VASCULAR SURGERY

HOW TO DIAGNOSE..?

• ANAMNESIS
• PHYSICAL EXAMINATION
• DISTAL EVALUATION
• ANKLE BRACHIAL INDEX (ABI)
• IMAGING STUDY
• INVASIVE PROCEDURE
ANAMNESIS
• TRAUMA OR NON TRAUMA CASES
• PARAESTESIA
• COLD ACRAL
• NON HEALING WOUND
• UNILATERAL LOWER EXTREMITY EDEMA
• ETC
PHYSICAL EXAMINATION
• HARD SIGN
• ACTIVE BLEEDING
• EXPANDING HEMATOMA
• END-ORGAN ISCHEMIA  PULSELESS, PALOR, PARESTHESIA, PAIN,
PARALYSIS
• PALPABLE THRILL & BRUIT
PHYSICAL EXAMINATION
• SOFT SIGN
• DIMINISHED PULSE
• PERIPHERAL NERVE DEFICIT
• HISTORY OF SHOCK & BLEEDING
• ABNORMAL ANKLE-BRACHIAL INDEX
PHYSICAL EXAMINATION EXTREMITY

• CAPILLARY REFILL TIME

• EDEMA  UNILATERAL
• PALE OR CYANOTIC OR NORMAL SKIN COLOR DISTAL
• COLD OR WARM OR NORMAL TEMPERATURE
• ULCER  NON HEALING WOUND
• ETC
DISTAL EVALUATION
ANKLE
BRACHIAL
INDEX
IMAGING STUDY
• DOPPLER ULTRASOUND VASCULAR
• MSCT ANGIOGRAPHY
• CONVENTIONAL ARTERIOGRAPHY
• PERCUTANEOUS TRANSLUMINAL ANGIOGRAPHY (PTA) 
CATHETERIZATION LAB
DOPPLER
VASCULAR
 MSCT ANGIOGRAPHY
• CT ANGIOGRAPHY HAS EXCELLENT SENSITIVITY AND
SPECIFICITY COMBINED WITH FEWER COMPLICATIONS
COMPARED TO CONVENTIONAL ARTERIOGRAPHY.
• COMPUTED TOMOGRAPHY ANGIOGRAPHY IS QUICKLY
EMERGING AS A LESS INVASIVE, MORE EFFICIENT, AND
SAFER ALTERNATIVE TO ARTERIOGRAPHY FOR THE
DIAGNOSIS AND LOCALIZATION OF VASCULAR TRAUMA IN
AN ACUTE LOWER-EXTREMITY INJURY.
CONVENTIONAL ANGIOGRAPHY
PERCUTANEOUS TRANSLUMINAL ANGIOGRAPHY

• DIGITAL SUBSTRACTION ANGIOGRAPHY

• VISUAL FLOW
• DIAGNOSTIC
• TREATMENT  ENDOVASCULAR SURGERY
VASCULAR CASES
• TRAUMA
• ARTERIAL  MAJORITY
• VEIN
• NON TRAUMA
• ARTERIAL
• VEIN
• LYMPHATIC
TRAUMA CASES  EMERGENCY
• HARD SIGN
• ACTIVE BLEEDING
• EXPANDING HEMATOMA
• END-ORGAN ISCHEMIA  PULSELESS, PALOR, PARESTHESIA, PAIN,
PARALYSIS
• PALPABLE THRILL & BRUIT
• SHOCK  HYPOVOLEMIC
• OTHER EMERGENCY CASE  ACUTE LIMB ISCHEMIA
SHOCK DUE TO BLEEDING

• EXTERNAL BLEEDING
• INTERNAL BLEEDING
• MASIVE HEMATOTHORAX
• ABDOMINAL BLEEDING
• PELVIC BLEEDING
• LONG BONE FRACTURE
 Primary survey – ABC (resusitasi cairan)
 Kontrol perdarahan  STOP BLEEDING !!
› Balut tekan
› Proximal tourniquet
› Proximal pressure point

 Pencegahan kontaminasi lebih lanjut

 Pemberian antibiotik + Anti tetanus

David VF : Management of the Mangled Extremity, American College of

Surgeons, Committee on trauma, Sub committee on Publication, 2002
NON TRAUMA CASES (COMMON)

