All Vascular Knowledge

Vascular Knowledge
For medical student

In SURGERY
. . .
Content
PAGE
History taking & Physical Examination
Arterial disease
Venous disease
11
Lymphatic disease
16
Vascular Injury
18
Limb ischaemia
33
Pulmonary embolism
59
Anatomy of legs venous system
63
Varicose vein
65
Deep vein Thrombosis
73
Chronic venous insufficiency
81
Facts & Figures

ANEURYSMAL DISEASE
87
ATHEROSCLEROSIS DISEASE
95
Chronic leg ulcer
102
EMBOLIC DISEASE
107
LYMPHOEDEMA
110
THORACIC OUTLET SYNDROME (TOS)
112
THROMBOLYTIC THERAPY
114
Varicose vein
115
VASCULAR NEOPLASIA
119
VASCULITIDES
120
VASOSPASTIC DISEASE
122
page [1]
1.1
(Peripheral vascular disease-PVD)

(pulmonary embolus)

1.2

atherosclerosis

page [2]

(pitting oedema)
(non-pitting oedema)

(aneurysm)
(thrombus) aneurysm
abdominal aortic aneurysm(AAA)

blue toe syndrome

AAA
AAA 12
Raynauds phenomenon
page [3]

Blockers

Buergers disease
(Thromoangittis obliterans)

thrombosis
axillary artery
1.3
Stethoscope
Blood pressure cuff
Tape measure
Hand held Doppler
page [4]
ABI Hand held doppler

Atherosclerosis

2 (Bilateral arm-brachial blood pressures)
page [5]
murmurs
carotid, subclavian, abdominal, femoral bruits
AAA

1.3.1
Atherosclerosis carotid bifurcation
internal carotid

(amaurosis fugax),
(transient ischaemic attacks-TIA) (stroke)
carotid
carotid carotid aneurysm tortuous carotid
artery
(amaurosis fugax)
retina cholesterol emboli retina
ulcerated plaques carotid, innominate arch arteries

internal carotid artery external carotid artery
internal carotid artery
(patency) carotid
aneurysm
page [6]
bruits
bruits (neurological deficit)

carotid artery stenosis vertebral artery stenosis
duplex scan carotid
(root of neck) bruits

subclavian steal syndrome
subclavian artery
vertebral artery

1.3.2

(hand claudication)
thoracic outlet syndrome peripheral vasospasm

microembolic infarction
delay
capillary refilling time (> 3 ) capillary refilling time
3
2 radial - ulnar
brachial biceps triceps
page [7]

aneurysm
brachial artery 2
(systolic pressure) 20 mmHg
brachial artery subclavian artery
bruit supraclavicular fossa subclavian artery stenosis
hand held Doppler sphygmanometry
1.3.3
AAA

thrombosis (embolization)
AAA
abdominal aorta
abdominal aorta
retroperitoneum
page [8]
abdominal aorta

AAA
aneurysm
aortic aneurysm abdominal aorta
AAA (antero-posterior)
aortic aneurysm
lateral (expansile) AAA
aortoiliac (aortoiliac occlusive disease)

bruit bruits
renal mesenteric artery
1.3.4

(intermittent claudication)
(rest pain) (gangrene)

(pain, pallor, paralysis paraesthesia and
pulselessness)
page [9]

femoropopliteal occlusive disease
atherosclerosis
positive Buergers test

presssure sore
gangrene
acute arterial embolism acute arterial thrombosis

(mottling)

gangrene 2-3

Femoral pulse inguinal ligament
Popliteal pulse
flex
popliteal 2 (origin)
gastronemius flex
atherosclerosis pulse
popliteal entrapment syndrome pulse
hyperextending
posterior tiblial dorsalis pedis
dorsalis pedis pulse ()
metatarsal bone 1 2 posterior tibial artery medial
page [10]
malleolus medial malleolus Achillis tendon

aneurysmal disease thrill

arteriovenous fistula 2

bruits
arteriovenous malformation fistula
adductor hiatus
atherosclerosis
1. Chamberlain J, Wyatt MG. History and examination. In: Davies AH, Beard JD, Wyatt
MG, editors. Essential Vascular Surgery. London: W.B.Saunders; 1999. p. 31-46
2. Lamont PM, Shearman CP, Scott DJA. Clinical assessment of the vascular system. In:
Lamont PM, Shearman CP, Scott DJA, editors. Vascular Surgery. Oxford: Oxford
University Press; 1998. p. 1-7.
3. Summer DS. Evaluation of acute and chronic ischemia of the upper exteremity. In:
Rutherford RB, editor. Vascular Surgery 5th Ed. Philadelphia: W.B.Saunders; 2000. p.
1122-39.
page [11]
2.1
2
(superficial system) (deep system-) superficial
system sympathetic
2

congenital venous abnormalities
()

(deep vein thrombosis-DVT)

(Superficial venous disease) (varicose veins)

(Lipo-dermatosclerosis)

(right sided heart failure)

DVT

10
page [12]
varicose vein, DVT DVT

pulmonary embolism
2.2
acute axillary
or subclavian thrombosis

Chronic subclavian vein cathelerization subclavian vein
Thoracic outlet syndrome subclavian vein subclavian vein

thrombosis

venous collateral
(venous gangrene)

arteriovenous fistula
hyperpigmentation venous hypertension
page [13]
Axillary vein Subclavian vein

bruit
2.3

(postphebitic syndrome)

2.3.1 Varicose vein
long saphenous vein

short saphenous vein
varicose vein incompetent perforators
incompetent perforators

(saphenofemoral incompetence)
saphenofemoral junction
Tourniquet (Trendelenburg) test
tourniquet trendelenburg test
page [14]

(tournequet)

(incompetence)

Saphenofemoral junction reflux
2.3.2 (Acute venous thrombosis)
2

skin nodule fat necrosis lymphangitis
(deep vein thrombosis-DVT)
DVT popliteal vein iliofemoral vein DVT
popliteal vein
(dorsiflexion) positive Homans
sign

(Pulmonary embolism) iliofemoral thrombosis
(Superficial venous dilatation)

inferior vena cava (inferior vena cava thrombosis)
iliofemoral thrombosis
phlegmasia cerulea dolens
13
page [15]
2.3.3 Postphlebitic syndrome

iliofemoral thrombosis thrombophlebitis

(venous hypertension)
(haemosiderin) eczema
(lipodermatosclerosis)
(granulation tissue)
granulation
tissue

1. Chamberlain J, Wyatt MG. History and examination. In: Davies AH, Beard JD, Wyatt MG,
editors. Essential Vascular Surgery. London: W.B.Saunders; 1999. p. 31-46
2. Lamont PM, Shearman CP, Scott DJA. Clinical assessment of the vascular system. In:
Lamont PM, Shearman CP, Scott DJA, editors. Vascular Surgery. Oxford: Oxford
page [16]
2
A. Primary (idiopathic) lymphoedema

