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Surgery.(General 2).Vascular > Arterial.5.chronic ischemia (Investigations and treatment) > Flashcards

Arterial.5.chronic ischemia (Investigations and treatment) Flashcards

1
Q

Investigation of chronic L.L ischaemia

A
  • Laboratory

* Radiological

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2
Q

Laboratory Investigation of chronic L.L ischaemia

A
  • Blood picture to detect anaemia or polycythaemia.
  • Blood sugar.
  • Serum cholesterol & triglycerides
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3
Q

Radiological Investigation of chronic L.L ischaemia

A
  1. Doppler
  2. Arterial duplex
  3. Arteriography
  4. Digital subtraction arteriography (DSA)
  5. Magnetic resonance angiography “MRA”
  6. Echocardiography & ECG.
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4
Q

Doppler in Radiological Investigation of chronic L.L ischaemia

A
  • Advantages
  • Normal finding
  • Abnormal finding
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5
Q

Advantages of Doppler in Radiological Investigation of chronic L.L ischaemia

A
  • To detect blood flow along an artery in which the pulse may be palpable or impalpable.
  • Measurement of A/B index
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6
Q

Measurement of A/B index in Advantages of Doppler in Radiological Investigation of chronic L.L ischaemia

A
  • Definition of A/B index
  • Normal Finding
  • Abnormal Finding
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7
Q

Definition of A/B index in Measurement of A/B index in Advantages of Doppler in Radiological Investigation of chronic L.L ischaemia

A

It’s the ratio of Ankle systolic blood pressure over the brachial systolic blood pressure

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8
Q

Normal Finding in Measurement of A/B index in Advantages of Doppler in Radiological Investigation of chronic L.L ischaemia

A

normal A/B index is 1.2

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9
Q

Abnormal Finding in Measurement of A/B index in Advantages of Doppler in Radiological Investigation of chronic L.L ischaemia

A
  • Severe atherosclerotic rigid vessels which cannot be compressed
  • Chronic ischaemia
  • Critical ischaemia
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10
Q

Severe atherosclerotic rigid vessels in Abnormal Finding in Measurement of A/B index in Advantages of Doppler in Radiological Investigation of chronic L.L ischaemia

A

A/B index > 1.3

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11
Q

Chronic ischaemia in Abnormal Finding in Measurement of A/B index in Advantages of Doppler in Radiological Investigation of chronic L.L ischaemia

A

A/B index < 1

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12
Q

Critical ischaemia in Abnormal Finding in Measurement of A/B index in Advantages of Doppler in Radiological Investigation of chronic L.L ischaemia

A

A/B index < 0.5

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13
Q

Normal finding in Doppler in Radiological Investigation of chronic L.L ischaemia

A

Normal sonogram consists of 3 sounds (triphasic)

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14
Q

Abnormal finding in Doppler in Radiological Investigation of chronic L.L ischaemia

A

In ischaemia the sonogram is monophasic.

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15
Q

Arteriography in Radiological Investigation of chronic L.L ischaemia

A
  • Indication
  • Advantages
  • The different techniques
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16
Q

Indication of Arteriography in Radiological Investigation of chronic L.L ischaemia

A

This invasive procedure is only performed if ischemia is severe enough to raise the need for revascularization procedures.

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17
Q

Advantages of Arteriography in Radiological Investigation of chronic L.L ischaemia

A

Provides the following information

1- Exact site and length of arterial block

2- state of the artery distal to the block (run off)

3- the collateral circulation

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18
Q

The different techniques of Arteriography in Radiological Investigation of chronic L.L ischaemia

A
  1. Direct femoral arteriography.
  2. Aortography :
  • Transfemoral aortography.
  • Translumbar aortography.
  • Transaxillary aortography.
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19
Q

Magnetic resonance angiography “MRA” in Radiological Investigation of chronic L.L ischaemia

A
  • Advantages

* Disadvantage

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20
Q

Advantages of Magnetic resonance angiography “MRA” in Radiological Investigation of chronic L.L ischaemia

A
  • Non invasive.

