Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 587 - файл
.pdf
Examination in Arterial Diseases
https://t.me/med1917
All pulsations of both right and left side should be written in a table form
Pulse Right Left
Dorsalis pedis Should be mentioned as Should be mentioned as
present / absent / feeble present / absent / feeble
Posterior tibial
Anterior tibial
Popliteal
Femoral
Radial
Ulnar
Brachial
Axillary
Subclavian
Carotid
Superficial temporal
121
Fig. 5.23: Palpation of superficial temporal artery.
Muscle power is also checked and graded. Grade
0—complete paralysis; Grade 1—flicker of contraction, but no movement; Grade 2—movement with the
elimination of gravity; Grade 3—movement against
gravity, not against resistance; Grade 4—movement
against partial resistance; Grade 5—normal movement
against full resistance (Fig. 5.25).
Regional lymph node examination: In infection nodes
may get enlarged.
A
B
Figs 5.24A and B: Measurement of girth is important to
find out the wasting. It should be compared to opposite side
and measured at a specific distance from a bony
prominence.
Auscultation
Auscultation over the artery for bruit is done using
bell of the stethoscope placed gently over the artery.
It signifies localised stenosis causing turbulent flow.
Machinery bruit/murmur is also heard in AV malformations/fistulas (Figs 5.26A to C).
122
https://t.me/med1917
SRB’s Clinical Surgery
A
Fig. 5.25: Muscle power should be checked against
resistance to find out the grade.
Neurological Examination
When associated neurological conditions are suspected
(like tabes dorsalis, syringomyelia, hemiplegia, transverse myelitis) muscle tone/power at ankle, knee and
hip, sensory examination for touch, pain and temperature, reflexes at ankle and knee and plantar should
be checked (Fig. 5.27).
Systemic Examination
Abdomen should be examined for the presence of
abdominal aortic aneurysms. It presents as pulsatile
mass above the umbilicus, vertically placed, smooth,
soft, nonmobile, not moving with respiration, resonant
on percussion. Expansile pulsation is confirmed by
placing the patient in knee-elbow position (Figs 5.28A
and B).
Cardiovascular system: CVS examination is essential
part of the arterial system to look for any associated
or causative factors. There may be embolic focus in
heart like fibrillation/endocarditis, etc. (Fig. 5.29).
Other systems like skeletal and respiratory systems
should be examined in detail.
B
Intermittent Claudication
Claudio means ‘I limp’ a Latin word. It is a cramp
like pain in the limb muscles which is ischaemic, not
C
Figs 5.26A to C: Auscultation over the major vessel like
femoral/carotid for bruit is important. It signifies stenosis
and turbulence flow of blood.
Examination in Arterial Diseases
https://t.me/med1917
Fig. 5.27: Sensation should be checked for neurological
deficit-especially in upper limb (cervical rib).
A
B
Figs 5.28A and B: Examination of abdomen for aortic
pulsation/aneurysm; old sympathectomy scar—are
important. Aortic aneurysm is looked for above the umbilicus,
in midline. It shows mass with expansile pulsation; vertically
placed; above the umbilicus; nonmobile; soft; smooth;
resonant; retroperitoneal (does not change in position in
knee-elbow position).
123
Fig. 5.29: Cardiovascular system examination is important
to look for mitral stenosis/endocarditis, etc.
felt prior to first step; but develops on exercise or
walks and relieved by rest, develops again by similar
type of exercise or walk. Due to arterial occlusion,
metabolites like lactic acid and substance P accumulate
in the muscle and cause pain. The site of pain depends
on site of arterial occlusion. Commonest site is calf
muscles. Pain in foot is due to block in lower tibial
and plantar vessels. Pain in the calf is due to block
in femoropopliteal site. Pain in the thigh is due to
block in the superficial femoral artery. Pain in the
buttock is due to block in the common iliac or aortoiliac
segment, often associated with impotence and is called
as Leriche’ s syndrome. Pain commonly develops when
the muscles are exercising. Cause for pain is accumulation of substance ‘P’ and metabolites. During exercise
increased perfusion and increased opening of collaterals washes away the metabolites. Claudication
distance is distance at which claudication appears.
