Lesson1_Acute_Arterial_Ischaemia_Notes.pdf

vascular system: acute occlusive arterial pathology lesson 1 acute occlusive arterial pathology  Qx Emergency: Limb in risk (or even patient´s life) ACUTE ISCHAEMIC SYNDROME  Sudden occlusion of LL blood flow in LL → Important ischaemia distally to obstruction → Massive muscle ischaemia → Muscl...

vascular system: acute occlusive arterial pathology lesson 1 acute occlusive arterial pathology  Qx Emergency: Limb in risk (or even patient´s life) ACUTE ISCHAEMIC SYNDROME  Sudden occlusion of LL blood flow in LL → Important ischaemia distally to obstruction → Massive muscle ischaemia → Muscle necrosis  Hyperpotassaemia + Metabolic Acidosis (lactic and pyruvic acid by anaerobic glycolysis) +/Myoglobinuria → RI (Renal Insufficiency)  +Fq: LL (especially femoral artery) atherosclerosis  Cardiovascular Risk Factor (injury factors): Hypercholesterolemia (↑ LDL) HBP DM Tobacco Produce endothelial dysfunction (vessel wall inflammation) -Endothelial adhesion molecules -Increased vessel permeability -Cytokines release: Attract Monocytes + Lymphocytes T (intima layer vessels) -LDL oxidation (LDL oxidase) atherosclerosis  Cardiovascular Risk Factor (injury factors): Hypercholesterolemia (↑ LDL) HBP DM Produce endothelial dysfunction (vessel wall inflammation) -Endothelial adhesion molecules Obesity -Increased vessel permeability -Cytokines release: Attract Monocytes + Lymphocytes T Tobacco (intima layer vessels) -LDL oxidation (LDKL oxidase) Monocytes Macrophages + LDL oxidase Foam cells (proinflammatory mediators) Fatty streak vessel wall Muscle cells + Foam cells + Lipids (Ch) Fibrous cap acute occlusive arterial pathology  AETIOPATHOGENESIS: 2 main causes EMBOLISM: Thrombus originated distally → migrates and impacts in peripheral artery +Fq origin: Heart (especially Heart Failure – ischaemic cardiopathy-, AF –Atrial Fibrillation-, MS –Mitral Stenosis-). Main vascular disease in UL (Upper Limbs) Site: Main arteries bifurcation THROMBOSIS IN SITU: Thrombus formed locally, normally aftermath of previous atherosclerotic injury +Fq: Chronic arterial ischaemia, By pass or endoprosthesis holders, iatrogenic (percutaneous catheterism), trauma,… acute occlusive arterial pathology  CLINIC: Proximal + dangerous > Distal.  “5P” rule: -Pain -Paraesthesia -Pallor (→ Cyanosis -lividness when chronic- → Extremity swelling W/ prenecrotic blisters → gangrene + Cold extremity) -Pulselessness -Paralysis Rutheford stablished clinic criteria for severity of acute ischaemia acute occlusive arterial pathology  D(x): Clinic  Image: Arteriography (Gold standard) = Location, Extension, Severity, Differentiates between Embolus and Thrombosis in situ USS (Doppler) = Site, Extension and previous arteriosclerosis. Angio-CT Scan + AngioMRI = Higher sensibility + Specificity  TREATMENT: Heparin (emergency) Extremity: Rest and incline. Analgesia for pain Severe (limb viability): Qx (open or endovascular) Embolus suspicion: Arterial embolectomy By pass thrombosis: Mechanical thrombectomy (or intra-arterial fibrinolysis) + angioplasty (or deviation) W/ or W/O stent  PHYSIOTHERAPY: PREVENTS COMPLICATIONS. NO CURE (differently from CHRONIC pathologies)      COMPLICATIONS:  General: Exitus (10-20% by Heart Attack or Arrythmias), Acute Renal Insufficiency (myoglobinuria), Amputation  Local: Compartment syndromes (fasciotomy). Rethrombosis (45% embolus, 55% thrombus) acute occlusive arterial pathology EXTRINSIC ARTERIAL COMPRESSIONS  Young. Infrequent Popliteal Artery Entrapment Syndrome (PAES)     Clinically = Intermittent Claudication PE: Popliteal , Posterior tibial and Dorsalis pedis pulses diminish. Might be normal, but reduced W/ dorsiflexion foot If severe → Qx (myotomy) Artery Endofibrosis Young, Cyclists (endurance sports). Mainly External Iliac (also in common iliac). Treatment: Qx  Repetitive movements in hyperflexion → Distension + Plication external iliac artery → Stenosis, Thrombus (occ dissection)  Clinic occ “buttock pain” misdiagnosed W/ musculoskeletal or neurological injury Thoracic outlet syndrome (TOS)   Compression brachial plexus, subclavian artery or vein in superior thoracic outlet Clinic: Nerve compression = Pain, Paraesthesia + “pin and needles” UL (especially cubital region). Artery compression = Exercise claudication (cold, pallor, numb and paraesthesia in limbs W/ exercise). Vein Compression = Effort Vein Thrombosis  Chronic situations → Subclavian aneurysm  Intermittent compression axillar or subclavian vein → Effort Venous Thrombosis (Paget-Schroetter syndrome)  PE unspecific. Image D(x): Aetiological (cervical rib)  Treatment: Neck and Shoulder girdle strengthening. Occ Qx acute occlusive arterial pathology VASCULAR TRAUMAS  +Fq cause death 1-45 years: Traffic, Work or Domestic Accidents, Violence (arms), Iatrogenic, Fx, Dislocation (elbow, knee). Mainly limbs, especially femoral artery (LL) and brachial artery (UL)  D(x):  Hard Signs: Evident bleeding, Distal pulses absent, Pulsatile or expansive haematoma, Distal neurological signs, Acute ischaemic signs  Soft signs: Hx of bleeding next to vessels, Nonpulsatile haematoma, Reduced peripheral pulses, Dubious neurological injury  TREATMENT: Vital Support (emergency)  1) BLEEDING CONTROL  2) Qx (1st Orthopaedic → 2nd Vascular): Occ amputation