Arterial ischemia – acute and chronic.
Principles of Surgery lecture series
18 October 2011
Barry Rubin MD PhD FRCSC
Vascular Surgery
UHN
1. Causes of acute leg ischemia.
2. How to differentiate causes of acute leg
ischemia.
3. Natural history of the disease.
4. Therapy.
Embolism
History
Risk factors
Embolic source
Atherosclerosis
Contra-lateral pulses
Murmur
Time for collaterals
to develop
Natural history
in situ thrombosis
Embolus in the aorta
Risk factors?
Symptoms?
Treatment?
Outcome?
Clot breaks off from another location and travels in arteries.
Embolism – angiographic picture.
Get better or worse with time?
Cardiac sources
of emboli –
90% of all
arterial emboli.
Myocardial infarction and mural thrombosis
Thrombus in left atrium
Clot on bicuspid aortic valve
Bacterial endocarditis
Arterial to arterial embolization
10% of all arterial emboli.
In situ thrombosis
Atherosclerotic
Plaque
Clot
Risk factors?
Symptoms?
Treatment?
Outcome?
Clot forms in a previously diseased artery.
In situ thrombosis - aortic occlusion
Risk factors?
Symptoms?
Treatment?
Outcome?
Get better or worse with time?
Iliac stenosis
Iliac stenosis
angioplasty
Iliac stenosis – post angioplasty and stent
Severe aorto-iliac disease
Severe internal carotid stenosis
Aortic occlusion
Aorto-bifemoral
bypass
How do
arteries go
from being
narrowed to
being totally
blocked:
►progression
to
in situ
thrombosis.
in situ thrombosis
Plaque rupture
Multi-level peripheral vascular disease
External iliac
Superficial femoral
Tibial
Embolism
History
no claudication
in situ thrombosis
claudication
Embolic source
yes
no
Risk factors for
atherosclerosis
no
yes
Contra-lateral pulses
yes
no
Murmur
maybe
no
Time for collaterals
to develop
no
yes
Natural history
gets worse
with time
gets better
with time
Chronic ischemia and types of foot ulcers
Arterial
Venous
Neuropathic
Leg ulcers
Arterial
Venous
Neuropathic
Location
Distal
Medial
malleolus
Pressure
point
Arterial disease
and risk factors for
atherosclerosis
Yes
No
No
Contra-lateral
pulses
No
Yes
Yes (maybe)
Skin changes of
venous HTN
No
Yes
No
Neuropathy
Maybe
No
Yes
Location
Arterial disease
and risk factors for
atherosclerosis
Contra-lateral
pulses
Skin changes of
venous HTN
Neuropathy