B. Secondary (obstructive) lymphoedema

primary lymphedema
3.1

(recurrent lymphangitis)
(hyperkeratosis)
page [17]
3.2
metatarsophalangeal joint buffalo hump

skin of an
orange (peau d orange )
Lymohedema
1. Chamberlain J, Wyatt MG. History and examination. In: Davies AH, Beard JD, Wyatt MG,
editors. Essential Vascular Surgery. London: W.B.Saunders; 1999. p. 31-46
2. Lamont PM, Shearman CP, Scott DJA. Clinical assessment of the vascular system. In: Lamont
PM, Shearman CP, Scott DJA, editors. Vascular Surgery. Oxford: Oxford University Press;
1998. p. 1-7.
page [18]
1
(Vascular Injury)
1.1

popliteal
artery

1.2
3
Table 1
Blunt injury
Penetrating injury
Road traffic accident

Stabbing
Domestic and industrial accidents
Gunshot wounds
Iatrogenic injury Radiological accident
1.2.1 (Blunt injury)
(tunica intima)
(tunica media-tunica adventitial)
intima (intimal flap)
(thrombosis)
popliteal
page [19]
artery

false aneurysm
(soft tissue)

traumatic
intimal flap

angiogram subclavian artery occlusion fracture clavicle

1.2.2 (Penetrating injury)

(Missile
embolism)
page [20]
1.2.3 (Iatrogenic Injury)

False aneurysm femoral artery
brachial radial
artery
false aneurysm catheter
1.3
page [21]
(Enlarging
haematoma)

bruit

(arteriovenous fistula)

axillary artery
branchial plexus branchial plexus
axillary subclavian
Traumatic arteriovenous fistula

(complete transection)
femoral popliteal arteries

(spasm)
page [22]
(partial tear)

() Doppler

(-)

(angiogram)

1.4
1.4.1

long bone
major joint dislocation
()

expanding haematoma thrills bruits

1.4.2 Hand held Doppler
ankle brachial pressure index
(ABPI) ABPI 1 ABPI
< 0.9
1.4.3.Duplex scan
non-invasive test

page [23]
1.4.4 X- RAY (Plain film)

X-ray
haematoma

vital sign

mediastinum chest X-ray (widening
mediastinum) thoracic aorta
1.4.5 Computerised Tomographic Angiography (CT scan angiography)
Computerised Tomography(CT)
(haematoma)
Helical Computerised Tomography CT scan
contrast Computer
1.4.6 Magnetic resonance imaging

invasive
MRI
1.4.7 Angiogram

angiogram

page [24]
angiogram vascular injury

1.5

( lactate ringer solution saline)
2
(Blind clamping)

Femoral artery

(Broad spectrum antibiotics)
Tetanus toxoid

page [25]

( supra-condylar fracture of the
humerus )

(numbness)
(paralysis) 6

(amputation)
myoglobinuria acute tubular necrosis
(acute
tubular necrosis)

(proximal-distal control)
(long saphenous vein)
vertical incisions

superior mediastinum
(anterior border)
sternocleidomastoid
median sternotomy

Vascular silastic sling

page [26]
1.5.1
4
(Lateral suture) suture
Patch angioplasty
End-to-end anastomosis

Interposition graft
2

(non-essential vessels) external carotid artery
(Lateral suture) monofilament sutures
(prolene)
(aortic
injury) (venous patch angioplasty)
1-2 .
(end to end anastomosis) anastomosis
2
interposition graft long saphenous vein
(reversed long saphenous vein graft)
page [27]

long saphenous vein
(Intraoperative assessment)
hand held Doppler angiogram

intimal flaps, false aneurysms and arteriovenous fistula

1.5.2

popliteal axillary vein
acute venous gangrene postphlebitic
syndrome
artificial graft
material (thrombosis)
1.6

1.6.1
common femoral artery 49%
popliteal artery 73%

popliteal veins popliteal artery injury
superficial femoral artery

profunda femoris artery
(crural artery) 1 3
2
tibioperoneal trunk tibioperoneal trunk
page [28]
2 (peroneal artery posterior tibial artery)

(> 6 hrs)
fascia (compartment syndrome)
compartment syndrome

fasciotomy
Fasciotomy compartment syndrome

1.6.2
axillary artery brachial artery
blunt trauma

brachial artery
brachial artery collateral circulation
radial ulnar artery

brachial plexus

(brachial plexus) (non-functional limb)
page [29]
1.6.3

common carotid artery

carotid

coma

zone 1 base of skull cricoid/ zone 2 cricoid cartilage
angle of mandible/ zone 3 angle of mandible
(pre-operative angiogram)
zone 1 zone 3

zone 2
zone 2
platysma

angiogram
carotid
(lateral suture) (Interposition grafting)
Vertebral arterial carotid
vertebral
internal jugular
vein internal jugular
page [30]
1.6.4
Blunt injury
descending thoracic aorta

X-Ray
superior mediastinum ( 8 .)
nasogastric tube trachea
aorta CT MRI
aorta aortography
Penetrating wound

sternum (median sternotomy) 4 (4th intercostal space)
left subclavian artery thoracic aorta
cardiopulmonary bypass
(paraplegia)
superior vena cava azygos vein
2
superior vena cava azygos vein
1.6.5

blunt trauma blunt trauma
mesenteric aorta aorta ( posterior
abdominal wall)
retroperitoneum intimal tear thrombosis

CT scan aortography
page [31]

(abdominal midline incision)

coeliac axis, superior mesenteric artery
inferior mesenteric artery 1 3
renal arteries, iliac
vessels inferior vena cava

1 7

1.8

popliteal artery
page [32]
1. Barros AAB. Vascular injury of the limbs. In Chant ADB. Barros AAB (eds).
Emergency Vascular Practice. Arnold 1997: 178-203.
2. Lamont PM, Shearman CP, Scott DJA. Vascular trauma. In Lamont PM, Shearman CP,
Scott DJA (eds). Vascular Surgery. Oxford University Press. 1998: 88-97.
3. Walker AJ. Vascular Trauma. In Davies AH, Beard JD, Wyatt MG (eds). Essential
Vascular Surgery. W.B.Saunders. 1999: 304-15.
4. Wall MJ, Garza J, Mattox KL In Chant ADB, Barros AAB (eds). Emergency Vascular
Practice: Arnold 1997:204-13.
page [33]
2

2.1

1. acute chronic limb ischaemia
2. (comorbid condition)
3.
4.
5.
2.2
2.2.1 (chronic limb ischaemia)
Atherosclerosis

atherosclerosis

aortoiliac artery, superficial femoral artery
80%
page [34]
Artherosclerotic plaque
Artherosclerotic plaque
2.2.2 (acute limb ischaemia)
2.2.2.1 Acute embolism
(solid mass)

