15A Artery
15A Artery
NNEAFOR CHARLES
FARIDA DIPA
SHALIZA ISHMAEL
GENERAL SURGERY CLERKSHIP 2017
INTRODUCTION
Atheroma
An abnormal mass of fatty or lipid material with a fibrous covering
which exists as a discrete, raised plaque within the intima of an artery.
The Anatomy of Blood Vessels
heart blood
Aorta Arteries
flows into
Superior/
Back to the
Veins Inferior Vena
heart
Cava
Blood Flow Through the Blood Vessels
As blood flows
from the aorta
toward the •Pressure decreases
capillaries and
from •Flow decreases
capillaries •Resistance increases
toward the
vena cava:
Histological Structure of Blood Vessels
ARTERIAL STENOSIS AND OCCLUSION
Cause and effect
Arterial stenosis or occlusion is commonly caused by atheroma but can occur
acutely as a result of emboli or trauma.
Stenosis or occlusion produces symptoms and signs that are related to the
organ supplied by the artery:
lower limb – claudication, rest pain and gangrene
brain– transient ischemic attacks and stroke
myocardium – angina and myocardial infarction
kidney – hypertension and renal failure
intestine – abdominal pain and infarction
The severity of the symptoms is related to the size of the vessel occluded and
the alternative routes (collaterals)available for blood flow
Features of lower limb arterial stenosis or
occlusion
Intermittent claudication
Rest pain
Cold, numb, paresthesia, color change
Ulceration
Gangrene
Assumes ambient temperature
Sensation decreased
Movement diminished or lost
Arterial pulsation diminished or absent
Arterial bruit
Slow venous refilling
Investigation of arterial occlusive disease
General • Dietary advice is required for those who are overweight and for
those with high blood lipids.
• Care of the ischemic foot is often required, especially in
diabetics.
• Medication may be required for diseases
associated with arterial disorders, such as
hypertension and diabetes.
• some antihypertensive (particularly β-blockers)
may exacerbate claudication.
• Raised blood lipids require active drug treatment
but even when the lipid profile is normal a statin
should be prescribed (e.g.40mg/day of
pravastatin).
Drugs
• An antiplatelet agent is also necessary, usually
75mgday−1of aspirin, with 75mgday−1of
clopidogrel as an alternative for those who are
aspirin intolerant.
• Other agents, such as vasodilators, are unlikely to
prove beneficial.
Transluminal angioplasty and stenting
Leg
arterial occlusion due to an embolus differs from occlusion due
to thrombosis on a pre-existing atheroma; in the latter case, a
collateral circulation has often built up over time. It is essential
to differentiate between the two as they require different
management.
Brain • The middle cerebral artery (or its branches) is most commonly
affected, resulting in major or minor (TIA) stroke.
• Amaurosis fugax
Venous air embolism is a rare complication of neck surgery if a large vein is inadvertently opened
and it maybe an accessory cause of death following a cut throat.
If a large volume of air is allowed to reach the right side of the heart it may form an air lock within
the pulmonary artery and cause right heart failure.
The treatment of air embolism is to put the patient in a head-down (Trendelenburg) position to
encourage the air to enter the veins in the lower part of the body.
The patient should also be placed on the left side to help the air to float to the ventricular apex,
away from the ostium of the pulmonary artery.
In extreme cases air may be aspirated from the heart through a needle introduced below the left
costal margin.
Oxygen should, of course, be administered. Air may rarely enter the left side of the heart at open
heart surgery or if a pulmonary vein is punctured when inducing a therapeutic pneumothorax.
It may also enter via a patent foramen ovale (a common
anomaly) as a paradoxical embolism. Air then may reach
the coronary and/or the cerebral circulation.
The limb is cold and the toes cannot be moved, which contrasts with venous occlusion when muscle
function is not affected.
• no history of claudication
• has a source of emboli
• suddenly develops severe pain or numbness of the limb
• limb becomes cold and mottled.
• Movement becomes progressively more difficult
• sensation is lost.
• Pulses are absent distally but the femoral pulse may be palpable, even thrusting, as distal
occlusion results in forceful expansion of the artery with each pressure wave despite the
lack of flow.
Treatment
Muscles swell within fixed fascial compartments and this can itself be a
cause of ischemia, with both local muscle necrosis and nerve damage
due to pressure, and distal effects such as renal failure secondary to the
liberation of myocyte breakdown products.
The usual site at which such surgery is necessary is the calf (especially
the anterior tibial compartment), but compartment syndrome may
occasionally affect the thigh and the arm.
Gangrene
Gangrene is a condition that involves the death and decay of
tissue, usually in the extremities due to loss of blood supply.
Injury from wrinkled sheets and maceration of the skin by sweat, urine or pus
must be prevented by skilled nursing and the use of an adhesive film dressing.
A bedsore can be expected if erythema appears that does not change color on
pressure.
The affected area must be kept dry and an aerosol silicone spray may be used.
Once pressure sores develop, they are difficult to heal. They may be treated by
lotions or by exposure to keep them as dry as possible. They should be kept
clean and debrided if necessary.
Frostbite
Frostbite is caused by exposure to cold. It is seen both in climbers at
high altitudes and in the elderly or the vagrant during cold, windy
spells.
The fissure is followed by a fibrous band that encircles the digit and
causes necrosis.
