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the popliteal artery pulsation. This movement is absent with
blockage of popliteal artery.
Disappearing pulse syndrome: Exercise the limb after feeling
the pulse. Pulse disappears once patient develops claudication. It is due to vaso
dilatation and increased vascular space
occurring as the result of exercise wherein arterial tension
cannot be kept adequately and so pulse will disappear
(unmasking the arterial obstruction).
Buerger’s postural test: Patient lying down on his back is
asked to raise the leg above. In normal individuals, limb
(plantar aspect of foot) remains pink even after raising above
90°. Ischaemic limb, when elevated shows marked pallor and
SRB’s Manual of Surgery
empty veins. The angle in which pallor develops is called as
Buerger’s angle of vascular insufficiency. If this angle is <30°,
it indicates severe ischaemia.
Systolic bruit may be heard over stenosed artery like subcla-
vian artery, femoral artery, carotid artery, iliacs, renal artery.
Adson’s test (Scalene manoeuvre): In a patient sitting on a
stool, the radial pulse is felt. The patient is then asked to take
a deep breath (to allow the rib cage to move upwards so as to
narrow the cervicoaxillary channel) and turn the face to same
side (to contract scalenus anterior muscle so as to narrow
the scalene triangle). If the radial pulse disappears or become
feeble it signifies cervical rib or scalenus anticus syndrome.
Elevated arm stress test (EAST), or modified Roos test: With
both the arms kept in 90° abduction and external rotation
position, patient is asked to make a fist and release repeatedly
for 5 minutes. In normal side, patient will continue to do the
manoeuvre whereas in diseased (thoracic outlet syndrome)
side patient gets pain and paraesthesia with difficulty in
continuing the manoeuvre. Patient drops the arm down to
relieve the symp
Costoclavicular compression manoeuvre (Falconer test):
toms.
Radial pulse becomes absent when patient draws his
shoulders backwards and downwards in excessive military
position. This is because at this position, subclavian artery
is compressed between first rib and clavicle, leading to
feeble or absent radial pulse. Halstead manoeuvre another
similar test.
Hyperabduction manoeuvre (Wright test): When affected
arm is hyperabducted, radial pulse becomes absent or feeble
due to compression of artery by pectoralis minor tendon.
Allen’s test: It is done to find out the patency of radial and
ulnar arteries. Both the arteries are compressed near the
wrist and allowed to blanch completely in one minute (In the
mean time patient closes and opens the fist several times for
further venous outflow). Palm appears pale and white. One of
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 respi
ration, resonant on percussion. Expansile
pulsation is confirmed by placing the patient in knee-elbow
position.
Auscultation for arterial bruit over femoral artery, abdominal
aorta, subclavian and carotid arteries is done.
Palpation of Blood Vessels
Dorsalis pedis artery is felt just lateral to the extensor hallucis
longus tendon at the proximal end of first web space, felt
against the navicular and middle cuneiform bones. It is absent
in 10% cases.
Posterior tibial artery is felt against the calcaneum just behind
the medial malleolus midway between it and tendo-Achilles.
Anterior tibial artery is felt anteriorly in the midway between
the two malleoli against the lower end of tibia just above the
ankle joint, lateral to extensor hallucis longus tendon.
Popliteal artery is difficult to feel. It is palpated better in
prone position with knee flexed about 40–50°, to relax the
popliteal fascia. It is felt in the lower part of the fossa over
the flat posterior surface of upper end of tibia. In upper end
of the fossa, artery is not felt as there is no bony area in
intercondylar region.
Femoral artery in the groin is felt just below the inguinal liga-
ment midway between anterosuperior iliac spine and pubic
symphysis. Often hip has to be flexed for about 10–15° to
feel it properly.
Radial artery is felt at the wrist on the lateral aspect against
lower end of the front of radius.
Ulnar artery is felt at the wrist on the medial aspect against
lower end of the front of ulna.
Brachial artery is felt in front of the elbow just medial to
biceps brachii tendon.
Axillary artery is felt in apex of the axilla against shaft of the
humerus.
Subclavian artery is felt against first rib just above the middle
of the clavicle.