It is very essential to assess the distance which is related
to the severity of muscle ischaemia. It is better assessed
using a treadmill. Claudication is not so common in
upper limb but can occur in muscles of forearm and
arm during writing or any upper limb exercise.
Pain at rest; pain in tissues other than muscles; pain
which does not disappear on rest—are not features
of intermittent claudication.
Aortoiliac block causes claudication in buttocks,
thighs, and calves; absence of femoral and distal pulses
124
https://t.me/med1917
SRB’s Clinical Surgery
bruit over aortoiliac region. Impotence occurs due to
defective perfusion through internal iliac arteries and
so into the penis causing erectile dysfunction (Leriche’s
syndrome). Iliac artery obstruction causes claudication
in thigh and calf; bruit over iliac arteries with absence
of femoral and distal pulses. Femoropopliteal obstruc-
tion causes claudication in calf with absence of distal
pulses but with palpable femoral. Distal obstruction
shows absence of ankle pulses with palpable femoral
and popliteal pulses.
Boyd’s classification (grading) of claudication—Three
grading:
Grade I: Patient complains of pain after walking, and
distance at which pain develops is called as ‘claudication
distance’. If patient continues to walk metabolites causing
pain are washed away in the circulation due to increased
blood flow in muscle and so pain subsides by opening
of the collaterals.
Grade II: Pain still persists when continued to walk; but
can walk with effort.
Grade III: Patient has to take rest to relieve the pain.
Three criteria to diagnose intermittent claudication:
1. Cramp like pain in a muscle (e.g. calf muscle);
2. Pain develops only when muscle is exercised;
3. Pain disappears when exercise stops
Fontaine classification of limb ischaemia
Stage 1: No clinical symptoms
Stage 2: Intermittent claudication
2a: Well compensated
2b: Poorly compensated
Stage 3: Rest pain
Stage 4: Gangrene, ischaemic ulcer
Critical Limb Ischaemia
It is persistently recurring ischaemic rest pain for
2 weeks or ulceration or gangrene of the foot or toes
with an ankle systolic pressure < 50 mm Hg or toe
systolic pressure < 30 mm Hg.
Pregangrene
It is the changes in tissue which indicates that blood
supply is precarious that it will soon be inadequate
to keep the tissues alive and presents with rest pain,
colour changes, oedema, hyperaesthesia with or without ischaemic ulceration. Pallor on elevation; conges-
scaling of skin are the typical features (Fig. 5.30).
Neurogenic claudication is pain in the leg during
walking due to neurological causes. It often mimics
vascular claudication but here arterial pulses are
normal. It is common in spinal cord stenosis due to
narrow canal.
V enous claudication is definitive but a rare entity; and
is observed in chronic pelvic venous obstruction as
a mechanical high venous pressure probably due to
iliac vein thrombosis.
Rest Pain
It is continuous aching in calf or feet and toes or in
the region depending on site of obstruction. It is ‘cry
of dying nerves’ due to ischaemia of the somatic nerves.
It signifies severe decompensated ischaemia. Pain gets
aggravated by elevation and is relieved in dependant
position of the limb. Pain is more in the distal part
like toes and feet. It gets aggravated with movements
and pressure. Hyperaesthesia is commonly associated
with rest pain. Rest pain is more during night time
as there is reduced heart rate and blood pressure during
night (sleeping time).
Fig. 5.30: Ischaemic ulcers in both upper and lower limbs.
Gangrene
It is macroscopic death of tissue in situ with or without
putrefaction. It can occur in toes, fingers, limbs,
localised area of skin and subcutaneous tissues,
muscles, organs like appendix, bowel, gallbladder,
testis and pancreas. It is with black/brown (colour)
change; senseless/painless; pulseless (no perfusion);
loss of temperature; loss of function.
