PATIENTS. LESS COMMON CAUSES INCLUDE EMBOLI FROM ULCERATED PLAQUES IN THE SUB CLAVIAN ARTERY,ANEURYSM OF THE ARCH VESSELS AND PARADOXICAL EMBOLI VIA APATENT FORAMEN OVALE. IN THE LEG,THE HEART IS AGAIN THE MOST COMMON SOURCE EMBOLI BUT THEY MAY ALSO ARISE FROM ULCERATED PLAQUES AND ANEURYSMS OF THE THORACIC,ABDOMINAL,FEMORAL,POPLITEAL ARTERRIES. OVER HALF OF THE LARGE EMBOLI FROM THE HEART LODGE IN THE FEMORAL AND POPLITEAL ARTERIES. THE ILIAC ARTERIES ARE INVOLVED IN APPROXIMATELY ONE-FIFTH THE ABDOMINAL AORTA IN ONE SIXTH

2 ARTERIAL PERIPHERAL VASCULAR DISEASES SOURCE EMBOLI (mural thrombi ) FROM THE HEART : -LEFT ATRIUM -LEFT VENTRICLE -AORTIC VALVE -MITRAL VALVE MURAL THROMBI ARISE SEQONDARY : - ATRIAL FIBRILATION -MYOCARDIAL INFARCTION - AORTIC AND MITRAL PROSTHETIC VALVE ARTERIAL THROMBOSIS OCCURS SEQONDARY TO INJURY,ARTERIOSCLEROSIS OBLITERANS,FEMORAL AND POPLITEAL ANEURYSM,COLLAGEN VASCULAR DISEASES,MYELOPROLIFERATIVE DISORDERS,DIC,DYSPROTEINEMIAS.

3 SYMTOMS AND SIGN RELATED TO THE SITE OF INVOLVEMENT AND IMMEDIATELY AVAILABLE COOLATERAL CIRCULATION IF THE PRESSURE DISTAL TO OBSTRUCTION FALLS TO BELOW 40 mmhg, THE CLINICAL PICTURE WILL BE DRAMATIC. THE INITIAL COMPLAINT IS PAIN IS THE MOST DISTAL PART OF THE LIMB PALLOR COLDNESS SENSATION OF NUMBNESS,CUTANEUS SENSATION IS LOST WITHIN THE FIRST HOUR WITHIN 6 HOUR ISCHAEMIC MUSCULAR CONTRACTURE DEVELOPS ASSOCIATED WITH SUB CUTANEUS HEMORRHAGE AND FOCAL AREA OF GANGREN FIXED STAINING OF THE SKIN IS THE MOST CERTAIN SIGN OF IRREVERSIBLE TISSUE DEATH.

4 DIAGNOSIS HISTORY OF THE SUDDEN ONSET OF PAIN,COLDNES,NUMBNESS DETECTION OF A BRUIT IS COMMON WHEN AN ARTERIAL PLAQUE OR ANEURYSM IS THE SOURCE OF THE EMBOLUS. HISTORY OF INTERMITTEN CLAUDICATION ISCHEMIC REST PAIN OF THE FEET IF THE SOURCE OF EMBOLI ORIGINATE FROM THE THORASIC AORTA,ABDOMINAL PAIN AND HEMATURIA MAY ALSO OCCUR THE DIAGNOSIS MAYBE SUSPECTED BY PHYSICAL EXAMINATION AND VERIFIED BY B MODE ULTRA SOUND ARTERIOGRAPHY

5 TREATMENT IMMEDIATE OPERATION IS REQUIRED FOR OCCLUSION OF THE MAJOR ARTERIES. HEPARIN SHOULD BE GIVEN IMMEDIATELY THE OCCLUSION MAY USUALLY BEREMOVED UNDER LOCAL ANESTHESIA,BUT IN SOME INSTANCES IT MAYBE NECESSARY TO BYPASS THE OBSTRUCTED AREA. STREPTOKINASE OR UROKINASE LOW DOSES DIRECTLY INTO THE THROMBOSIS VIA AN ARTERIAL CATHETER TRANSLUMINAL ANGIOPLASTY,OR OR BY PASS GRAFTING AFTER LYSIS OF THE THROMBUS. IF THE CAUSE OF THE PROBLEM IS EMBOLIC LONGTERM ANTICOAGULATION WITH WARFARIN OR COUMADIN SHOULD BE EMPLOYED MICRO EMBOLI SHOULD BE EXPECTANTLY WITH ASPIRIN

