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MANAGEMENT OF CHRONIC ISCHAEMIA = Management Of Senile Gangrene = Management Of Gangrene In The Big Toe
I- Personal history:
Age:
Ø Young Raynaud's d., cervical rib, collagen disease, emboli.
Ø Middle Buerger's disease, Diabetes.
Ø Old Atherosclerosis.
Sex:
Ø Female Raynaud's disease.
Ø Male Buerger's disease.
Special habits: Smoking Burger's disease.
II- Complaint:
Pain = Intermittent claudication.
Ø Character cramping pain.
Ø Site Depends on the site of obstruction.e.g.
Aortic bifurcation occlusion pain in the gluteal region.
Femoral artery occlusion pain the hamstring muscles.
Popliteal artery occlusion pain in the calf muscles.
ØPrecipited by Exercise
Ø Relieved by Rest.
Claudication time Duration of pain.
Claudication distance the distance before each attack.
The longer the claudication period (time) and the shorter the claudication distance the severe the degree of ischaemia.
Rest pain Pain while the patient in his bed. It reflects severe degree of ischaemia.
Pallor: distal to obstruction. Raynaud phenomenon may be described.
Parasthesia: occurs in acute and chronic ischaemia.
Cold limb: the level of temperature change detected by examination.
Paralysis: = as in acute ischaemia.
Sloughing and gangrene.
Impotence in aorto-iliac occlusion "LeRiche syndrome" Impotence + bilateral loss of femoral pulsation.
III- Present history:
Onset: Sudden Acute ischaemia. Gradual chronic ischaemia.
Course: Progressive chronic vascular occlusion.
Regressive Embolism.
Ž Affected Limb:
Ø Upper Limb Raynaud's disease. Cervical rib.
Ø Lower Limb Atherosclerosis. Buerger's disease.
IV- Past history:
Ø Cardiac lesion Arterial embolism.
Ø Diabetes Diabetic ischaemia. Ø Collagen disease.
V- Examination:
Colour changes: pallor, cyanosis , mottling, Raynaud phenomenon.
Ø Buerger's angle: i.e. the angle at which pallor occurs.it decrease with the increase of ischaemia.
Venous refilling:
Elevate the limb the veins will be evacuated make the Limb dependent again and detect the refilling time It with severity of ischaemia.
Temperature:
Comparing with the healthy side, the level of occlusion can be predicted. How?
Arterial Pulsation:
Ø All pulsation sites must be examined comparing it with the healthy side.
Ø State of the artery must be detected.
If you feel pulsation distal to obstruction it may be from collaterals, so, ask the pnt to do excersise if disappear it is of collateral.
Atrophic changes: e.g. ulceration, pigmentation and loss of hairs.
Gangrene:
Moist Dry
- Obstruction. Sudden with venous spasm Gradual with patent veins.
- Infection. 2ry infection as in diabetes. No infection.
- Skin. Moist and macerated. Dry, wrinkled.
- Line of demarcation. Ill defined or absent. will defined.
- Line of separation. No time for its occurrence. Distal to the line of demarcation.
VI- Investigations:
Doppler ultrasound (Velocity detector):
Tracing of the arterial flow can be done by it. It may give:
Ø Triphasic signal: in patent artery.
Ø Biphasic sigual: in cases of distal obstruction or stenosis.
Ø Monophasic signals: in caseswith proximal obstruction.
Segmental pressure measurement can be done using Doppler tracing of pulse over tibial vessels by applying the cough over the calf and putting the Doppler probe over the tibial vessel around the ankle.
The Ankle Brachial index (ABI) can be calculated by dividing the measured pressure at the tibial vessel over the measured pressure at the brachial artery.
Normally the ABI is more than 1.0. If it decreased below 0.9 this reflects a degree of ischemia. According the ABI chronic ischemia can be classified and the need for surgical reconstruction can be judged.
Classification of chronic ischemia:
Duplex scanning of the vessels: not only qualitative data can be obtained but also quantitative data can be measured by this double ultrasonography set.
Plethysmography:
As the limb undergoes transient changes over the cardiac cycle so, when a cuff is rapped over the limb and attached to a pointer over a drum it can draw a curve representing this volume change which depend upon the arterial flow. This investigation becomes historical and no longer in use.