Examination in Arterial Diseases
https://t.me/med1917
Dry Gangrene
It is dry, desiccated, mummified tissue caused by
gradual slowing of bloodstream. There is a line of
demarcation between dead and viable tissue and is
localised. It is noninfected gangrene.
Wet Gangrene
It is due to both arterial and venous block with
superadded putrefaction and infection. It spreads
proximally and there is no or unclear line of
demarcation. It spreads faster. It is infected gangrene.
It is soft and boggy.
Necrosis: It is microscopic cell death.
Sequestrum is dead bone in situ .
Slough is dead soft tissue.
Eschar is dried thick dead tissue/slough; seen in burns.
Atheroma (Greek-gruel) raised, focal, intimal fibro-
fatty plaque containing a core of lipid with fibrous
cap.
Embolus (Greek-peg) is an abnormal, intravascular
solid/liquid/gaseous material which is undissolved,
transported from its site of origin to distant site/sites
(Fig. 5.31).
Arteriosclerosis is thickening and loss of elasticity
of arterial wall.
125
T ype of separation—Separation by aseptic ulceration
is seen in dry gangrene. Separation by septic ulceration
is seen in infected cases and wet gangrene. Rest pain,
tenderness, pus discharge can occur at line of
demarcation.
Note: Pressure at arterial end of capillary is 32 mm Hg;
pressure at venular end of capillary is 12 mm Hg.
Features of ischaemia
Marked pallor, purple blue cyanosed appearance
Thinning of skin
Diminished hair
Loss of subcutaneous fat
Brittle nails, with transverse ridges
Ulceration in digits
Wasting of muscles
Tenderness and temperature (cold)
Features of severe ischaemia
Systolic ankle pressure less than 50 mm Hg
Systolic toe pressure is less than 30 mm Hg
Ankle brachial index is less than 0.3
Buerger’s angle of insufficiency less than 20 degrees
Capillary filling time more than 30 seconds
Delayed reactive hyperaemia time
Presence of ischaemic ulcers, gangrene
Causes of ischaemic ulceration
Large artery obliteration
Atherosclerosis
Arterial embolism
Small artery obliteration
Raynaud’s disease
TAO
Small artery embolism
Diabetes mellitus
Scleroderma
Vasculitis
Infective causes
Physical agents like pressure, radiation, burns, trauma
Fig. 5.31: Ischaemic bleb in the leg in a patient with
peripheral vascular disease. Note patient has undergone
amputation of two toes earlier.
Line of Demarcation
It is a line between viable and dead or dying tissue
indicated by a band of hyperaemia. It also indicates
that disease is well localised. Final separation or final
line of demarcation between healthy and gangrenous
tissue occurs by development of a layer of granulation
tissue in between. It is hyperaesthetic due to exposed
nerve endings.
Investigations for Arterial Diseases
Blood tests: Hb%, blood sugar, lipid profile, peripheral
smear, platelet count.
Doppler (Christian Johann Doppler—Austrian
physicist) to find out the site of block.
Duplex scan: It is combination of B mode ultrasound
and Doppler study. Difference in transmitted beam
of the ultrasound and reflected beam is called as
Doppler shift which is assessed and converted into
audible signals. It is used to study the site, extent,
severity of block, and also about collaterals. Audible
126
https://t.me/med1917
sound—with normal flow and sound is important.
Turbulence is heard with stenosed partially blocked
artery . Audible sound will be absent if there is complete
block. Using Doppler probe blood pressure at various
levels can be assessed. Pulse wave tracing along the
artery is also important.
Plethysmography: It measures the blood flow in
limbs. W ater filled volume recorder; air filled volume
recorder; mercury in silastic gauze is used after
occluding the venous outflow. It is a noninvasive
method. Segmental plethysmography using occlusion
cuffs of 65 mm Hg pressure is placed at thigh, calf and
ankle levels and then quantitative measure of pulsation
is done.
Oscillometry: Detection of presence/poor/absence of
oscillations, identify the level of block. Sudden drop
in oscillations may be due to embolic obstruction. Level
of amputation can be decided by this.