Facial artery is felt against body of mandible at the insertion
of masseter.
Common carotid artery is felt medial to sterno mastoid muscle
at the level of thyroid cartilage against carotid tubercle
(Chassaignac tubercle) of transverse process of 6th cervical
vertebra (in carotid triangle).
Superficial temporal artery is felt just in front of the tragus of
the ear against zygomatic bone.
the arteries is released and colour of hand is noted. Normally
hand will become pink and flushed in no time; whereas in
INVESTIGATIONS FOR ARTERIAL DISEASES
obstruction, the area will still remain pale. Other artery is also
released and looked for changes in hand. Often test has to be
repeated to get proper information.
Segmental pressure measurements: Segmental BP is
measured at multiple levels (upper and lower thigh, upper
calf and ankle); pressure reductions between levels help to
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localise the occlusion; normally pressures increase as one
moves further down the leg (>20 mmHg gradient abnormal);
test is inaccurate in calcified artery walls.
Blood tests: Low Hb delays healing due to poor oxygenation;
raised WBC count may be due to infection; raised platelet
count may precipitate thrombosis (of arteries and veins
both); blood sugar and glycosylated haemoglobin (HbA1C)
reflects the diabetic problem; lipid profile; peripheral smear;
renal function tests (serum creatinine).
Doppler to find out the site of block—hand held Doppler
can be used (Doppler: Christian Johann Doppler, Austrian
physicist).
¾
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 sound is heard with normal
flow, and sound is important. Turbulence is heard when
there is 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.
Fig. 1.304: Angiogram showing vessels in both lower limbs; note
the significant block on the left side.
INDICATIONS FOR ANGIOGRAM
B
x Thromboangiitis obliterans (TAO), atherosclerosis
x Raynaud’s phenomenon, arteriovenous (AV) fistulas
x Haemangiomas
x Thoracic outlet syndrome (e.g. cervical rib)
x Aneurysms, neoplastic conditions
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CHAPTER 1L General Surgery: Arterial Diseases
Fig. 1.303: Hand held Doppler is simpler way to identify
and assess the artery.
¾
Arterial diameter, blood flow rate, velocity of flowing
blood, assessment of stenosed segment is properly done
using Doppler.
Angiography:
¾
Angiography is the appropriate investigation for arterial
diseases.
¾
Retrograde transfemoral Seldinger (Sweden) angiography:
–
It is commonly done angiogram. It is done only when
femorals are felt. If femoral pulsation is not felt then
angiogram is done either transbrachially (left brachial
artery), or transaortic.
–
Other angiograms are carotid angiogram, coeliac
angiogram, superior mesenteric angiogram, coronary
angiogram.
SELDINGER TECHNIQUE (STEPS)
B
1. Arterial cannula is passed into the artery, e.g. femoral artery
2.
Needle is removed and guidewire is passed through the cannula
Cannula is removed
3.
4.
Dilator is passed over the guidewire
Dilator is removed and arterial catheter (5 French sized) is passed
5.
over the guidewire
6. Guidewire is removed
–
Femoral artery is used because it can be easily felt and
cannulated to pass an arterial catheter.
–
Water soluble iodine dye (Sodium diatrizoate) is injected.
X-rays are taken to see the block, its extent in the affected
limb.
–
In TAO cork screw appearance is characteristic. Distal
run off through collaterals is also important.
–
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 detect renal artery stenosis,
renal carcinomas, renal anomalies (vascular). But
one should be remembered that angiogram in limb
Half of us are blind, few of us feel and we are all deaf.—William Osler
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may precipitate further rapid thrombus formation,
worsening ischaemia and precipitating gangrene.
–
Dye is injected either to an artery or vein. Injecting into
a vein is technically easier but larger dose of dye is
required. Injecting into an artery is technically difficult
COMPLICATIONS OF RETROGRADE ANGIOGRAM
B
x Bleeding, hypotension; Haematoma formation
x Dissection of the vessel wall, pseudoaneurysm
x Embolic blue toe syndrome; Thrombosis, AV fistula
x Infection, osmolarity discomfort; Anaphylaxis—4%
¾
Direct aortic angiogram, practiced earlier, is discour-
aged at present because of the risk of aortic dissection
and paraplegia due to blockage/spasm of anterior spinal
artery.