* suitable for renal failure

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21
Q

Disadvantage of Magnetic resonance angiography “MRA” in Radiological Investigation of chronic L.L ischaemia

A
  • Less accurate than interventional angiography

* expensive and not therapeutic

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22
Q

Lines of treatment of chronic L.L ischaemia

A
  1. Conservative treatment
  2. Endovascular surgery
  3. Open surgery
  4. Lumbar sympathectomy
  5. Amputation
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23
Q

Conservative treatment in Lines of treatment of chronic L.L ischaemia

A
  • Indications

* List

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24
Q

Indications of Conservative treatment in Lines of treatment of chronic L.L ischaemia

A

Grades I & IIa ischemia

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25
Q

List of Conservative treatment in Lines of treatment of chronic L.L ischaemia

A
  1. Mild exercises not causing pain “as regular walking for 1/2 to 1 hr/day
  2. Complete abstinence from smoking.
  3. Correction of anaemia as this helps tissue oxygenation.
  4. D.M, HTN and hyperlipidaemia should be corrected.
  5. Care of the feet
  6. Medications
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26
Q

the reason why Mild exercises not causing pain in conservative treatment of chronic ischemiaare useful

A

they help to open the collateral circulation & improve claudication distance

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27
Q

Care of the feet in List of Conservative treatment in Lines of treatment of chronic L.L ischaemia

A
  • The reason why It’s important

* Procedures

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28
Q

The reason why It’s important in Care of the feet in List of Conservative treatment in Lines of treatment of chronic L.L ischaemia

A

as a patient with chronic ischemia has a compromised circulation and any minor injury to the foot can precipitate gangrene

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29
Q

Procedures of Care of the feet in List of Conservative treatment in Lines of treatment of chronic L.L ischaemia

A
  • Clean the feet daily and keep them dry
  • Avoid feet trauma, e.g: during nail trimming.
  • The patient should not walk bare-footed.
  • Any interdigital fungal infection should be treated
  • In winter he should wear woolen socks to avoid cold injury.
  • The patient should not apply external heat.
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30
Q

Medications in List of Conservative treatment in Lines of treatment of chronic L.L ischaemia

A

a. Dipyridamole (persantin) & clopidogrel
b. Baby aspirin :
c. Pentoxifylline
* vasodilators have no role in atherosclerotic vessels

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31
Q

Dipyridamole & clopidogrel in Medications in List of Conservative treatment in Lines of treatment of chronic L.L ischaemia

A
  • Trade name of Dipyridamole

* Mechanism of action

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32
Q

Trade name of Dipyridamole in Medications in List of Conservative treatment in Lines of treatment of chronic L.L ischaemia

A

persantin

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33
Q

Mechanism of action of Dipyridamole & clopidogrel in Medications in List of Conservative treatment in Lines of treatment of chronic L.L ischaemia

A

Prevents platelets aggregation.

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34
Q

Baby aspirin in Medications in List of Conservative treatment in Lines of treatment of chronic L.L ischaemia

A
  • Dose

* Mechanism of action

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35
Q

Dose of Baby aspirin in Medications in List of Conservative treatment in Lines of treatment of chronic L.L ischaemia

A

150 mg/day

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36
Q

Mechanism of action of Baby aspirin in Medications in List of Conservative treatment in Lines of treatment of chronic L.L ischaemia

A

Prevents platelet adhesiveness.

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37
Q

Pentoxifylline in Medications in List of Conservative treatment in Lines of treatment of chronic L.L ischaemia

A
  • Trade name

* Mechanism of action

38
Q

Trade name of Pentoxifylline in Medications in List of Conservative treatment in Lines of treatment of chronic L.L ischaemia

39
Q

Mechanism of action of Pentoxifylline in Medications in List of Conservative treatment in Lines of treatment of chronic L.L ischaemia

A
  • Improves RBCs deformability

* allowing them to negotiate their way through narrowed small vessels.

40
Q

indications for intervention in chronic ischemia

A
  1. Critical ischaemia :
    As denoted by rest pain, ischaemic ulcers or minor gangrene.
  2. Severe incapacitating claudication :
    That interferes with the patient’s work and style of life
41
Q

limbsalvage surgery.

A

Surgery in a case of critical ischemia aiming at saving the limb

42
Q

what to do with A patient with a limited dry gangrene of a toe

A

can be investigated to check if reconstructive vascular surgery can be performed.