Ankle-brachial pressure index (ABPI): Normally
it is 1. If it is less than 0.9, it means ischaemia is present.
If it is 0.3 or less signifies severe ischaemia with
gangrene. It may be normal at rest in early mild
ischaemia but alters (reduces) during exercise. Ankle
pressure is assessed by placing pressure cuff in lower
calf just above the malleoli, with hand held Doppler
placed over dorsalis pedis or posterior tibial artery,
sound is heard during deflation of the cuff. Normal
ankle pressure is very variable. A pressure less than
50 mm Hg may be critical. Toe pressure is often
assessed by using appropriate sized cuffs, and by
placing photoplethysmography probes on the pulp of
the digit. T oe pressure less than 30 mm Hg is significant.
Angiography: (Enaz Moniz first did carotid angiography, 1927) Retrograde transfemoral Seldinger
angiography: It is commonly done. It is done only
when femorals (at least one of the femorals should
be felt) are felt. If femoral pulsation is not felt then
angiogram is done either transbrachially (left brachial
artery), or through transaortic direct puncture.
Indications for angiogram are—T AO; atherosclerosis;
Raynaud’s phenomenon; A-V fistulas; haemangiomas;
thoracic outlet syndrome (e.g. cervical rib); aneurysms;
neoplastic conditions.
Femoral artery is cannulated; needle is removed;
guidewire is passed (under C arm guidance); cannula
SRB’s Clinical Surgery
is removed; through guidewire Seldinger (Sweden
radiologist) arterial polythene catheter ( 5 French, 1.7
mm) is passed proximally in retrograde direction and
water soluble iodine dye (Sodium diatrizoate) is
injected. A trial of 5 ml is injected initially to observe
iodine sensitivity . Later full dose is injected. X-rays are
taken to see the block, and its extent in the affected limb.
T wo types of arteriography are done. Catheter tip is kept
in main aorta and 30-50 ml bolus of dye is injected to
see main branches and their patterns (entire arterial
tree)—is called as free flush arteriography. If catheter
tip is placed in one of the main specific artery and dye
is injected—is called as selective angiography. In T AO
cork screw appearance due to dilatation of vasa
vasorum is characteristic. Distal run off through collaterals (inverted tree/spider leg collaterals); blockage—
sites, extent, and severity; severe vasospasm causing
corrugated/rippled artery—ar e other specific findings.
Distal run off is amount of dye filling in the main vessel
distal to the obstruction through collaterals. If distal run
off is good then ischaemia is compensated. If distal run
off is poor then ischaemia is decompensated. If catheter
is passed still proximally angiogram of opposite side
is possible. Seldinger technique can also be used (to
study) to do renal angiogram to study renal artery
stenosis, renal carcinomas, renal anomalies (vascular)
(Figs 5.32A to C). Complications of retrograde
angiogram are—bleeding; dissection of vessel wall;
formation of haematoma and pseudoaneurysm; atheroembolisation into distal vessels (causes blue toe
syndrome); thrombosis; AV fistula; infection; osmolarity discomfort (osmolarity of contrast agent is 8 times
of normal plasma); vasodilatation and hypotension;
nephrotoxicity; anaphylaxis (4%).
Other angiograms are carotid angiogram (direct
puncture angiogram), celiac angiogram, superior
mesenteric angiogram, coronary angiogram. Direct
aortic angiogram, practiced earlier, is discouraged
at present because of the risk of aortic dissection and
paraplegia due to blockage of anterior spinal artery.
Conventional ionic contrast agents like sodium
diatrizoate is cheaper, and commonly used. Nonionic
agents are costly but have less osmolarity than
conventional, also have less chance of nephrotoxicity
and idiosyncrasy. It is preferred in old age and diabetics.