SRB’s Manual of Surgery
¾
Digital subtraction angiography (DSA)
–
Here vessel (artery) is delineated in a better way by
eliminating other tissues through computer system.
AV fistulas, haemangiomas, lesion in circle of Willis,
vascular tumours, other vascular anomalies are well
made out.
CT angiogram/MR angiogram.
Ultrasound abdomen to see aneurysm/aorta and its anatom-
Treadmill test/ECG/echocradiography to assess cardiac/
Plethysmography: It measures the blood flow in limbs.
but small dose of dye is sufficient.
–
Advantages: 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: Cost factor and availability.
–
Complications: Anaphylaxis, bleeding, thrombosis.
ical changes/other vessels in the abdomen/other organs.
coronary status.
Water-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 mmHg pressure is placed
at thigh, calf and ankle levels and then quantitative measure
of pulsation is done.
Ankle-brachial pressure index: Normally it is 1. If it is less
than 0.9, it means ischaemia is present. If it reaches 0.3 or
below then it signifies severe ischaemia with gangrene.
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 anaesthetise entire limb). If the ischaemic disease is at vasospasm
stage (like in TAO), nerve block will relieve the sympathetic
vasospasm and skin temperature rises. It is compared to
mouth temperature of the patient.
Fig. 1.305: DSA showing total block of right common iliac
artery due to thrombosis.
Fig. 1.306: CT angiogram showing abdominal aorta,
branches and renal vessels.
A B
Figs. 1.307A and B: Aortic and aortoiliac CT angiogram.
It is to assess the degree of vasospasm which is used as a
predictor of the efficacy of sympathectomy.
(Rise in skin temperature minus 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, sympa-
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thectomy is not beneficial.
Transcutaneous oximetry: By placing polarographic elec-
trodes over the skin over thigh, leg and foot of oxygen tension
(tcPO2) can be measured which is reflection of underlying
tissue perfusion. Normal tcPO2 in the foot is 50–60 mmHg.
Level less than 40 mmHg shows inadequate wound healing.
Level below 10 mmHg suggests critical ischaemia with
complete failure of wound healing.
Other tests
¾
Xenon 133 isotope method is used to study muscle
blood flow. Xenon 133 after mixing with normal saline is
injected IM to study its clearance.
¾
Two electromagnetic electrodes are placed in contact with
arterial wall in opposite directions which pick up moving
blood force to feed into electronic amplifier. But it is
invasive as artery has to be dissected to place electrodes.
¾
Angioscopy to visualise the vessels directly.
Treatment Plan for Arterial Diseases
Stopping smoking; supervised exercises; regular controlled
walk, diet (carbohydrate and lipid free diet); care of limbs.
Control of hypertension, diabetes; antilipid drugs like atorv-
astatin 10 mg or pravastatin 40 mg; low dose aspirin 75 mg;
clopidogrel 75 mg; vasodilators; ticlopidine; dipyridamole;
cilostazole 100 mg are different drugs used.
Percutaneous transluminal balloon angioplasty (PTA) done
mainly to iliac arteries, subclavian arteries, renal artery,
carotid and occasionally leg arteries and mesenteric or
gastrointestinal arteries. PTA with stenting using expandable stents to the arteries is also often done to get a better
result.
Bypass graft surgeries—aortofemoral; femorofemoral;
iliofemoral, etc. Dacron, human umbilical vein (3 mm), saphenous vein; PTFE (polytetrafluoroethylene)—are different
grafts used.
Endarterectomy, atherectomy, thrombectomy, profunda-
plasty, etc.
x Arterial diseases can be major arterial (occlusive) diseases or
peripheral arterial (occlusive) diseases
x Major arterial diseases occur in aorta, carotids and iliac arteries
x Peripheral arterial occlusive diseases occur in limb vessels and
distal vessels; commonly lower limbs but can occur in upper
limbs also
x Effects of occlusion depends on anatomy of arteries; collateral
circulations, degree and extent of the disease occlusion, demand
of the tissues
x Presentations are being—pain; pallor; pulselessness; poikilo-
thermia (cold periphery); paresis; paraesthesia (due to diversion
of blood from skin to muscles); pressure effects.