•ARTERIAL
•VEIN
•LYMPHATIC
NON TRAUMA CASES COMMON
SYMPTOMS
• PARAESTESIA
• COLD ACRAL
• NON HEALING WOUND
• UNILATERAL LOWER EXTREMITY EDEMA
ARTERIAL DISEASES
•THROMBO-EMBOLISM
•ARTERIOSCLEROSIS
•RAYNAUD DISEASE
•BURGER DISEASE
•CLAUDICATION INTERMITTEN
ARTERIAL THROMBO-EMBOLISM

• SUDDEN INTERRUPTION OF BLOOD FLOW TO AN ORGAN OR

BODY PART DUE TO A CLOT (THROMBUS) TRAVEL FROM
OTHER ORGAN (EMBOLUS).
 ACUTE LIMB ISCHEMIA
Pathophysiology
Metabolic syndrome and reperfusion injury,
Thrombo-embolism (dysritmia)
Clinical classification
I. Viable
II. Threatened
a. Marginally
b. Immediately
III. Irreversible

Clinical diagnosis ( Five P’s) or 6 P’s

Pain, pulselessness,pallor,paresthesia and paralysis (+)
poikilothermia
ETIOLOGY OF ACUTE LIMB ISCHEMIA
1.Embolic Occlusion
Origin of arterial emboli
* Arterial fibrillation
* Rheumatic MS(90% from heart)
* Myocardial infarction
Less common causes
* Debris from aneurysm * Prosthetic heart valves
* Debris from ateriosclerotic plaques
* Left atrial myxoma * Ventricular aneurysm
* Bacterial endocarditis * other

2.Acute Arterial Thromboembolism

3.Bypass Graft Thrombosis
4. Other
ARTERIOSCLEROSIS

• ANY HARDENING (AND LOSS OF

ELASTICITY) OF MEDIUM OR LARGE
ARTERIES
• ATHEROSCLEROSIS, A SPECIFIC
FORM OF ARTERIOSCLEROSIS 
FATTY PLAQUES
 RAYNAUD DISEASE
• CONDITION THAT AFFECTS THE BLOOD SUPPLY TO THE FINGERS, TOES
AND OCCASIONALLY THE EARS AND NOSE.

• RAYNAUD’S ATTACK, OR EPISODE, THE BLOOD VESSELS CONSTRICT

(NARROW) AND THE BLOOD SUPPLY TO THESE AREAS IS REDUCED.

• SKIN COLOR CHANGES WHICH ARE OFTEN ACCOMPANIED BY A

THROBBING OR BURNING SENSATION, COLD, AND NUMBNESS.

• TYPE:
• PRIMARY RAYNAUD’S OR RAYNAUD’S DISEASE NO OTHER
MEDICAL PROBLEM
• SECONDARY RAYNAUD’S OR RAYNAUD’S PHENOMENON  OTHER
MEDICAL PROBLEM
BURGER DISEASE
• BUERGER'S DISEASE  THROMBOANGIITIS OBLITERANS
• BLOOD VESSELS BECOME INFLAMED, SWELL AND BLOCKED WITH BLOOD CLOTS
(THROMBI)  INFECTION AND GANGRENE.
• USUALLY IN THE HANDS AND FEET  ARMS AND LEGS.
• QUITTING ALL FORMS OF TOBACCO IS THE ONLY WAY TO STOP BUERGER'S
DISEASE.
CLAUDICATION INTERMITTEN
• A CLINICAL DIAGNOSIS GIVEN FOR MUSCLE PAIN (ACHE,
CRAMP, NUMBNESS OR SENSE OF FATIGUE),[1] CLASSICALLY IN
THE CALF MUSCLE, WHICH OCCURS DURING EXERCISE, SUCH
AS WALKING, AND IS RELIEVED BY A SHORT PERIOD OF REST.
FONTAINE CLASSIFICATION OF PERIPHERAL ARTERIAL OCCLUSIVE
DISEASE

I. Sense of cold,numbness, Raynaud’s syndromes

II. Intermittent claudication

III. Rest pain

IV. Ulcer, gangrene

PHYSICAL EXAMINATION
1. Inspection
a. Trophic change
b. Color change
c. Ischemic ulcer
d. Gangrene
2. Palpation
a. Temperature
b. Pulse
3. Auscultation : Bruit
VEIN
•THROMBOSIS
•PHLEBITIS
•VEIN INSUFFICIENCE
•VARICES
DEEP VEIN THROMBOSIS (DVT)