43
Q

Endovascular surgery in Lines of treatment of chronic L.L ischaemia

A
  • Indications

* Modalities

44
Q

Indications of Endovascular surgery in Lines of treatment of chronic L.L ischaemia

A
  • Localized segment stricture in large or medium sized artery
  • Localized ( < 2 cm)
  • Large medium sized ( aorta ~~ superficial femoral)
45
Q

Modalities of Endovascular surgery in Lines of treatment of chronic L.L ischaemia

A
  1. Percutaneous transluminal angioplasty (PTA)

2. Intravascular stents :

46
Q

Percutaneous transluminal angioplasty (PTA) in Modalities of Endovascular surgery in Lines of treatment of chronic L.L ischaemia

A
  • Procedures
  • Success rate
  • Complications
47
Q

Procedures of Percutaneous transluminal angioplasty (PTA) in Modalities of Endovascular surgery in Lines of treatment of chronic L.L ischaemia

A
  • A special balloon catheter is introduced percutaneously along a guide wire until it lodges in the stenotic segment
  • The balloon is then inflated and kept for about one minute to dilate the stenosed segment
48
Q

Success rate of Percutaneous transluminal angioplasty (PTA) in Modalities of Endovascular surgery in Lines of treatment of chronic L.L ischaemia

A

Success rate is about 95%

49
Q

Complications of Percutaneous transluminal angioplasty (PTA) in Modalities of Endovascular surgery in Lines of treatment of chronic L.L ischaemia

A
  1. Hematoma
  2. A-V fistula
  3. Restenosis
50
Q

Procedures of Intravascular stents in Modalities of Endovascular surgery in Lines of treatment of chronic L.L ischaemia

A

After balloon angioplasty a stent can be inserted to prevent the elastic recoil of the arterial wall and keep the lumen patent.

51
Q

Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A
  1. By-pass surgery :

2. Thromboendarterectomy

52
Q

By-pass surgery in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A
  • The idea

* Modalities

53
Q

The idea of By-pass surgery in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A

The idea is to bypass the obstruction by inserting a graft from the healthy artery above to another healthy artery below the obstruction

54
Q

Modalities of By-pass surgery in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A
  • Anatomical By-pass surgery

* Extra-anatomical By-pass surgery

55
Q

Anatomical By-pass surgery in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A
  1. Aorto-bifemoral bypass surgery is done using dacron or Gortex
  2. Femoro-popliteal bypass using the saphenous vein (best) or Gortex graft
  3. Femoro-distal bypass using the long saphenous vein in site or Gortex graft
56
Q

Indication of Aorto-bifemoral bypass surgery is done using dacron or Gortex in Anatomical By-pass surgery in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A

For aorto-iliac disease

57
Q

Indication of Femoro-popliteal bypass using the saphenous vein (best) or Gortex graft in Anatomical By-pass surgery in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A

For superficial femoral artery block

58
Q

Indication of Femoro-distal bypass using the long saphenous vein in site or Gortex graft in Anatomical By-pass surgery in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A

For occlusive disease below popliteal artery

59
Q

Anatomical by-pass surgery for treatment of aorto-iliac disease

A

Aorto-bifemoral bypass surgery is done using dacron or Gortex

60
Q

Anatomical by-pass surgery for treatment of superficial femoral artery block

A

femoro-popliteal bypass using the saphenous vein (best) or Gortex

61
Q

Anatomical by-pass surgery for treatment of occlusive disease below popliteal artery:

A

Femoro-distal bypass using the long saphenous vein in site or Gortex graft

62
Q

Advantages of dacron graft

A

Easy to be handled at time of operation.

63
Q

Disadvantages of dacron graft

A

It is a knitted (wide bores) graft & thus needs to be pre-clotted to avoid massive hemorrhage when blood flow is established.

Liable for degeneration & aneurysmal dilatation.

Recently dacron grafts are woven OR coated with albumin or collagen eliminating the need for pre-clotting but increasing the cost of the graft.

64
Q

Alternative name for Gortex graft

A

polytetraflourethylene “PTFE”

65
Q

Advantages of Gortex graft

A

It is a woven (narrow bores) graft & thus does not need pre-clotting.

Not liable for aneurysmal dilatation

66
Q

The saphenous vein has valves that allow blood is flow from belowupwards only.

To overcome this problem one of two techniques are used :

A
  • Reversed saphenous venous graft

* In situ saphenous venous graft with valvotomy

67
Q

Mechanism of Reversed saphenous venous graft

A

A segment of the long saphenous vein is harvested and reversed so that the valves do not interfere with blood flow.

68
Q

Mechanism of in situ saphenous venous graft with valvotomy

A

The upper and the lower ends of a suitable segment of the long saphenous are used for anastomosis while the vein is left in situ.

The valves are destroyed by a valvulotome, and the vein tributaries are ligated.