ATHEROSCLEROSIS
It is a chronic, complex inflammatory condition of elastic and
muscular arteries, involving as systemic and segmental. It begins
in childhood as fatty streaks.
Risk factors
T
Definitive
• Hypercholesterolaemia, and hyperlipidaemia (cholesterol >200
mg%; high LDL (>100 mg%); low HDL (<35 mg%)
• Cigarette smoking; Hypertension; Diabetes mellitus
Relative
• Age—elderly; Common in males
• Sedentary life, obesity; Family history
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CHAPTER 1L General Surgery: Arterial Diseases
DISEASES OF THE ARTERIES
Atherosclerosis.
Thromboangiitis obliterans (TAO) (Buerger’s disease).
Raynaud’s disease.
Conditions causing Raynaud’s phenomenon: Like sclero-
derma, rheumatoid arthritis, SLE, granulo matosis, vasculitis
of other causes.
Embolus.
Aneurysms.
Other causes: Fibromuscular dysplasia, radiation, Takayasu’s
arteritis.
Fig. 1.308: Angiogram showing atherosclerosis.
Pathogenesis
All risk factors cause initial endothelial injury, both
mechanical as well as toxic. This reduces significantly
“Real attitude of giving is when you lack”.
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normal atheroprotective features of endothelium (barrier
function; antiadhesive effect; antiproliferative effect on
smooth muscles of arterial wall). Progressive atheromatous plaque formation, thrombosis, migration and proliferation of vascular smooth muscle cell occur. Migrated
smooth muscle cells into intima act as neointima and this
migration is stimulated by PDGF (platelet-derived growth
factor released by endothelial smooth muscles, platelets);
which (this migrated smooth muscle) newly becomes
secretory to produce large quantity of matrix of the plaque.
Lipid (LDL) gets oxidised to release factors which promote
inflammation and coagulation and factors which prevent
SRB’s Manual of Surgery
production of protective nitric oxide. Macrophages stabilise the plaque.
Pathology constitutes of atherosclerotic plaque which
Blood sugar, fasting lipid profile, Doppler, angiogram (CT/
DSA), US abdomen, ECG, echocardiography are essential
investigations. Angiogram shows typical narrowed artery,
site, extent, percentage of stenosis, and collaterals.
Antiphospholipid antibody (APLA) estimation is done to
identify antiphospholipid antibody syndrome (APLS/Hughes’
syndrome). It is an autoimmune, hypercoagulable state
caused by antiphospholipid antibodies. APLS provokes
thrombosis in both arteries and veins as well as causes
pregnancy-related complications such as miscarriage, stillbirth, preterm delivery, and severe preeclampsia. It causes
lower limb DVT (venous) and arterial thrombosis (causing
stroke); it is diagnosed by ELISA test for APLA. It is treated
by aspirin and anticoagulant (Warfarin).
contains smooth muscle cells, connective tissue matrix,
macrophages and lipid (the feature of atherosclerosis).
Ulceration and calcification occurs in these plaques. Ulcer-
ated plaque is highly thrombogenic causing thrombosis and
further critical block of the vessel leading to tissue ischaemia
and infarction distally.
Plaques are more at the dividing junctions of the artery
where stress and shear force of the blood flow is more.
Plaques are dynamic in nature with progression and regression phases.
Plaque progression has got a unique ability of adaptation so
that as the plaque progresses, lumen caliber is been tried to
COMPLICATIONS OF ATHEROSCLEROSIS
B
x Narrowing of the arteries: Coronary, cerebral, renal, mesenteric,
iliofemoral. > 70% narrowing (severe) causes reduced blood flow.