(Rheumatic heart disease)
80% atrial fibrillation
page [35]
emboli
artery bifurcation
2.2.2.2 Acute thrombosis

thrombosis
atherosclerosis moderate/severe atherosclerotic stenosis
plaque rupture clotting factor
thrombosis superficial
femoral artery popliteal artery thrombosis

polycythaemia
2.3
5

1.
2.
3
4.
5.
2.3 1.

acute chronic ischemia
Acute ischaemia onset
onset sudden chronic
ischaemia
collateral vessel
thrombosis
atherosclerosis (acute occlusion on top chronic arterial occlusion)
page [36]
arterial embolism atherosclerosis

collateral vessel

embolism
(distal) collateral vessel
collateral vessel
2.3 1.1 acute ischaemia (5P)

Pain
Pallor
Pulselessness
Paralysis
Paresthesia
acute limb ischaemia
embolism thrombosis
Emboli
- Atheromatous emboli ()
-Amniotic fluid, bone marrow
-Foreign body catheter tip bullet
Atheromatous emboli thrombus
- Left ventricular walls myocardial infarction (MI)
- Left atrium atrial fibrilation
- Mitral aortic valve disorder
- Atheromatous disease aorto-iliac artery
acute limb ischaemia embolism
thrombosis embolism
page [37]
embolism atrial fibrillation MI
2.3 1.2
Intermittent claudication
Rest pain
Ulceration/gangrene
Chronic Ischaemia

atheromatous disease Popliteal aneurysm
collateral vessel
vessel
Rest pain at night
page [38]
Ulcer chronic arterial occlusion
Digital gangrene arterial occlusion
page [39]
2.3.2 (location of the occlusion)

acute ischaemia
proximal chronic ischaemia
aortic iliac occlusion

collateral circulation
calf vessel occlusion (crural
vessel) superficial femoral artery occlusion

onset
2.3.2.1 Aorto-iliac occlusive disease
aorta iliac segment
Buttock, thigh calf (claudication) chronic
disease atheromatous lesion collateral vessel
erectile
impotence Leriches syndrome
Rene Leriche
embolus thrombosis aortoiliac
segment aortic occlusion
buttock, perineum
2.3.2.2 Common femoral artery occlusive disease

femoral pulse
embolism femoral artery
bifurcation
page [40]
2.3.2.3 Superficial femoral artery occlusive disease
superficial femoral artery (SFA)

adducator hiatus (Hunters canal)
SFA

collateral circulation profunda femoris artery
profunda femoris artery SFA
common femoral artery
2.3.2.4 Popliteal artery occlusive disease

popliteal artery genicular artery
collateral circulation profunda femoris artery popliteal artery
2.3.2.4 Crural artery occlusive disease

anterior tibial artery,
posterior tibial artery, peroneal artery

2.3.3.(Status of limb)

2.3.3.1 acute ischaemia
2.3.3.1.1. Thrombolysis
Thrombolysis
(revascularisation)
severe ischaemia thrombolysis
page [41]
2.3.3.1.2.
revascularisatrion
toxic metabolite free radical
metabolic acidosis, acute renal failure, myoglobinuria MI
(primary amputation) severe
ischaemia irreversible limb ischaemia
2.3.3.1.3 (saving a
viable limb or primary amputation)
- pain (tenderness) anterior posterior

compartment advanced ischaemia
irreversible ischaemia
- paresthesia
(pins and needles) (numbness)
severe acute critical ischaemia
- pallor severe ischaemia
(mottling)
(fixed mottling)
(irreversible ischaemia)
- pulselessness
- paralysis
2.3.3.2
(intermittent claudication)
aortoiliac
page [42]
occlusion buttock
1-2
oxygen

(shopping)
intermittent claudication

(rest pain)

gravity

gravity
(dependent oedema) microcirculation
gangrene
(ulcer)
(gangrene) wet gangrene dry
gangrene
- wet gangrene
sepsis
- dry gangrene dry

gangrene granulation tissue

(autoamputation)
2.3.4. (fitness of the patient)
page [43]
severe limb
ischaemia Bypass operation
revascularisation
severe MI severe limb iscahemia embolism
embolectomy reperfuse MI toxic metabolite free radical
co-existing disease

(overtreat)

renal
failure
2.3.4.1 Pre-event causes
Cardiac disease
Angina pectoralis, previous MI, cor pulmonale, left ventricular failure
Lung disease
Chronic obstructive pulmonary disease, asthma
Renal disease
Chronic renal failure
Metabolic disease
Diabetes mellitus, malignancy, cachexia
flexion contracture
2.3.4.2 Per-event causes
Dehydration
Acidosis
Uncontrolled diabetes
Organic psychosis
page [44]
2.3.4.3 post-event causes
Myoglobinuria renal failure

Severe acidosis revascularisation
MI
thrombolysis
2.3.5 (investigation)

2.3.5.1. Clinical examination

pulse
2.3.5.2.
- BUN. Creatinine Electrolyte
aorta
(major operation)
renal artery disease
- Full Blood Count, plasma viscosity polycythaemia,
thrombocytosis, hyperviscosity syndrome
- Coagulation study anticoagulant coagulation
liver disease baseline
- EKG chest X-ray
page [45]
2.3.5.3. Fixed wave Doppler examination

Doppler probe
probe

Ankle Brachial index

2.3.5.4. Treatmill testing
Chronic ischaemia
arterial occlusion .
10
3 /
Chronic lung disease, Angina pectoralis
percutaneous angioplasty
bypass surgery
page [46]
2.3.5.5.Duplex scan
2 ultrasound (B-mode)
abdominal (aorta/iliac) popliteal aneurysm rare
aneuysm femoral aneurysm Doppler scan
(occlusive disease) wave flow
(degree of stenosis) duplex
scan non-invasive test
Duplex scan
2.3.5.6. Contrast arteriography
contrast media x-ray lumen
(conventional arteriography)
arteriography (resolution-clearity) Digital
subtraction arteriography (DSA)
Digital angiogram
page [47]
Angiogram = Road map for surgery

2.3.5.7. Computerised Tomographic Angiography
Helical Computerised Tomography(CT)
CT scan
CT
scan contrast Computer
Carotid Body Tumor
Carotid Artery
2.3.5.8. Magnetic Resonance Arteriography (MRA)

Magnetic
(Angiogram)

page [48]
Angiogram

Angiogram Iodine Iodine
MRA
X ray

Angiogram
MRA
page [49]
2.4
2.4.1

2.4.1.1. (life style altenation)

(Secondary Smoking)

Collateral Vessel

60%
2.4.1.2. Angioplasty
Angioplasty
balloon
superficial femoral artery
fluroscopy
balloon balloon

