Arterial diseases

1. ARTERIAL DISEASES
DR. MD. SHERAJUL ISLAM
FCPS (Surgery), FACS(USA),FMAS(INDIA)
Assistant Professor, Surgery
Sheikh Sayera Khatun Medical College

2. Anatomy of arteries
The arterial wall is composed of three layers:
The adventitia
Outermost layer
Composed of connective tissue, neural fibres and small capillaries
It is the main site for the nutrition and innervation of the vessel
The media
Thickest layer of the vessel wall
Composed of smooth muscle cells and connective tissue bundles
Provide its strength and elasticity

3. Anatomy of arteries
The intima
Innermost layer
Lined with an endothelial cell layer that functions both as an interface
between the circulating blood and the arterial wall
A source of vasoactive products that prevent thrombosis and regulate the
vascular tone by inducing vasoconstriction and vasodilation

4. DISEASES OF THE ARTERIES
• Atherosclerosis
• Thromboangiitis obliterans (Buerger’s disease)
• Raynaud’s disease
• Conditions causing Raynaud’s phenomenon:
Scleroderma
Rheumatoid arthritis
SLE
Granulomatosis
Vasculitis of other causes

5. DISEASES OF THE ARTERIES
• Embolus
• Aneurysms
• Other causes:
Fibromuscular dysplasia
Radiation
Takayasu’s arteritis

6. ATHEROSCLEROSIS
Atherosclerosis is a systemic disease of the large and medium
sized arteries in which lipid and fibrous material accumulate
between the intima and media of the vessel, eventually causing
narrowing of the lumen

8. ATHEROSCLEROSIS
It is a degenerative process triggered by endothelial cell dysfunction followed by
the adhesion and infiltration of inflammatory cells (macrophages and T
lymphocytes), which leads to the formation of fibrocellular plaques
As these plaques continue to grow, they cause an inflammatory reaction that
triggers smooth muscle proliferation in the affected area, resulting in luminal
narrowing and a reduction of blood flow through the vessel

9. Composition of Atherosclerotic Plaque

10. ATHEROSCLEROSIS
Risk factors for the development of atherosclerosis include
Smoking
Hypertension
Dislipidaemia
Diabetes mellitus
Coagulation disorders

11. ATHEROSCLEROSIS
This process start as early as childhood, with endothelial fat streaks being
the first manifestations
This chronicity and gradual stenosis allows for the formation of collateral
arterial channels to the affected organ
The ischaemic symptoms vary depending on the
vessel involved
the degree of narrowing
the presence or absence of collaterals
• Examples
Angina pectoris with diseased coronary arteries
Intermittent claudication with diseased arteries in the extremities
Renovascular hypertension with affected renal arteries

12. ATHEROSCLEROSIS
Another complication of this inflammatory process is the ulceration and
acute rupture of an unstable plaque, leading to either acute occlusion of
the artery (thrombosis) or a distal showering of the plaque material
(embolism)
Acute occlusion does not allow for the development of collaterals and
therefore leads to symptoms of acute ischaemia
Some manifestations of this process include acute myocardial infarctions,
strokes and acute limb ischaemia

13. ATHEROSCLEROSIS
• Despite the fact that atherosclerosis is a systemic disease, the plaques
tend to occur more in specific areas, mainly those with high turbulence,
low shear stress and flow stagnation
• As such, regions of arterial bifurcation are the most susceptible to the
development of atherosclerotic disease
• The most common site for these plaques are the coronary arteries,
carotid bifurcation, aortic bifurcation and proximal iliac arteries, as well
as the lower extremity arteries at the site of the adductor canal

14. INTERMITTENT CLAUDICATION
Claudio means “I limp” a Latin word
It is a crampy pain in the muscle seen in the limbs
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
• The most common 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 segment
• Pain in the thigh is due to block in the superficial femoral artery