Ischaemia, ulcerations, gangrene can occur
x Embolism: From atheromatous plaques
x Aneurysm formation: Mainly abdominal aorta and also in periph-
eral arteries
x Fatty streaks: Fibrous atheromatous plaque with fibrous, lipid and
basal zones → Complicated plaque with calcification, ulceration,
narrowing
Management
be preserved until critical stage occurs. Stenosis more than
40% is said to be critical. Beyond this, compensatory mecha-
nism fails causing rapid progression and further stenosis of
lumina. Stenosis more than 40% causes atrophy of tunica
media making arterial wall mechanically unstable leading into
dilatation and aneurysm.
Common arteries involved are—infrarenal part of abdominal
aorta, coronary arteries, iliofemoral vessels, carotid bifurcation, popliteal arteries. It is less common in upper limb
arteries, common carotid, renal and mesenteric arteries.
Features and Evaluation
It is common after 50 years, but can occur at earlier age
group.
It occurs in males and females. Family history is common.
Smoking, hypertension, diabetes, raised cholesterol are
common causes.
Veins are not diseased. Arterial wall is thickened on palpation.
Thrill and bruit over femoral, renal, carotid arteries may be
felt/heard. It suggests localised stenosis with turbulence of
blood flow.
Features of ischaemia in the affected limb seen. Absence/
Risk factor modification: Avoid smoking; control of hyperten-
sion, diabetes, hypercholesterolaemia; weight reduction by
diet, and exercise.
Drugs: Antiplatelet agents (aspirin 75 mg, clopidogrel 75
mg); cilostazol 50 mg bd; atorvastatin to reduce cholesterol;
pentoxiphylline.
Percutaneous transluminal angioplasty (PTA) is very useful
for iliac blocks and lower limb blocks.
Surgeries:
¾
Thrombectomy, endarterectomy, profundaplasty.
¾
Reverse/saphenous vein graft.
¾
By pass grafts—iliofemoral, aortofemoral, iliopopliteal,
femorofemoral grafts.
¾
Amputations if limb is gangrenous—toe/below knee,
above knee. Forefoot and Syme’s amputations are not
feasible in vascular conditions.
Note:
Lumbar sympathectomy and omentoplasty are not much useful in
atherosclerotic limb. Omental vessels as such are often poorly perfused in
atherosclerotic patients due to involvement of coeliac trunk.
Aortoiliac Occlusive Disease
feeble pulses including main arteries of the limb—femorals.
Abdomen should be examined for aortic aneurysm.
Transient ischaemic attacks, chest pain, eye problems,
mesenteric ischaemia, altered renal function may be associated.
Common site of symptomatic atherosclerotic occlusive arterial
disease of lower limb is infrarenal abdominal aorta and iliac
arteries. Aortic bifurcation is the most common site of occlusion.
Often disease may also extend into infrainguinal level.
Types of Aortoiliac Occlusive Disease
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Type I: Disease localised to distal abdominal aorta and common
iliac arteries.
Type II: Wide spread aortic and iliac disease.
Type III: Multiple level diseases along with infrainguinal diseases.
leak, aortovenacaval/aortoduodenal fistula, mesenteric
ischaemia (colonic), impotence.
¾
Indirect extra-anatomical bypass: It is quicker and technically easier and is suitable to patients who cannot tolerate
anatomical bypass. Axillo-bifemoral graft is used, only in
such occasional situation.
¾
Nonoperative catheter-based endovascular procedure:
If stenosis is less than 5 cm percutaneous transluminal
angioplasty (PTA) with or without intravascular stents
can be done. It is useful for single or multiple short focal
stenoses. It is now proved that long-term patency of PTA
is equal to surgical intervention.
Infrainguinal Arterial Occlusive Disease
It is either part of type III aortoiliac disease (aortoiliac femoral) or
femoropopliteal tibial disease. Superficial femoral artery is most
commonly involved. Involvement of long segment of the artery is
common. Occasionally, a short stenotic segment may be present.
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CHAPTER 1L General Surgery: Arterial Diseases
Fig. 1.309: Types of aortoiliac occlusive disease.
Features
Common in 5th and 6th decades. Common in males.
Claudication in buttock, Leriche syndrome with impotence,
distal ischaemia are the features.