Angioplasty aorta iliac artery
anterior tibial artery posterior tibial artery

page [50]
Angioplasty
2.4.1.3. Bypass Surgery
(conduit)
Bypass surgery
1. intermittent claudication
2. critical limb ischaemia rest pain, gangrene chronic

ulcer
(conduit) Bypass Surgery
long saphenous vein
bypass surgery long saphenous vein
Bypass
phebitis
varicose vein (arm vein)
page [51]
vein graft
bypass surgery
bypass surgery Bypass
Surgery 2
1. polytetrafluoroethylene (PTFE)
2. polyethylene terephthallate (dacron)
PTFE dacron
PTFE
(Thrombosis dacron)
inguinal ligament ( flow
) PTFE dacron
aorta iliac artery
Dacron graft
page [52]
Axillofemoral bypass
page [53]
axillofemoral bypass
Femorofemoral bypass
page [54]
Femorotibial bypass vein graft

(Amputation)
(amputation)

outflow
amputation
2.4.1.4 amputation

1. Digital amputation Ray
amputation
2. Transmetatarsal amputation metatarsal
3.Below knee amputation

4. Gritti stoke amputation Knee joint

femur

page [55]
5. Above knee amputation

Below knee amputation
Below knee amputation long posterior flap
Stroke MI
intermittent claudication critical limb ischaemia
(gangrene, ulcer) 2% critical limb ischaemia
50% 5
Bypass Surgery
(distal anastomosis)
page [56]
femoropopliteal bypass
(patency) femoroperoneal bypass

synthetic materials bypass femoral artery
posterior tibial artery 5 bypass
50% PTFE bypass 25%
2.4.2
2.4.2.1. Heparin
heparin
heparin
(stasis)
Collateral Vessel Collateral Vessel
heparin 5,000
(IU) 500
1,000 / Actvated Partical Thromboplastin Time
(APTT) 2 3 .. heparin Actvated
Partial Thromboplastin Time 2 3 Control
2.4.2.2. Thrombolysis
Thrombolysis

Coronary acute arterial thrombosis
angiogram

1 2 streptokinase,
urokinase, tissue thromboplastin
page [57]

(Thrombolysis)
Angiogram

thrombosis

Angioplasty bypass operation
2.4.2.3. Embolectomy
Embolism
Forgarty balloon catherter catherter
Embolism (arteriotomy)
balloon
embolus (
) arteriotomy

MI atrial myxoma
2.5

5
, ,
,
page [58]
1. Lamont PM, Shearman CP, Scott DJA. Lower limb arterial disease. In: Lamont PM,
Shearman CP, Scott DJA, editors. Vascular Surgery. Oxford: Oxford University
Press; 1998. p. 75-87.
2. Tennant WG. Limb ischaemia. In: Macintyre IM, Smith RC, editors. The RCSE
SELECT Program. Dundee: Dundee University Press; 2000. p. 1-25.
3. Walker AJ. Vascular Trauma. In: Davies AH, Beard JD, Wyatt MG, editors.
Essential Vascular Surgery. London: W.B.Saunders; 1999. p. 304-15.
page [59]
4
Pulmonary embolism
Pulmonary embolism (PE) deep vein
thrombosis (DVT) 1 5 DVT PE 50 %
85% PE DVT 5%
pelvic vein PE PE

Pulmonary artery sudden death

pulmonary infarction
emboli
chronic pulmonary artery hypertension
pulmonary embolism
4.1
PE hypoxia, tachypnea

pleural rub
page [60]
4.2
4.2.1. Arterial blood gas PaO2 PaCO2 respiratory
alkalosis
4.2.2.Chest X-ray
pulmonary vein
wedge shaped infract
4.2.3. EKG Q wave and T-wave
inversion lead III 20%
4.2.4. Ventilation perfusion scan
radio isotope

technetium labelled
microspheres microspheres
PE microspheres
radioactivity
radioactive gas (Krypton , xenon) aerosol
(DTPA) gamma camera pulmonary embolism
radioactive gas technetium labelled
microspheres atelectasis pneumonia
technetium labelled microspheres radioactive gas
page [61]
perfusion scan
4.2 5.Pulmonary angiogram
pulmonary angiogram (gold standard)
pulmonary embolism invasive investigation
massive pulmonary embolism thrombolysis
pulmonary angiogram
(contrast) pulmonary circulation filling defects
pulmonary embolism
4.2 6. CT angiographs
major thrombus
pulmonary artery
4.3
3
4.3.1 Anticoagulation
anticogulation DVT heparin
page [62]
Coumadin 3 PE
Anticoagulation
4.3.2 Thrombolytic therapy massive pulmonary
emboli haemodynamic
4.3.3 Caval filter
embolism inferior vena cava
iliac vein recurrent PE
anticoagulation anticoagulation
caval filter
1. Davies AH. Deep venous thrombosis and pulmonary embolism. In: Davies AH,
Beard JD, Wyatt MG, editors. Essential Vascular Surgery. London:
W.B.Saunders; 1999. p. 266-77.
2. Lamont PM, Shearman CP, Scott DJA. Venous disease. In: Lamont PM, Shearman
CP, Scott DJA, editors. Vascular Surgery. Oxford: Oxford University Press;
1998. p.118-29.
3. Stonebridge PA. Varicose vein, venous insufficiency and deep vein thrombosis. In:
Macintyre IMC, Smith RC, editors. The RCSE SELECT Program. Dundee: Dundee
page [63]
2
1.1 (superficial system) 3
Long saphenous veins
Short saphenous Veins
Perforating Communicating veins
Long saphenous veins
medial malleolus
medial femoral veins groin 4-6
groin long saphenous veins
variations
Saphenous branch femoral nerve long saphenous veins

venous stripping venous stripping
Short saphenous vein lateral

malleolus variation
Short saphenous vein popliteal veins (60%)
( long saphenous 20 % 20%
) Sural nerve
venous stripping short saphenous vein
Perforator veins deep superficial systems

superficial systems deep systems
superficial systems deep systems 50
perforator
page [64]
1.2 (deep system)

3
2 (
) 6
popliteal vein popliteal artery popliteal fossa
adductor hiatus
medial
profunda vein common femoral vein groin

1 ()
Residual arterial pressure
(foot and calf muscle pumps)
negative intrathoracic pressure

semilunar bicuspid
300 inguinal ligament
inguinal ligament , perforator
soleal sinusoidal vein
superficial systems deep systems
1. Davies AH. Varicose Vein. In: Davies AH, Beard JD, Wyatt MG, editors. Essential
Vascular Surgery. London: W.B.Saunders; 1999. p. 252-60.
University Press; 2000. p. 1-25
page [65]
2
(Varicose vein)
superficial vein
superficial vein
deep system () superficial system
superficial system deep system
deep system superficial system
saphenofemoral valve groin saphenopopliteal
junction perforating vein
2.1
2
Primary varicose vein
Secondary varicose vein deep venous thrombosis
2.1.1 Primary varicose vein

superficial system deep system saphenofemoral junction

2.1.2 Secondary varicose vein
deep venous thrombosis (DVT)
DVT (venous incompetence) DVT
superficial systems superficial venous hypertension
deep venous incompetence

page [66]
varicose vein great saphenous varicose vein Short

saphenous varicose vein
2.2

page [67]
(Cramps)
2.3
(Thrombophlebitis)
deep vein thrombosis pulmonary embolism
Chronic venous insufficiency ( 5)