15. INTERMITTENT CLAUDICATION
• 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 wash the metabolites

16. Boyd’s classification of claudication
• Grade I: Patient complains of pain after walking, and distance
in which pain develops is called as ‘claudication distance’ If
patient continues to walk, due to increased blood flow in
muscle and opening of collaterals metabolites causing pain are
washed away and pain subsides
• Grade II: Pain still persists on continuing walk; but can walk
with effort
• Grade III: Patient has to take rest to relieve the pain

17. Claudication
• Arterial—typically develops after walking for certain distance and
resolves rapidly within 5 minutes once walking is stopped
• Neurogenic—pain develops in standing or walking and
disappears immediately after stopping walk; normal feeling
pulses without ischaemic changes are present
It is usually due to narrow lumbar canal (spinal canal stenosis)
• Venous—it is rare but definitely occurs. It is observed in chronic
pelvic venous obstruction as a mechanical high venous pressure
It is usually due to iliac vein thrombosis
Peripheral pulses are normal

18. Claudication
•Beta blockers may aggravate claudication
• Claudication is not that common in upper limb but can
occur during writing or any upper limb exercise

19. REST PAIN
• It is continuous aching in calf or feet and toes or in the region
even at rest 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 dependent
position of the limb
• Pain is more in the distal part like toes and feet
• It gets aggravated with movements and pressure.

20. REST PAIN
• Hyperaesthesia is common association with rest pain
• Rest pain is increased in lying down and elevation of foot; it may
be reduced on hanging the foot down
• Rest pain is worst at night and so patient is sleepless at night
• Rest pain is apparently reduced by holding the foot with hand,
probably due to suppression of transmission of pain sensation

21. THROMBOANGIITIS OBLITERANS
(TAO)
Synonym: Buerger’s Disease

22. Buerger’s Disease
• Very commonly seen in young and middle aged males
• Seen only in smokers and tobacco users
• Not usually seen in females due to genetic reasons
• Almost always starts in lower limb, may start on one side and later
on the other side

23. Buerger’s Disease
• Upper limb involvement occurs only after lower limb is diseased
• Only upper limb involvement can occur but it is rare
• A non atherosclerotic inflammatory disorder involving medium
sized and distal vessels with cell mediated sensitivity to type I and
type III collagen

24. Buerger’s Disease
• 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 micro abscesses, along with neutrophil
and giant cell infiltration, with skip lesions

25. 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

26. Pathogenesis
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

27. Pathogenesis
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

28. Buerger’s Disease
• There is vasospasm → intimal hyperplasia →
thrombosis → panarteritis→ obliteration; tender, cord like
veins with superficial migratory thrombophlebitis (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 not involved by TAO

29. Indexes
Smoking index (SI) =
Number of cigarettes Number of years
smoked per day 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

30. 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

31. Classification 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

32. Clinical Features
• Common in male smokers between the 20-40 years of age group
• It is a smoker’s disease
• Intermittent claudication in foot and calf progressing 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

33. Investigations
• Hb%
• Blood sugar
• Arterial Doppler and Duplex scan (Doppler + B
mode U/S)

34. Investigations
•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

35. Investigations
• Transbrachial 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

36. Treatment
• Stop smoking. “Opt for either cigarette or limb,
but not both.”

37. Treatment
• Drugs:
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

38. Treatment
• 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

39. Treatment
• Analgesics, often sedatives, antilipid drugs like atorvastatin may be
needed
• 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 tissue
metabolism.

40. Treatment
• Vasodilators and anticoagulants are of no use in TAO.

41. Treatment
Care of the Limbs:
• Buerger’s position and exercise—regular graded
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
•In Buerger’s exercise leg is elevated and lowered
alternatively, each for 2 minutes for several times at time

42. Treatment
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.

43. Treatment
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.

44. Treatment
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

45. Treatment
Amputations are done at different levels depending on site, severity
and extent of vessel occlusion
• Usually either below-knee or above-knee amputations 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

46. Treatment
Gene Therapy
• Intramuscular injection of vascular endothelial growth factor
(VEGF) which is an endothelial cell mitogen that promotes
angiogenesis