• MOST LIKELY TO OCCUR IN DEEP

VEINS OF THE CALF (80%)
• 25% OF THROMBI THAT OCCUR IN
CALF WILL EXTEND TO THE POPLITEAL
& FEMORAL VEINS
• PE MAY BE THE FIRST SIGN OF DVT
DVT MANIFESTATIONS
• WHEN CLOT IS IN FORMATIVE STAGE, MAY NOTICE NO
SYMPTOMS
• USUALLY PROFOUND TENDERNESS; AFFECTED EXTREMITY MAY
BE LARGER (UNILATERAL EDEMA)
• DULL ACHING ESP WHEN WALKING: MOST COMMON
• SEVERE PAIN, ESP WHEN WALKING
• CYANOSIS OF EXTREMITY
• SLIGHTLY ELEVATED TEMP
• GENERAL MALAISE
HOMAN’S SIGN
• WAS LONG CONSIDERED CLASSIC MANIFESTATION—THIS IS NO
LONGER TRUE

• SIGN IS NOT SPECIFIC TO DVT & CAN BE ELICITED BY ANY CONDITION

OF THE CALF

• AS CALF MUSCLES CONTRACT, THERE IS RISK OF DETACHING

THROMBUS FROM THE WALL
SUPERFICIAL VEIN THROMBOSIS (SVT)
• THROMBI FORM PRIMARILY IN UPPER EXTREMITIES
• PRIMARY CAUSE: TRAUMA TO VENOUS WALL ASSOC W/VENOUS
CATHETERS, REPEATED VENOUS PUNCTURES, USE OF STRONG IV
SOLUTIONS THE PRODUCE INFLAMMATORY RESPONSE 
THROMBOPHLEBITIS
SVT MANIFESTATIONS
• DULL, ACHING PAIN OVER AFFECTED AREA: KEY
• MARKED REDNESS ALONG VEIN
• INCREASED WARMTH OVER AREA OF INFLAMMATION
• PALPABLE CORDLIKE STRUCTURE
• MORE IMMEDIATE ATTENTION IS REQUIRED IF EDEMA, CHILLS,
HIGH FEVER; SUGGESTS COMPLICATIONS OF INFLAMMATION
 (CRHONIC) VEIN INSUFFICIENCY
• DISORDER INVOLVING STASIS OF BLOOD IN LOWER
EXTREMITIES AS RESULT OF OBSTRUCTION & REFLUX OF
VENOUS VALVES
• ASSOC W/CHANGES IN VENOUS CIRCULATION RESULTING
FROM THROMBOPHLEBITIS & VALVULAR INCOMPETENCE,
VARICOSE VEINS
 CLINICAL MANIFESTIONS
• LOWER LEG EDEMA
• ITCHING
• BROWN PIGMENTATION/CYANOSIS OF SKIN OF LOWER LEG/FOOT
• FIBROSIS/HARDNESS OF SUBCUTANEOUS TISSUES
• STASIS ULCERS OVER ANKLE, MOST OFTEN MEDIAL
COMPLICATION: ULCER DEVELOPMENT
• BLOOD POOLS IN LOWER LIMB AND PERIPHERAL CIRCULATION
SLOWS; INSUFFICIENT OXYGEN & NUTRIENTS TO CELLS
• CELLS DIE CAUSING FORMATION OF VENOUS STASIS ULCERS
• IN ATTEMPT TO HEAL STASIS ULCER, BODY INCREASES SUPPLY
OF OXYGEN, NUTRIENTS, AND ENERGY TO AREA; BUT IT DOES
NOT REACH THE DISEASED TISSUES DUE TO IMPAIRED
CIRCULATION = ENLARGED ULCERS
VARICOSE VEINS
VARICOSE VEINS
• MAY DEVELOP ANYWHERE IN BODY, BUT MOST DEVELOP IN
LOWER EXTREMITIES
• VEIN IN LEGS MOST OFTEN AFFECTED: LONG SAPHENOUS
• OCCUR IN 1 OUT OF 5 PEOPLE; MORE COMMON FEMALES > 35;
WHITES > BLACKS; FAMILIAL TENDENCY
• CAUSES
• SEVERE DAMAGE OR TRAUMA TO SAPHENOUS VEIN
• EFFECTS OF GRAVITY PRODUCED BY LONG PERIODS OF STANDING
• TYPES
• PRIMARY: NO DEEP VEINS INVOLVED
• SECONDARY: CAUSED BY OBSTRUCTION OF DEEP VEINS (MOST
COMMON)
PATHOPHYSIOLOGY
• MAJOR CAUSE: SUSTAINED STRETCHING OF VASCULAR WALL
DIE TO LONG-STANDING INCREASED INTRAVENOUS PRESSURE
• VALVES BECOME INCOMPETENT BECAUSE THEY CANNOT CLOSE
PROPERLY DUE TO STRETCHING
• PROLONGED STANDING, THE FORCE OF GRAVITY, LACK OF LOWER
LIMB EXERCISE, & INCOMPETENT VENOUS VALVES ALL WEAKEN
MUSCLE-PUMPING MECHANISM, & RETURN OF VENOUS BLOOD
TO HEART DECREASES
• AS CLIENT STANDS FOR LONG TIME, BLOOD POOLS AND VESSEL
WALL CONTINUES TO STRETCH, AND VALVES BECOME
INCREASINGLY INCOMPETENT
Normal vs Abnormal
 CLINICAL MANIFESTATIONS
• SEVERE, ACHING PAIN IN LEG
• LEG FATIGUE &/OR HEAVINESS
• ITCHING OVER AFFECTED LEG (STASIS
DERMATITIS)
•FEELINGS OF HEAT IN THE LEG
• VISIBLY DILATED VEINS
• THIN, DISCOLORED SKIN ABOVE ANKLES
• COMPLICATIONS: INSUFFICIENCY, STASIS
ULCERS, CHRONIC STASIS DERMATITIS,
THROMBOPHLEBITIS
COLLABORATIVE INTERVENTIONS
• CONSERVATIVE MEASURES INCLUDE ANTIEMBOLISM
STOCKINGS AND REGULAR WALKING & LEG
ELEVATION
• MILD ANALGESICS MAY RELIEVE PAIN
• COMPRESSION SCLEROTHERAPY & VEIN STRIPPING
• ENDOVENOUS LASER ABLATION
LYMPHATIC DISEASES