2.4
2.4.1

DVT
secondary varicose vein DVT
2.4.2

long short saphenous veins Chronic venous insufficiency

2.4.3 Brodie Trendelenburg test

( )
page [68]
Tourniquet (mid thigh)

tourniquet
tourniquet saphenofemoral junction
tourniquet
tourniquet Saphenopopliteal Perforator
incompetence() tourniquet
2 tourniquet

pulse pulse ankle-brachial pressure
index
2.4.4
3
Varicography
superficial deep system
(Recurrent
varicose vein) varicography invasive
DVT

Continuous wave Doppler (CWD )
Doppler
saphenofemoral junction
> 0.5 (prolong
reverse of flow) valvular incompetence ()

DVT
DVT DVT
hyperpigmentation
page [69]
1.1 Duplex evaluation Bmode ultrasound Doppler
1.2 Ascending venography

deep vein x-ray
duplex ultrasound
2.5
2.5.1 Conservative treatment

conservative treatment

2.5.2 (Sclerotherapy)
page [70]

(sclerosing agent sodium tetradecyl)
(elastic bandage)
3

(great saphenous vein)
saphenofemoral
incompetence

2.5.3
2
1. (deep system)
(superficial system) Saphenofemoral junction,
saphenopopliteal junction above knee perforators
2. venous stripping vein
avulsion

(recurrent varicose vein)
2.5.3.1 long saphenous vein
groin skin crease
saphenofemoral junction (stripping of
the long saphenous vein)

saphenous nerve long saphenous
vein stripping
page [71]
vein stripper
stab
avulsions 2 3

2.5.3.2 short saphenous vein
10% short saphenous vein
incompetence saphenopopliteal junction

stab avulsion
saphenopopliteal junction vein stripper
(sural nerve)
2.6
(recurrent varicose vein)
(conservative treatment) 90%
35%
20%

page [72]
W.B.Saunders; 1999. p. 266-77.
3. Davies AH. Venous ulceration. In: Davies AH, Beard JD, Wyatt MG, editors. Essential
C, Scott DJA, editors. Vascular Surgery. Oxford: Oxford University Press; 1998.
p.118-29.
page [73]
3
Deep vein Thrombosis
Deep vein thrombosis (DVT)
(Thrombus)
(pulmonary artery) Pulmonary embolism
Virchow deep vein thrombosis 3
1. stasis
2. Endothelial injury
3. Hypercoagulable
DVT
Venous
endothelial

venous thrombosis
3.1 DVT 2
3.1.1 (Background factors)
DVT

4

Estrogens
DVT
(Thrombophilia) deficiency of antithrombin , activated protein C
page [74]
resistance, Antiphospholipid antibody, lupus anticoagulant

Homocysteinaemia
3.1.2 DVT
hip joint

myocardial infarction
Paralysis lower limb
Severe infection
Inflammatory bowel disease
Nephrotic syndrome
Polycythaemia
Paraproteinaemia
Paroxysmal nocturnal haemoglobinaemia
Bechets disease
3.2 Pathophysiology DVT
DVT

thrombus Pulmonary infarction thrombus
acute right heart failure

3.3
60% DVT DVT
2
page [75]
. calf vein thrombosis

. iliofemoral thrombosis
Pitting oedema deep vein
thrombosis
(phlegmasia caerula dolens)
(venous gangrene)
phlegmasia caerula dolens

3.4
2
3.4.1 Non invasive tests duplex scan
B mode ultrasound
ultrasound
echogenicity
echogenicity Doppler
page [76]
duplex scan
iliac vein
vena cava
3.4.2 Invasive investigation Bilateral ascending venography
2
DVT deep vein
collateral vessel
(thrombosis)
venogram
3.5
2
3.5.1 deep vein
thrombosis 3

pulmonary embolism
page [77]
pulmonary embolism
2
3.5.1.1

DVT

3.5.1.2 DVT
3.5.1.2.1 Anticoagulation
heparin heparin (bolus)
100 150 units/kg. heparin
activated partial thromboplastin time
(APTT) 2 low molecular weight
heparin (LMWH)
Continuous heparin Anticoagulation
page [78]
-
heparin fresh frozen plasma
- heparin (heparin induced thrombocypenia -HIT)
heparin 3-4 %
2-3 heparin

continuous heparin
(oral anticoagulant) coumadin
5 heparin 5
heparin coumadin
prothrombin time 2
oral anticoaguant (Dematitis)
DVT 3
DVT DVT
3.5.1.2.2 Thrombolysis
(phlegmasia cerulea dolen)

thrombosis plasminogen activator (TPA)
3.5.1.2.3 Caval filter

inferior vena cava
pulmonary embolism
pulmonary embolism

(free floating iliac vein thrombosis caval thrombosis)
3.5.2 DVT (prophylaxis)
DVT DVT
hip joint heparin
pulmonary embolism 50%
page [79]
(haematoma)

(Thrombocytopenia)
heparin
-
- (intracerebral haemorrhage)
- HIT
heparin low molecular weight heparin (LMWH)

heparin DVT 5

DVT DVT
DVT
(thrombophilia)
3.6 DVT
DVT DVT
DVT anticoagulation 3 10%
DVT 3 iliofemoral deep vein
thrombosis pulmonary embolism 10 20%
page [80]
W.B.Saunders; 1999. p. 266-77
2. Davies AH. Venous ulceration. In: Davies AH, Beard JD, Wyatt MG, editors. Essential
CP, Scott DJA, editors. Vascular Surgery. Oxford: Oxford University Press;
1998. p.118-29.
page [81]
5
Chronic venous insufficiency (CVI)
venous
hypertension CVI (deep vein
thrombosis-DVT ) deep venous occlusion
( deep or superficial venous valvular incompetence ) 2
CVI primary varicose vein primary deep venous valvular
incompetence
chronic venous insufficiency

125
30% 3
- Unobstructed conduit
page [82]
-
-
venous hypertension
Lipodermatosclerosis ( thickened pigmented skin)
(venous ulcer) venous

hypertension chronic venous insufficiency
2
. Fibrin cuff
venous hypertension protein
. venous hypertension
venous ulcer
venous ulcer
page [83]
Chronic venous insufficiency with skin change
Venous gangrene
5.1
40%
primary varicose vein
deep vein
page [84]
5.2
DVT
peripheral arterial disease
chronic venous ulcer
medial malleolus
5.3
deep superficial venous drainage