69
Q

Extra-anatomical by-pass in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A
  • Indications

* Modalities

70
Q

Indications of Extra-anatomical by-pass in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A
  1. Patients unfit for major surgery but with a good run-off.
  2. Patients in whom a prosthesis has become infected or thrombosed.
71
Q

Modalities of Extra-anatomical by-pass in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A
  1. femoro-femoral crossover graft (or axillo-femoral)

2. axillo bifemoral graft

72
Q

femoro-femoral crossover graft in Modalities of Extra-anatomical by-pass in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A
  • Indication

* Procedures

73
Q

Indication of femoro-femoral crossover graft in Modalities of Extra-anatomical by-pass in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A

To relieve an iliac artery occlusion when the other iliac is patent with a strong femoral pulse.

74
Q

Procedures of femoro-femoral crossover graft in Modalities of Extra-anatomical by-pass in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A

An 8 mm Dacron graft is tunneled subcutaneously above the pubis & anastomosed to the common femoral arteries on each side

75
Q

Indication of axillo bifemoral graft

A

for leriche syndrome

76
Q

Thromboendarterectomy in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A
  • Procedures

* Indication

77
Q

Procedures of Thromboendarterectomy in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A

This means removal of the thrombus, intima and the inner media leaving a patent lumen that becomes rapidly endothelialized.

78
Q

Indication of Thromboendarterectomy in Open surgical techniques in Lines of treatment of chronic L.L ischaemia

A
  • This procedure is applicable for large arteries with localized obstruction, e.g. a localized narrowing in an iliac artery.
  • Usually not done nowadays due to feasibility of PTA.
79
Q

patients diagnosed with chronic ischemia with no good distal run off

A

Little can be done for these patients

Lumbar sympathectomy :

Amputation :

80
Q

Lumbar sympathectomy in Lines of treatment of chronic L.L ischaemia

A
  • Indications
  • Disadvantages
  • Contraindications
  • Ganglia removed
81
Q

Indications of Lumbar sympathectomy in Lines of treatment of chronic L.L ischaemia

A

Persistent ulcer

patient with rest pain and ischemic ulcer

82
Q

Disadvantages of Lumbar sympathectomy in Lines of treatment of chronic L.L ischaemia

A

Does not improve blood supply of the muscles “worsens muscle ischemia

83
Q

Contraindications of Lumbar sympathectomy in Lines of treatment of chronic L.L ischaemia

A
  1. Intermittent claudication

2. Diabetic patient

84
Q

The reason why Intermittent claudication is considered from Contraindications of Lumbar sympathectomy in Lines of treatment of chronic L.L ischaemia

A

as Surgery Cause V.D of skin more than that of muscle

85
Q

The reason why Diabetic patient is considered from Contraindications of Lumbar sympathectomy in Lines of treatment of chronic L.L ischaemia

A

as he is already suffering from peripheral neuropathy.

86
Q

Ganglia removed in Lumbar sympathectomy in Lines of treatment of chronic L.L ischaemia

A

L2,3&4.

L1 is preserved to avoid retrograde ejaculation.

87
Q

Amputation in Lines of treatment of chronic L.L ischaemia

A
  • The proper policy
  • Indications
  • Mechanism of Recognition of the proper level
  • A common mistake performed by a beginner on treating A patient with a limited dry gangrene of a toe
88
Q

The proper policy of Amputation in Lines of treatment of chronic L.L ischaemia

A

The proper policy is to wait until spontaneous separation occurs or an amputation at the proper level is performed

Minimal dry gangrene is not an emergency.

89
Q

Indications of Amputation in Lines of treatment of chronic L.L ischaemia

A

a. Spreading or massive gangrene.
b. Spreading infection.
c. Severe uncontrollable pain, the patient himself asks for amputation

90
Q

Mechanism of Recognition of the proper level of Amputation in Lines of treatment of chronic L.L ischaemia

A

Palpable popliteal pulse )> Below knee amputation “BKA”

Absent popliteal pulse)> Above knee amputation “AKA”.

91
Q

A common mistake performed by a beginner on treating A patient with a limited dry gangrene of a toe in Amputation in Lines of treatment of chronic L.L ischaemia

A

amputation of the toe.

92
Q

The reason why amputation of a toe with limited dry gangrene is a common mistake

A

as spread of gangrene may follow the operation.

Surgery.(General 2).Vascular (16 decks)

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