DSA (Digital Subtraction Angiography): Here artery
is delineated in a better way by eliminating other tissues
Examination in Arterial Diseases
https://t.me/med1917
127
A
Figs 5.32A to C: Seldinger angiogram—retrograde femoral approach. Observe the angiogram showing block in main
vessel with opened up collaterals, adequate distal run off and also showing adequate collaterals (Courtesy Dr Vasudeva
Rao, Vascular Surgeon, Manipal Hospital, Bengaluru).
B
C
through computer system. A-V fistulas, haemangiomas, lesion in circle of Willis, vascular tumours,
and other vascular anomalies are well made out. Dye
is injected either to an artery or vein. Injecting into
a vein is technically easier but requires larger dose
of the dye. Injecting into an artery is technically difficult
but small dose of dye is sufficient. Advantages are
—Only vascular system is visualised; other systems
are eliminated by computer subtraction. Small lesion,
its location and details are better observed with greater
clarity. Disadvantages are cost factor and availability .
Complications are—anaphylaxis, bleeding, thrombosis (Figs 5.33A and B).
CT angiogram is very useful in aortic diseases and
dissecting aneurysm.
Magnetic resonance angiogram (MRA): MRA with
gadolinium enhancement [time of flight (TOF)]
A
Figs 5.33A and B: (A) DSA showing left sided aortoiliac
block, (B) DSA after balloon angioplasty causing adequate
dilatation of the left sided aortoiliac segment.
B
enhancement is very useful noninvasive method. It
is the test of choice for AV malformations.
U/S abdomen: T o see abdominal aneurysm or nature
of aorta and other vessels.
Plain X-ray of the part: To see calcifications in
atherosclerosis, Monckeberg’s arterial calcification;
calcification in aneurysm, cervical rib, etc. (Figs 5.34A
and B).
Brown’s vasomotor index: Specific nerve of the
ischaemic limb is anaesthetised like posterior tibial
nerve or ulnar nerve (local anaesthesia or spinal
anaesthesia is given to anaesthetize entire limb). If
the ischaemic disease is at vasospasm stage (like in
TAO), nerve block will relieve the sympathetic
128
https://t.me/med1917
SRB’s Clinical Surgery
Study of blood flow: Although specific it is less
commonly used. Intramuscular injection of Xenon 133
in normal saline or Technetium 99 isotope injection
is used to see the clearance as an assessment of blood
flow in leg muscles. If isotope is injected intravenously,
using gamma camera, direct visualisation of artery
is done. Using electromagnetic flow meter, rate of
blood flow up to 1% also can be detected. But it is
technically difficult.
Transcutaneous oximetry: By placing polarographic
electrodes over the skin over thigh, leg and foot oxygen
tension (tcPO2) can be measured which is reflection
of underlying tissue perfusion. Normal tcPO2 in the
foot is 50-60 mm Hg. Level less than 40 mm Hg shows
inadequate wound healing. Level below 10 mm Hg
A
suggests critical ischaemia with complete failure of
wound healing.
Diseases of the Arteries
Atherosclerosis
Risk factors for atherosclerosis: Firm causes:
Hypercholesterolaemia, hypertriglyceridaemia and
hyperlipidaemia; cigarette smoking; hypertension;
diabetes mellitus. Relative causes: elderly; male;
sedentary life; family history; hyperhomocystinaemia.
Atherosclerosis can cause ischaemia at various
levels—foot; leg; thigh; entire limb; can be bilateral
disease; upper limb ischaemia—depends on the vessel
involved and extent of block it has caused (Fig. 5.35).
B
Figs 5.34A and B: X-ray abdomen AP and
lateral view showing calcified aorta.
vasospasm and skin temperature rises. It is compared
to mouth temperature of the patient.
Rise in skin temperature—rise in mouth temperature
divided by rise in mouth temperature is called as
Brown’s vasomotor index. If it is more than 3.5, it
is due to vasospasm, and can be relieved by
sympathectomy. If less than 3.5, sympathectomy is
not beneficial.
Fig. 5.35: Plain X-ray showing calcified femoral arteries
due to atherosclerosis.