Duplex scanning
(deep and superficial vein)

superficial vein deep vein

valvular incompetence () deep
system
5.4
2
1 chronic venous insufficiency
(primary varicose vein)
( 2)
2 (deep venous insufficiency)
(compression bandaging)

5.4.1 (Compression bandaging)

venous ulcer
page [85]
four layer compression bandaging 4

5.4.2
CVI

(conduit)

5.5
30-50% CVI primary varicose vein
90%
CVI

74% 12
5.6

page [86]
1. Davies AH. Deep venous thrombosis and pulmonary embolism. In: Davies
AH, Beard JD, Wyatt MG, editors. Essential Vascular Surgery. London:
W.B.Saunders; 1999. p. 266-77.
3. Davies AH. Venous ulceration. In: Davies AH, Beard JD, Wyatt MG, editors.
Essential Vascular Surgery. London: W.B.Saunders; 1999. p. 261-65.
4. Lamont PM, Shearman CP, Scott DJA. Venous disease. In: Lamont PM,
Shearman CP, Scott DJA, editors. Vascular Surgery. Oxford: Oxford
University Press; 1998. p.118-29.
5. Stonebridge PA. Varicose vein, venous insufficiency and deep vein thrombosis.
In: Macintyre IMC, Smith RC, editors. The RCSE SELECT Program. Dundee:
Dundee University Press; 2000. p. 1-25.
page [87]
FACTS AND FIGURES

(ANEURYSMAL DISEASE)
(localized)
2
1. True
2. False
aneurysm
Fusiform aneurysm axis of vessel
Saccular aneurysm tangential of axis
Dissecting aneurysm intima

1.3.1.Congenital
Berry aneurysm
Marfans syndrome
Ehler-Danlos
1.3.2.Acquired
1.3.2.1 Trauma / iatrogenic
o Instrumentation (arterial monitoring lines )
o Intravenous drug abusers
1.3.2.2 Inflammation / infection
o Syphilis ,TB
o Mycotic
o Retroperitoneal fibrosis
1.3.2.3 Degeneration - atherosclerosis
page [88]

Aorta 95% atherosclerosis
(infra-renal aorta) 95%
Iliac artery, femoral artery, popliteal artery
Circle of Willis
Splenic artery/ hepatic artery / mesenteric artery ( < 1%)
Rupture
Thrombosis
Local pressure symptoms
Source of embolism
ABDOMINAL AORTIC ANEURYSM

Ultrasound and CT scan
ANEURYSM
o 1.
o 2.
o 3. infra suprarenal
o 4. iliac artery
page [89]
U/S Abdominal aortic aneurysm
CT abdomen Abdominal aortic aneurysm
page [90]
CT reconstruction Abdominal aortic aneurysm
angiogram Abdominal aortic aneurysm
> 60
atherosclerosis
page [91]
2
1.

Hypovolemic shock
2.

Myocardial infarction
Peptic ulcer disease
Pancreatitis
Renal colic
2
1. Aneurysm
(Resuscitation)
(Emergency abdominal aortic repair)
50% 100%
2. Aneurysm
Aneurysm
Aneurysm
50 %
5%
(UK
small aneurysm trial)
.
page [92]
- 5.5 cm Aneurysm
( )
- Aneurysm Aneurysm
12 %
. < 5.5 cm
ultrasound CT scan
0.5%
- 5.5 cm
- > 1.0 cm
-
Abdominal aortic aneurysm
(early complication)

o Hypovolaemic shock
o Cardiogenic shock
o ARDS
o DIC
page [93]
Anastomotic leak haemorrhage

Reperfusion injury
o Systemic hyperkalaemia
o Myoglobinuria causing renal failure / cardiac arrhythmia
Acute ischaemia embolism thrombus aneurysm
embolectomy
Inferior mesenteric artery ligation gut ischaemia
Renal hypoperfusion- renal failure
Spinal- paraplegia
(late complication)
Graft
Thrombosis
Infection
Aorto-enteric fistula
Sexual dysfunction
abdominal aortic repair 5
80%
Endovascular aortic stenting
aneurysm
aneurysm (Endovascular stenting)
page [94]
endovascular surgery in abdominal aortic aneurysm
page [95]
FACTS AND FIGURES

ATHEROSCLEROSIS DISEASE

fibrous tissue plaque

Histopathology plaque
Activated macrophage infiltration
Smooth muscle proliferation
Calcification
1.1.1 Atherosclerosis

1.1.2 Atherosclerosis 2
1. intermittent claudication
2. acute thrombosis atherosclerotic plaque

1.
2.
3. Collateral circulation
page [96]
1.1.3
1.1.3.1 Doppler (hand held Doppler) bedside
vessel pulse signals triphasic

monophasic
Ankle-brachial pressure index severity
1.1.3.2 Duplex Scan
1.1.3.3 Arteriography
1.1.3.4 Magnetic resonance angiography (MRA)
1.1.3.2-1.1.3.4

1.1.4 atherosclerosis

1.1.4.1 CAROTID DISEASE
bifurcation of common carotid artery and internal carotid
artery platelet emboli
Amaurosis fugax
Transient ischaemic attacks
Cerebral infarction (stroke)
(Carotid endarterectomy) internal
carotid artery 70%
internal carotid artery
70% stenosis
page [97]
Carotid endarterectomy atherosclerotic

plaque carotid
1%, 4% Hypoglossal nerve injury (
dissection) 5%
1.1.4.2 SUBCLAVIAN ARTERY

Proximal subclavian artery stenosis Steal
syndrome
vertebral artery subclavian artery stenosis
steal syndrome vertebro basilar insufficiency
Vertigo, tinnitus , nausea collapse
endarterectomy jump graft
Angiogram Subclavian steal syndrome

1.1.4.3 SUPERIOR MESENTERIC AND INFERIOR MESENTERIC ARTERY
DISEASE
(Occlusion)
(mesenteric infarction)
page [98]
endarterectomy bypass
(Bowel resection of non
viable gut)
1.1.4.4 RENAL ARTERY DISEASE

renin angiotensin aldosterone system
Transluminal angioplasty (radiological

intervention) renal artery endarterectomy
1.1.4.5 AORTO ILIAC DISEASE
distal aorta proximal common iliac artery
Collateral vessels

(Chronic)
Buttock
Impotence
aorto-iliac disease Lehriches syndrome
(Transluminal angioplasty)
5
50-60%
(bypass surgery) (Dacron)
page [99]
Aorta bifemoral graft

5 90%
5%
abdominal aortic aneurysm repair
Axillo bifemoral Femoral femoral crossover graft