6 ARTERIOSCLEROSIS OBLITERANS THE PRIMARY LESION OF ATERIOSCLEROSIS IN THE INTIMAL PALQUE,WICH PROGRESSIVELY NARROWS AND MANY INSTANCES,LEAD TO COMPLETE OCCLUSION OF THE LARGE AND MEDIUM SIZED ARTERIES. INCIDENCE : AORTA ABDOMINAL,ILIAC ARTERIES,POPLITEAL ARTERIES,POSTERIOR TIBIAL ARTERIES,ANTERIOR TIBIAL ARTERIES,

7 CLINICAL FEATURES INTERMITTEN CLAUDICATION : THE PAIN THAT OCCURS IN A MUSCLE WITH INADEQUATE BLOOD SUPPLY THAT IS STRESSED BY EXERCISE. DISCOMFORT AS ACRAMP WITH DISAPPEARS WITHIN 1 OR 2 MIN AFTER THE STOPING THE EXERCISE PARASTHESIA NUMBNESS GANGRENE OF THE TOES AND DISTAL FOOT WHEN THE DISEASES REACHES THIS ADVANCED STAGE ULCERS TROPHIC NAIL CHANGES THE LOSS OF PULSES DISTAL TO THE MOST PROXIMAL LEVEL OF THE DISEASES BRUITS

8 DIAGNOSTIC ASSESSED SIMPLY BY MEASURING THE ANKLE SYSTOLIC BLOOD PRESURE AT REST AND FOLLOWING EXERCISE TO THE POINT OF CLAUDICATION. PLETHYSMOGRAPH ULTRASONIC VELOCITY DETECTOR IN GENERAL,IF THE SYSTOLIC RESSURE AT THE ANKLE IS GREATER THAN ONE HALF THAT RECORDER FROM THE ARM,OCCLUSION ONE SEGMEN IS MOST LIKELY. ANKLE PRESSURE LESS THAN ONE HALF OF THE ARM SYSTOLIC PRESSURE ARE MOST OFTEN OBSERVED WITH MULTIPLE LEVEL OF DISEASE. ARTERIOGRAPHY ULTRASONIC DUPLEX SCANNING

9 THERAPHY MILD AND MODERATE INTERMITENT CLAUDICATION MAY BENEFIT FROM A RIGOUS,DAILY EXERCISE TRAINING PROGRAM PENTOXYFILLINE WEIGHT REDUCTION STOP SMOKING DIRECT ARTERIAL SURGERY TRANSLUMINAL ANGIOPLASTY

10 THROMBOANGITIS OBLITERANS ( BUERGER S DISEASE ) NON ATHEROMATOUS LESION INVOLVING ARTERIES,VEIN,NERVES NERVES OCCURING IN YOUNG MALES AND FREQUENTLY LEADING TO NON HEALING ULCERS AND GANGRENE THE EXACT PATHOGENESIS IS OBSCURE RELATIONSHIP WITH TOBACO SMOKING AND CHEWING ABNORMAL CELLULER AND HUMORAL IMMUNE RESPONSES TO TYPE I AND III COLLAGEN SMALL ARTERIES OF THE HAND AND FEET INTENSE INFLAMMATORY COMPONENT,FIBROUS ENCASEMENT OF THE ENTERIC NEURO VASCULAR BUNDLE

11 Clinical features SUSPECT THE DIAGNOSIS MALE PATIENT YEARS AGE HISTORY : SUPERFICIAL MIGRATORY PHLEBELITIS COLD SENSITIVITY TRIPHASIC COLOURS RESPONS INSTEP CLAUDICATION