The treatment in the early stage is by Z-plasty and in the later stages by
amputation
Ergot
Wet gangrene
amputation
Spreading cellulitis
Arteriovenous fistula
Paralysis
Amputation = removal of a body extremity by surgery or trauma
"to cut away", from ambi- ("about", "around") and putare ("to
prune").
Control of infection
Nutritional status
Complications
Early complications include hemorrhage, which requires return to the operating room for
hemostasis, hematoma, which requires evacuation, and infection, usually in association with a
hematoma.
Wound dehiscence and gangrene of the flaps are caused by ischemia; a higher amputation may
well be necessary.
Amputees are at risk of deep vein thrombosis and pulmonary embolism in the early
postoperative period and prophylaxis with subcutaneous heparin is essential for several weeks
after operation.
ANEURYSM
They can either be true aneurysms, containing the three layers of the arterial wall
(intima, media, adventitia) in the aneurysm sac
False aneurysms, having a single layer of fibrous tissue as the wall of the sac, e.g.
aneurysm following trauma.
Aneurysms can also be grouped according to their shape (fusiform, saccular,
dissecting) or their etiology (atheromatous, traumatic, syphilitic, mycotic, etc.).
Aneurysms occur all over the body in major vessels, including the aorta, and the
iliac, femoral, popliteal, subclavian, axillary and carotid arteries. They may also
occur in cerebral, mesenteric, splenic and renal arteries and their branches.
All aneurysms can cause symptoms, as a result of expansion, thrombosis, rupture or the
release of emboli.
The symptoms relate to the vessel affected and the tissues it supplies. Most aneurysms
of clinical significance can be palpated and, typically, an expansile pulsation is felt.
Transmitted pulsation through a mass lesion, cyst or abscess lying adjacent to a large
artery may be mistaken for aneurysmal pulsation.
Patients most commonly present with back and/or abdominal dis-comfort. Pain
may also occur in the thigh and groin because of nerve compression.
An operation is indicated in patients who are otherwise reasonably fit. The risk of
operation is particularly increased in the presence of hypertension, chronic
airway disease, recent myocardial infarction and impaired renal function.
Chronological age is not a bar to surgery but only a few patients are fit enough
for this type of procedure once over the age of 80.
Asymptomatic abdominal aortic aneurysm
Urinary catheter
Popliteal artery aneurysm accounts for 70% of all peripheral aneurysms; two-thirds are bilateral.
Examination of the abdominal aorta is indicated if a popliteal aneurysm is found because one-
third are accompanied by aortic dilatation.
Popliteal aneurysms present as a swelling behind the knee or with symptoms caused by
complications, such as severe ischemia following thrombosis or distal ischemic ulceration as a
result of emboli.
Urgent surgery, possibly with intra-arterial thrombolysis, is indicated in the acute situation.
Ultrasonography and CT or magnetic resonance imaging can be helpful in confirming the diagnosis.
False aneurysm of the femoral artery occurs in 2% of patients after arterial surgery at
this site. Some are infective in origin and rupture is possible; these require surgical
correction. Local repair with re anastomosis at the groin under suitable antibiotic
cover may be successful, but bypass, clear of the infected area, with subsequent
excision of the infected graft is often the only way of preventing further problems.
Iliac aneurysm
Arterio-venous fistulas for hemodialysis access are also created surgically. All
arteriovenous communications have a structural and a physiological effect.
Treatment is by embolization.
Often, only one or two of the three manifestations are present. Histologically,
there are inflammatory changes in the walls of arteries and veins, leading to
thrombosis.
Treatment is total abstinence from smoking, which arrests, but does not
reverse, the disease. Established arterial occlusions are treated as for
atheromatous disease, but amputations may eventually be required.
Other types of arteritis
Arteritis occurs in association with many connective tissue disorders, e.g. rheumatoid
arthritis, systemic lupus erythematosus and polyarthritis nodosa.
Temporal arteritis is a disease in which localized infiltration with inflammatory and giant
cells leads to arterial occlusion, ischemic headache and tender, palpable, pulseless
(thrombosed)arteries in the scalp. Irreversible blindness occurs if the ophthalmic artery
becomes occluded.
The surgeon may be required to perform a temporal artery biopsy, but this should not delay
immediate steroid therapy to arrest and reverse the process before the ophthalmic artery is
involved.
Cystic myxomatous degeneration
This idiopathic condition usually occurs in young women and affects the hands more than
the feet.
There is abnormal sensitivity in the arteriolar response to cold.These vessels constrict and
the digits (usually the fingers) turn white and become incapable of fine movements. The
capillaries then dilate and fill with slowly flowing deoxygenated blood, resulting in the
digits becoming swollen and dusky. As the attack passes off, the arterioles relax,
oxygenated blood returns into the dilated capillaries and the digits become red. Thus, the
condition is recognized by the characteristic sequence of
• blanching
• dusky cyanosis
• red engorgement
• accompanied by pain.
Superficial necrosis is very uncommon. This condition must be
distinguished from Raynaud’s syndrome, which has similar
features.
The term Raynaud’s syndrome is most often used for a peripheral arterial manifestation
of a collagen disease such as systemic lupus erythematosus or rheumatoid arthritis.
The clinical features are as for Raynaud’s disease but they may be much more
aggressive. Raynaud’s syndrome may also follow the use of vibrating tools. In this
context it is a recognized industrial disease and is known as ‘vibration white finger’.
Nifedipine, steroids and vasospastic antagonists may all have a role in treatment.
Patients with vibration white finger should avoid vibrating tools.
Acrocyanosis
Medscape