(Unfit / high risk patients) 5 Femoral
femoral crossover graft 60%
1.1.4.6 FEMORAL ARTERY AND CRURAL ARTERY DISEASE

superficial femoral artery (
adductor canal) (crural
artery disease)
2
. Intermittent claudication
(atrophic change)

(gangrene)
.
acute thrombosis atherosclerosis pain, pale,
pulseless , parasthesia , paralysis (5P)
Ankle brachial pressure index (ABPI)

(systolic pressure)
page [100]
(dorsalis pedis artery posterior tibial artery) (brachial artery)

Doppler ultrasound right
dorsalis pedis artery 60 mmHg brachial artery 120 mmHg
ABPI = 0.5 (60/120)
ABPI < 0.7 moderate ischaemia < 0.5 severe
ischaemia rest pain and sever ischaemia
calcification

. bypass

(autogenous vein
graft great saphenous vein) (prosthetic graft)
( 1)
femoropopliteal bypass ()
graft 2 femorodistal bypass(
femorotibial bypass)
1
1 bypass graft
5
5-Year patency
Vein graft
Prosthetic graft
Femoro- popliteal
65-70%
55-65%
Femoro-distal bypass
50%
20-30%
. (Transluminal angioplasty)
- < 10 cm
page [101]
- 5 Transluminal angioplasty
40-50%
.

bypass
Anastomotic leak
Thrombosis and occlusion
Infection
page [102]
FACTS AND FIGURES

(chronic leg ulcer)

6
1. Venous disease
2. Arterial disease
3. Mixed venous arterial disease
4. Neuropathic diabetes
5. Neoplastic
Squamous cell carcinoma Marjolins
ulcer
Basal cell carcinoma
Malignant melanoma
6.
Pretibial
osteomyelitis
autoimmune disease
3.1 (VENOUS ULCERS)
venous insufficiency venous ulcer 2
Fibrin cuff theory fibrin venous insufficiency
oxygen Cellular
hypoxia
Oxygen-free radical theory oxygen free radical

page [103]
venous ulcer
squamous cell carcinoma

deep venous insufficiency
Duplex scan
incompetence

page [104]
1. venous insufficiency superficial vein

varicose vein ( great
saphenous vein saphenofemoral junction ligation, venous stripper
stab avulsion)
2. deep venous insufficiency conservative
treatment
Four layer compression bandage
Daily dressing
split thickness skin grafting
3.2. (DIABETIC ULCELRS)
3.2.1
3.2.1.1 (Arterial insufficiency)
( Macro vessel disease)
(Micro vessel disease) (loss of

regulatory function)
3.2.1.2. (Neuropathy)
Sensory neuropathy afferent sensation

Sympathetic dysfunction-
3.2.1.3.
page [105]
diabetic foot
3.2.2 (Management of the diabetic foot)

1.
2.
3.
4. 2
(aggressive debridgement)
femorodistal bypass
page [106]
1. Davies AH. Venous ulceration. In: Lamont PM, Shearman CP, Scott DJA, editors.
Vascular Surgery. Oxford: Oxford University Press; 1998. p. 261-65.
2. Green J, Wajed S. Vascular system. In: Green J, Wajed S, editors. Surgery Facts
and Figures. London: Greenwich Medical Media LTD; 2000. p. 141-60.
Press; 1998. p. 118-29.
page [107]
FACTS AND FIGURES

EMBOLIC DISEASE
(solid mass)

Platelet / fibrin aggregates
Fat
Air
Amniotic fluid
Infective
Metastatic
emboli

o Atrial fibrillation
o Post myocardial infarction
o Endocarditis
o Ventricular aneurysm
o Mitral valve
o Prosthetic valve
Aorta aortic aneurysm
clot Abdominal aortic aneurysm IMA
page [108]

Aortic bifurcation Saddle embolus
Popliteal trifurcation

Pale / pulse less / pain / parasthesia /
paralysis (5P)
6
arterial occlusion Abdominal aortic aneurysm
Acute embolic event () bolus dose heparin (5000 unit)

heparin 500-1000 unit
o Embolectomy Fogarty balloon catheter
page [109]
o heparin 500-1000 unit

PTT 2 control
o 10-20%
Slower onset
o thrombolytic therapy
page [110]
FACTS AND FIGURES

LYMPHOEDEMA
extracellular fluid
extravascular compartment- (subcutaneous tissues)
5.1 lymphoedema
5.1.1. Congenital (primary) lymphoedema (Milroys disease)

Milroys disease 3
- Lymphoedema congenita-
- Lymphoedema praecox-
- Lymphoedema tarda-
Non-pitting oedema
Hypoplasia of lymphatic vessel

lymphangiography
5.1.2. Acquired (secondary) lymphoedema
secondary lymphoedema
- Trauma-major limb trauma
- Iatrogenic
Surgical bloc dissection of nodal area upper limb oedema post breast
surgery
Radiotherapy to lymphatic bed
- Infection
Repeated acute infections (e.g. barefoot)
Chronic bacterial infection TB, fungus
page [111]
Parasitic-filariasis elephantiasis
- Malignancy carcinomatosis

(subcutaneous vessels)

Hypoproteinaemia
Cardiac failure
Deep vein thrombosis
5.2
Recurrent cellulitis
Ulceration
Malignancy (rare) lymphangiosarcoma (Stewart-Treves syndrome), Basal cell
carcinoma, Squamous cell carcinoma, melanoma, fibrous histiocytoma
5.3 lymphoedema
(Conservative treatment)

Compression stockings Intermittent limb compression pump

2. Lamont PM, Shearman CP, Scott DJA. Lower limb arterial disease. In: Lamont
PM, Shearman CP, Scott DJA, editors. Vascular Surgery. Oxford: Oxford
page [112]
FACTS AND FIGURES


thoracic outlet

Fibromuscular bands
Cervical ribs
clavicle, scalenius muscles
first rib
Subclavian artery
Subclavian vein
Brachial plexus C8- T1 roots
4.1
Arterial
Cold, pale (ischaemic)
Embolism
Raynauds syndrome
Venous
Cyanosis
Oedema
Thrombosis
Nerve
Pain
Paresthesia
page [113]
Weakness
4.2 (Differential diagnosis)
C-spine pathology
Distal nerve compression
Pancoast tumour
Raynauds disease
Atrial fibrillation (AF) peripheral embolism
Clotting disorder hypercoagulable states (protein C deficiency)
4.3
Chest X-ray (CXR)
Magnetic resonance imaging
Angiogram
4.4
. conservative treatment (physiotherapy)
thoracic outlet
. (Thoracic outlet
decompression) conservative treatment
2. Lamont PM, Shearman CP, Scott DJA. Upper limb disease. In: Lamont PM,
Press; 1998. p. 49-58.
3. Thompson JF. Subclavian and upper limb disease. In: Davies AH, Beard JD,
Wyatt MG, editors. Essential Vascular Surgery. London: W.B.Saunders; 1999. p.
138-54.
page [114]
FACTS AND FIGURES