Femoral artery pulsations below are absent. Systolic bruit
over aorta and iliac arteries may be heard suggesting stenosis.
Atheromatous plaque may dislodge and may cause embolus
causing acute presentation.
Aortic angiogram is diagnostic.
Management
Treatment for diabetes, hyperlipidaemia, etc.
Surgical treatment is the mainstay.
¾
Direct anatomical reconstruction
–
Aortoiliac endarterectomy is reboring/disobliteration
procedure useful for type I disease. Diseased intima,
plaque with thrombus is removed by arteriotomy along
the entire length which is closed later using 4-zero/5zero polypropylene continuous sutures (open endarterectomy). In lengthy disease, after making two small
arteriotomies at proximal and distal diseased parts,
endarterectomy loop is passed to remove the intima
with diseased plaque (semi-closed endarterectomy).
Advantages: It avoids prosthetic graft and its complications. Problem is—reocclusion and restenosis.
–
Aortofemoral bypass graft is the gold-standard
surgical procedure for type I and II disease. Long-term
patency rate is 70–80%. Woven Dacron graft is used.
Complications are—bleeding, thrombosis, embolisation, graft blockage, graft failure, graft infection, graft
Management
If the popliteal artery below knee is patent femoropopliteal
bypass is the ideal procedure used. Otherwise one of the
patent branches is used for bypass. In situ saphenous vein
graft is ideal; reverse saphenous vein graft or synthetic
femoropopliteal graft can also be used.
Profundaplasty may be done to improve the collateral circula-
tion through profunda femoris (deep femoral).
A
B
Figs. 1.310A and B: Aortofemoral bypass graft.
Character is like a tree; reputation is like its shadow. The shadow is the one we think of but actually tree is the real thing.
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Note:
Percutaneous transluminal angioplasty (PTA) in infrainguinal blocks is
occasionally useful, only when stenosis is short and well-localised; otherwise it is not a good option. Angioplasty with laser drilling is often tried.
THROMBOANGIITIS OBLITERANS
Syn. Buerger’s Disease
The disease (occurs) in young adults between the ages of twenty
and thirty-five or forty years…. Upon exami
or both feet are markedly blanched, almost cadaveric in appearance,
cold to the touch, and that neither the dorsalis pedis nor the posterior
tibial artery pulsates…. After months… trophic disturbances make
SRB’s Manual of Surgery
their appearance…. Even before the gangrene, at the ulcerative
stage, amputation may become imperative because of the intensity
of the pain.
1908 (Professor of Urology, 1879 to 1943)
It is a disease very commonly seen in young and middle-aged
males; seen in smokers and tobacco users; not usually seen
in females due to genetic reasons (but can occur in females
very rarely). It is more common in Israel, Japan and India.
The disease is most common in South Asian.
Almost always starts in lower limb, may start on one side and
later on the other side. Upper limb involvement occurs only
after lower limb is diseased. Only upper limb involvemnt can
occur (not uncommon) but it is rare.
It is nonatherosclerotic inflammatory disorder involving
medium sized and distal vessels with cell mediated sensitivity
to type I and type III collagen.
It is common in Jewish people; it is rare even in female
smokers.
Hormonal influence, familial nature, hypersensitivity to
cigarette, altered autonomic functions are probable different
causes.
Lower socioeconomic group, recurrent minor feet injuries,
poor hygiene are other factors.
It is segmental, progressive, occlusive, inflammatory disease
of small and medium-sized vessels with superficial thrombophlebitis often may present as Raynaud’s phenomenon
with microabscesses, along with neutrophil and giant cell
infiltration, with skip lesions.
nation we see that one
—Leo Buerger
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.
Note:
• There is vasospasm → intimal hyperplasia → thrombosis → panarteritis
→ obliteration; tender, cord like veins with superficial migratory throm-
bophlebitis (30%); with nerve involvement due to vasa nervorum block/
spasm. Arterial lumen is blocked but not thickened like atherosclerosis.
• In 10% disease is bilateral; 10% females may get the disease (but rare);
10% seen in upper limbs.