•LYMPHANGITIS
•LYMPHADENITIS
•LYMPHEDEMA
LYMPHANGITIS
• INFLAMMATION OF LYMPHATIC CHANNELS DUE TO INFECTIOUS OR
NONINFECTIOUS CAUSES. POTENTIAL PATHOGENS INCLUDE BACTERIA,
MYCOBACTERIA, VIRUSES, FUNGI, AND PARASITES.
• LYMPHANGITIS MOST COMMONLY DEVELOPS AFTER CUTANEOUS
INOCULATION OF MICROORGANISMS INTO THE LYMPHATIC VESSELS
THROUGH A SKIN WOUND OR AS A COMPLICATION OF A DISTAL INFECTION
LYMPHADENITIS
• INFECTION OF THE LYMPH NODES (ALSO CALLED
LYMPH GLANDS). IT IS A COMMON
COMPLICATION OF CERTAIN BACTERIAL
INFECTIONS

• LYMPHADENOPATHY 
SWOLLEN/ENLARGED LYMPH NODES". IT COULD
BE DUE TOINFECTION, AUTO-IMMUNE DISEASE,
OR MALIGNANCY.
LYMPHEDEMA
• SWELLING THAT GENERALLY OCCURS IN ONE ARMS OR LEGS. SOMETIMES BOTH
ARMS OR BOTH LEGS MAY BE SWOLLEN.
• LYMPHEDEMA IS CAUSED BY A BLOCKAGE IN LYMPHATIC SYSTEM
• THE BLOCKAGE PREVENTS LYMPH FLUID FROM DRAINING WELL, AND AS THE FLUID
BUILDS UP, THE SWELLING CONTINUES.
• LYMPHEDEMA IS MOST COMMONLY CAUSED BY THE REMOVAL OF OR DAMAGE TO
LYMPH NODES AS A PART OF CANCER DEVELOPMENT
THANK YOU