Angiography:
By injection of radio - opaque dye "Diodrast 50%"
a) Directly to the artery (intra-operative completion angiography)
b) Trans--femoral aortography. The catheter pass under local anesthesia into the femoral, iliac and abdominal and may be thoracic aorta. The artery needed for angiography can be selected under screen monitoring and special catheres.
c) Translumbar angiography may be needed if both femoral arteries are occluded. But it is dangerous and cause big retroperitoneal hematoma.
d) Transbrachial may be used as an approach to the aorta in cases with bilateral femoral occlusion. Many radiologists prefer this way instead of translumbar approach.
e) Digital subtraction angiography (DSA): It gives clear picture for the dye after substraction of shaddow of surrounding tissues. So, The dye can be injected intravenous "Digital Venous Imaging" (DVI) or injected intra-arterial with low dose. It can be used in:
µ Risky patients to avoid side effects of big doses of diodrast.
µ Cases with difficult arterial catheterization.
µ Diagnosis of AV fistula, as both venous phase and arterial phase can be clearly illustrated.
Ø Value of angiography: * State of collateral.
* Site and extent of obstruction.
* Distal run off vessels can be detected.
Ø As it is invasive technique, it is better to be limited to preoperative diagnosis.
Magnetic Resonance Angiography (MRA): can be done with no need to puncture the veins of the diseased limb.
Computerized Tomography Angiography (CTA): can be done without contrast using phase contrast or time-of-flight techniques. Gadolinium can also be given intravenously with better accuracy in areas of slow flow or vessel tortuousity.
Medical sympathectomy:
µ By injection of local anesthetic around the sympathetic chain. It can assess the feasibility of sympathectomy before doing it surgically.
‘ Laboratory Investigation:
µ 1. Blood sugar curve,
2.Lipid profile: Cholesterol, Triglycerides, High density lipoprotein (HDL) and Low density lipoprotein (LDL) blood level.
3. Complete blood picture
4. Coagulation profile.
5. Immunological study in case of possibility of vasculitis.
VI- Treatment:
(1)Medical measures:
(A) General condition:
Ä Prohibit smoking.
Ä Treatment of anaemia & control of hypertension and diabetes.
(B) Establishment of good blood supply:
Ä Vasodilators e.g. Papaverine but give low response in diseased vessels.
Ä Buerger's excersises: "Repeated leg raising and lowering in lying position". But if pain is occurred stop the excersise.
Ä Artificial heating: on the other Limb or over the abdomen not in the ischaemic limb.
Ä Paravertebral sympasthetic block.
(C) Care of the foot:
Ä Keep it clean and dry. Ä Careful trimming of nails.
Ä Avoid injections in its veins.
(2) Surgical measures:
Reconstructive vascular surgery.
Sympathectomy.
Amputations for gangrenous Limbs.
[a] Re constructive vascular surgery:
Thrombendarterectomy:Excision of the thrombus with the diseased intima as in cases of astherosclerosis. Either through longitudinal arteriotomy or by using special loop stripper. Best done in the carotid atherosclerosis with repeated transient ischemic attacks(TIA)
Profundoplasty: Simple operation done even under local anesthesia.
The aim is to dilate the orifice of the profunda femoris by different techniques which may increase vascularity of the limb.
Profundoplasty
Aortobifemoral bypass
Axillobifemoral bypass
Arterial bypass procedures: The aim is to bypass occluded segment.
The by-pass operations is either:
1- Anatomical by pass e.g. Aortobifemoral and femoropopliteal bypass.
2- Extra-anatomical by-pass grafting e.g. Axillobifemoral or femoro-femoral by-pass.
Types of grafts:
Autogenous:
1-Arterial grafts which can resist infection.
2-Venous grafts e.g. saphenous vein graft either reversed or in-situ.
Artificial grafts. e.g. Teflon or Dacron grafts.
Sympathectomy:
Indications:
As adjuvant to reconstructive surgery.
If reconstructive surgery is impossible e.g. arteritis or vasospstic conditions.
If chronic ischaemia affecting small cutaneous vessels.
Effects:
Vasodilatation increases blood supply, also it can relieve the pain.
Approaches:
1-Trans-cervical, transthoracic, and posterior surgical approaches.
2- Thoracoscopic approach carry the advantages of simplicity and low morbidity.
[c] Amputations:
Indications:
µ Intolerable pain.
µ Intractable infection.
µ Gangrene.
µ Usually we do above knee amputation as the popliteal and tibial vessels are diseased in almost all cases while the profunda femoris usually escape from atherosclerosis.
µ Below knee amputation may be done with lumbar sympathectomy giving variable results.
SOURCE: DR AYMAN SALEM'S BOOK
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