Streptokinase ( streptococci )
Urokinase ()
Tissue plasminogen activator (TPA ) non-antigenic
plasminogen activator
thrombolytic activity
Acute thrombosis of an artery or bypass graft
Acute embolism
Acute thrombosis as a complication of angioplasty
Thrombosis of a popliteal aneurysm
Critical ischaemia with neurological deficit (intracerebral hemorrhage)
Irreversible ischaemic change of limb (gangrene)
The early postoperative period
page [115]
FACTS AND FIGURES
(VARICOSE VEINS) superficial veins
2.1.
2.1.1 (Primary cause)

Genetic
collagen
Incompetence of valve system
(Retrograde flow) deep system perforating vessels
Transmural pressure
2.1.2. (Secondary cause)
Post-thrombosis deep system
Pelvic tumours
Short saphenous varicose vein
page [116]
Examination
Trendelenberg tests incompetence
2.2.
2.2.1 Long saphenous vein (LSV)
Sapheno-femoral junction incompetence (90%)
reflux Mid-thigh/mid-calf perforators
Antero-medial
2.2.2 Short saphenous vein (SSV)
incompetence Sapheno-popliteal junction Mid-calf perforators
Postero-lateral calf Popliteal fossa
lateral malleolus
2.3. (Investigations)
Deep system
Superficial system LSV SSV
page [117]
incompetence
Duplex scan
Venography
2.4
Cosmetic/patient request (90%)

Bleeding
Ulceration
(Contra-indications)
Deep vein insufficiency (DVI) or previous DVT
2.5
LSV
3 High tie (Saphenofemoral junction), strippling of long
saphenous vein stab avulsion
SSV
Ligate Saphenopopliteal junction avulsion
Saphenopopliteal junction variation
junction duplex scan
page [118]

LSV, SSV
Saphenous nerve , Lateral popliteal nerve
foot drop
(Recurrence)
1.
2. perforator incompetence
3. Deep system incompetence
sclerotherapy
saphenofemoral saphenopopliteal
incompetence
1. Davies AH. Varicose Vein. Chronic leg ischaemia. In: Davies AH, Beard JD,
Wyatt MG, editors. Essential Vascular Surgery. London: W.B.Saunders; 1999. p.
252-60.
Press; 1998. p. 118-29.
page [119]
FACTS AND FIGURES

VASCULAR NEOPLASIA
(Rare)
Carotid body tumour (chemodectoma)
Angiosarcoma
Kaposi sarcoma AIDS
Glomus tumours
x-ray carotid body tumor
2. Lamont PM, Shearman CP, Scott DJA. Lower limb arterial disease. In: Lamont
PM, Shearman CP, Scott DJA, editors. Vascular Surgery. Oxford: Oxford
3. Shearman CP, Beard JD. Chronic leg ischaemia. In: Davies AH, Beard JD, Wyatt
MG, editors. Essential Vascular Surgery. London: W.B.Saunders; 1999. p. 21531.
page [120]
FACTS AND FIGURES

VASCULITIDES
1.4.1 Thromboangitis obliterans (Buergers disease)

20-30

(gangrene)
Antibodies elastin, type I and II collagen
HLA A 9, B5

Steroid / anticoagulants
Sympathectomy amputation
1.4.2 Takayasus disease
15-45
aorta brachiocephalic branches

Steroid surgical replacement
1.4.3 Giant cell arteritis

50

page [121]
superficial temporal artery

ophthalmic artery involvement
: (Biopsy) superficial temporal artery
high dose steroid
1.4.4 Small vessels vasculitides
Polyarteritis nodosa
Kawasaki disease
Wegeners granulomatosis
Churg-Strauss syndrome
Henoch-Schoenlein purpura

1.5. (Infective arteritis)

Tuberculosis
Syphilis
Leprosy
Bacterial infections
Viral infections
thrombosis, fibrosis, occlusion, aneurysm formation
page [122]
FACTS AND FIGURES

VASOSPASTIC DISEASE
Vasomotor sympathetic
(small vessels)
Raynauds disease
digital vasospasm
(without primary cause)
gangrene
, ( betablockers),

Systemic lupus erythrematosus (SLE)
Systemic sclerosis (CREST)
Rheumatoid arthritis
Sjogrens syndrome

(conservative)
1.
2. Prostacyclin gangrene
sympathectomy 30-40%
page [123]

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Vascular Knowledge

For medical student

Anatomy of legs venous system

Deep vein Thrombosis

Chronic venous insufficiency

Facts & Figures

Chronic leg ulcer

THORACIC OUTLET SYNDROME (TOS)

ABI Hand held doppler

(root of neck) bruits

aortoiliac (aortoiliac occlusive disease)

malleolus medial malleolus Achillis tendon

aneurysmal disease thrill

(right sided heart failure)

varicose vein, DVT DVT

Thoracic outlet syndrome subclavian vein subclavian vein

Axillary vein Subclavian vein

2.3.1 Varicose vein

long saphenous vein

tourniquet trendelenburg test

(Superficial venous dilatation)

2.3.3 Postphlebitic syndrome

metatarsophalangeal joint buffalo hump

Road traffic accident

1.2.1 (Blunt injury)

angiogram subclavian artery occlusion fracture clavicle

1.2.3 (Iatrogenic Injury)

false aneurysm catheter

Traumatic arteriovenous fistula

1.4.4 X- RAY (Plain film)

1.4.6 Magnetic resonance imaging

angiogram vascular injury

superficial femoral artery

2 (peroneal artery posterior tibial artery)

Fasciotomy compartment syndrome

2.2.2.2 Acute thrombosis

arterial embolism atherosclerosis

2.3 1.1 acute ischaemia (5P)

embolism atrial fibrillation MI

Rest pain at night

Ulcer chronic arterial occlusion

Digital gangrene arterial occlusion

2.3.2 (location of the occlusion)

aortic iliac occlusion

2.3.2.3 Superficial femoral artery occlusive disease

superficial femoral artery (SFA)

2.3.2.4 Crural artery occlusive disease

- pain (tenderness) anterior posterior

- dry gangrene dry

2.3.4.3 post-event causes

Myoglobinuria renal failure

2.3.5.3. Fixed wave Doppler examination

Ankle Brachial index

Angiogram = Road map for surgery

2.3.5.8. Magnetic Resonance Arteriography (MRA)

2. critical limb ischaemia rest pain, gangrene chronic

Femorotibial bypass vein graft

3.Below knee amputation

4. Gritti stoke amputation Knee joint

5. Above knee amputation

Below knee amputation long posterior flap

Short saphenous vein lateral

Perforator veins deep superficial systems

1.2 (deep system)