• Large arteries are usually not involved by TAO.
Smoking index (SI) =
Number of years
of smoking
SI >300 is a risk factor
Pack Years Index (PYI) =
Number of years Number of packets of
of smoking cigarettes per day
PYI >40 is a risk factor
Shianoya’s criteria for Buerger’s disease
x Tobacco use. Only in males
x Disease starts before 45 years
x Distal extremity involved first without embolic or atherosclerotic
features
x Absence of diabetes mellitus or hyperlipidaemia
x With or without thrombophlebitis
Number of cigarettes
smoked per day
Pathogenesis
Smoke contains carbon monoxide and nicotinic acid
↓ ← Carboxyhaemoglobin
Causes initially vasospasm and hyperplasia of intima
Thrombosis and so obliteration of vessels occur, commonly
medium-sized vessels are involved.
Panarteritis is common
Usually involvement is segmental
↓
↓
↓
Classication of TAO
Type I: Upper limb TAO—rare.
Type II: Involving leg/s and feet—crural/infrapopliteal.
Type III: Femoropopliteal.
Type IV: Aortoiliofemoral.
Type V: Generalised.
Clinical Features
Common in male smokers between the 20–40 years of age
group. It is a smoker’s disease.
Fig. 1.311: Dry gangrene of leg. Patient needed
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above knee amputation.
Intermittent claudication in foot and calf pro gressing to rest
pain, ulceration, gangrene.
Recurrent migratory superficial thrombophlebitis.
Absence/Feeble pulses distal to proximal; dorsalis pedis,
posterior tibial, popliteal, femoral arteries.
May present as Raynaud’s phenomenon.
Investigations
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CHAPTER 1L General Surgery: Arterial Diseases
B
Fig. 1.312B
Figs. 1.312A and B: Bilateral lower limb TAO causing gangrene of
both feet. Patient needs amputation on both sides.
Hb%. Blood sugar, ABPI.
Arterial Doppler and Duplex scan (Doppler + B mode US).
CT angiogram is useful especially when intervention is
planned.
• Transfemoral retrograde angiogram through Seldinger
technique:
– Shows blockage—sites, extent, and severity.
– Cork screw 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.
Fig. 1.313: Gangrene foot.
Transbrachial angiogram: If femorals are not felt, then trans-
brachial angiogram (through left side brachial artery—left
subclavian artery—and so to descending aorta) should be done.
Ultrasound abdomen to see abdominal aorta for block/
aneurysm.
Vein, artery, nerve biopsy.
A
Fig. 1.312 A
The art of seeing invisible things is called as ‘clinical vision’.
Fig. 1.314: Gangrene of all toes in a foot in TAO patient.
174
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SRB’s Manual of Surgery
Fig. 1.316: Ischaemic features in upper and lower limbs (four limbs).
Fig. 1.315: Ischaemic ulcer foot in a TAO patient.
Treatment
Stop smoking. “Opt for either cigarette or limb, but not both.”
Fig. 1.319: Angiogram showing block in main vessel with opened up
collaterals and adequate distal run off.
Fig. 1.317: Skip ischaemic ulcers are common in vascular diseases.
It suggests severe ischaemia up to most proximal ulcer level.
Fig. 1.318: CT angiogram of lower limb (leg area) showing
segmental block.
Fig. 1.320: Angiogram showing adequate collaterals.
Drugs
Low dose of aspirin 75 mg once a day—antithrombin activity.
Prostacyclins, ticlopidine, praxilene, carnitine.
Clopidogrel 75 mg; atorvastatin 10 mg; parvostatin 40 mg;
cilostazole 100 mg bid—is a phosphodiesterase inhibitor
which improves circulation (ideal drug).
All drugs act at the collateral level than on the diseased vessel.
Analgesics, often sedatives, antilipid drugs like atorvastatin
may be needed. Complamina retard (xanthine nicotinate)
tablet which was used daily once earlier, is presently not
in use. However, graded injection of xanthine nocotinate
3000 mg from day 1 to 9000 mg on day 5 is often practiced
to promote ulcer healing, helps to increase claudication
distance as a temporary basis. Low molecular dextran may
be also used.