Examination in Arterial Diseases
https://t.me/med1917
Thromboangiitis obliterans (TAO/Buerger’s
disease, Leo Buerger—Urologist)
It is a disease exclusively seen in males of young age
group (Not seen in females due to genetic reason).
It is seen only in smokers and tobacco users. Always
starts in lower limb, may start on one side and later
on the other . Upper limb involvement occurs only after
lower limb is diseased. It is a panvasculitis.
Pathogenesis: Smoke contains carbon monoxide and
nicotinic acid → causes initially vasospasm and
hyperplasia of intima → thrombosis and so obliteration
of vessels occurs. Commonly medium sized vessels
are involved. Panarteritis is common. Usually
involvement is segmental. Eventually artery , vein and
nerve are together involved. Nerve involvement causes
rest pain. Patient presents with features of ischaemia
in the limb. Once blockage occurs, plenty of collaterals
open up depending on the site of blockage, either
around knee joint or around buttock. Once collaterals
open up, through these collaterals, blood supply is
maintained to the ischaemic area. It is called as
compensatory peripheral vascular disease. If patient
continues to smoke, disease progresses into the
collaterals, blocking them eventually , leading to severe
ischaemia and is called as decompensatory peripheral
vascular disease. It is presently called as critical limb
ischaemia. It causes rest pain, ulceration, gangrene.
Shianoya’s criteria for Buerger’s disease: Tobacco
use; only in males; disease starts before 45 years;
distal extremity involved first without embolic or
atherosclerotic features; absence of diabetes mellitus
or hyperlipidaemia; with or without thrombophlebitis.
Migratory superficial thrombophlebitis is common.
Occasionally arteries in GI tract, heart and lungs can
get involved. It is common in lower socioeconomic
group. It is probably an autoimmune disease with often
familial susceptibility . Claudication is common in foot
and calf. Later ischaemia, rest pain, ulcers, gangrene
129
develop. Claudication is not common in thigh and
buttock. Retrograde Seldinger angiogram shows
blockage-sites, extent, severity is noted (see Fig. 5.32);
corkscrew appearance of the vessel due to dilatation
of vasa vasorum; inverted tree/spider leg collaterals;
severe vasospasm causing corrugated/rippled artery;
distal run off is amount of dye filling in the main vessel
distal to the obstruction through collaterals. If distal
run off is good then ischaemia is compensated. If distal
run off is poor then ischaemia is decompensated (Figs
5.36A to F and 5.37).
Raynaud’s Phenomenon
It is an episodic recurrent vasospasm, i.e. arteriolar
spasm. It leads to sequence of clinical features called
as Raynaud’s syndrome. It is common in digits.
Exposure to cold or stress causes initial pallor; later
cyanosis with pain and paraesthesia; eventual
hyperaemic response causes marked rubor.
Raynaud’ s syndrome: It is sequence of clinical features
due to arteriolar spasm.
1. Local syncope: It is due to vasospasm, causing
white, cold palm and digits along with tingling and
numbness.
2. Local asphyxia: It is due to accumulation of
deoxygenated blood as the result of vasospasm
causing bluish discolouration of palm and digits
with burning sensation (it is due to accumulated
metabolites).
3. Local recovery: It is due to relief of spasm in the
arteriole, leading to return of blood to the
circulation causing flushing and pain in digits and
palm (Pain is due to increased tissue tension).
4. Local gangrene: If spasm persists more than
ischaemic time (more than one hour in upper
limb), then digits go for ulceration and gangrene.
Does not occur regularly but is an occasional event
in the cycle.
Smoking index [SI] = Number cigarettes Number of years
SI > 300 is a Risk factor
Pack Years Index [PYI] = Number of packets of Number of years of
PYI > 40 is a Risk factor
smoked per day × of smoking
cigarettes per day × of smoking
130
https://t.me/med1917
SRB’s Clinical Surgery
A
B
C
E
Figs 5.36A to F: Different types of ischaemic ulcers. Also note wasting, loss of hair,
D
F
shininess and other features of ischaemia.
Соседние файлы в папке @xirurgi_2025