Naftidofuryl is useful in intermittent claudication; it alters the
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tissue metabolism.
Gene Therapy: Intramuscular injection of vascular endothelial
growth factor (VEGF) which is an endothelial cell mitogen that
promotes angiogenesis.
Note:
• Vasodilators and anticoagulants are of no use in TAO.
• Drugs like pentoxiphylline increases the flexibility of RBC’s and helps
them reach the microcirculation in a better way so as to increase the
oxygenation. Its efficacy is more in venous ulcer than arterial diseases
(now).
Care of the Limbs
Buerger’s position and exercise—regular graded isometric
exercises up to the point of claudication improves the
collateral circulation. In Buerger’s position, head end of bed
is raised; foot end of bed is lowered to improve circulation.
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CHAPTER 1L General Surgery: Arterial Diseases
BUERGER’S EXERCISE
B
Patient is in supine position, legs elevated to 45 degree. Time taken
for blanching is observed and for 2 more minutes limb is kept
elevated. Patient is made to sit in high sitting position with limb
in lowered position for 2 minutes. Lastly patient is made in supine
position for 5 minutes. This sequence is done 5 times/session with
3 sessions a day.
Care of feet (Chiropady): Exposure of feet to more cold and
warm temperature should be avoided; trauma even minor
like nail paring or pressure at pressure points in feet should
be avoided. Dryness of feet and legs should be avoided by
applying oil to the feet and legs. Footwear should be selected
carefully. It is better to wear socks with footwear. Heel raise
by raising the heels of shoes by 2 cm decreases the calf
muscle work to improve claudication.
Chemical Sympathectomy
Sympathetic chain is blocked to achieve vasodilatation by injecting
local anaesthetic agent (xylocaine 1%) paravertebrally beside
bodies of L 2, 3 and 4 vertebrae in front of lumbar fascia, to achieve
temporary benefit. Long time efficacy can be achieved by using
5 mL phenol in water. It is done under C-arm guidance. Feet will
become warm immediately after injection. Problems are—possible
risk of injecting phenol into IVC/aorta, spinal cord ischaemia.
Surgery
Omentoplasty to revascularise the affected limb.
Profundaplasty is done for blockage in profunda femoris
artery so as to open more collaterals across the knee joint
(It often makes better perfusion to the knee joint and flap of
below-knee amputation).
Lumbar sympathectomy to increase the cutaneous perfusion
so as to promote ulcer healing. But it may divert blood from
muscles towards skin causing muscle more ischaemic.
Fig. 1.3 21: Bilateral TAO. Patient has undergone right-sided above knee
amputation and left-sided lumbar sympathectomy. Ischemic ulcer on
left-sided foot is seen.
Amputations are done at different levels depending on site,
severity and extent of vessel occlusion. Usually either belowknee or above-knee ampu tations are done.
Ilzarov method of bone lengthening helps in improving the
rest pain and claudication by creating neo-osteogenesis and
improving the overall blood supply to the limb.
TAKAYASU’S PULSELESS ARTERITIS
(Mikito Takayasu, 1938—Ophthalmologist, Japan)
It is progressive, initially symptomless panarteritis involving
aortic arch and branches of aorta of unknown etiology, probably immunological.
It is common in young females (85%); common in Japan;
commonly subclavian artery is involved (85%); involves all
layers of arteries of upper limb and neck; often bilateral. It
remains unnoticed for long time.
Features
Fever, myalgia, arthralgia, upper limb claudication.
Absence of pulses in upper limb/limbs, neck; hypertension.
Fainting on turning the neck or change in position; atrophy
of face.
Thrill/bruit along major arteries of upper limb and neck are
the features.
Optic nerve atrophy without papilloedema.
Weakness and paraesthesia of upper limb.
Cerebral softening, convulsions, hemiplegia can occur.
Occasionally it can be life-threatening. Myocardial infarction;
embolism, ischaemia are other complications.
DSA; MR angiography and Doppler are the investigations.
Learn to see, learn to hear, learn to feel, learn to smell—that is clinical method.
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