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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%
Artherosclerotic plaque
Artherosclerotic plaque
2.2.2 (acute limb ischaemia)
2.2.2.1 Acute embolism
(solid mass)
(Rheumatic heart disease)
80% atrial fibrillation
emboli
artery bifurcation
2.3 1.2
Intermittent claudication
Rest pain
Ulceration/gangrene
Chronic Ischaemia
atheromatous disease Popliteal aneurysm
collateral vessel
vessel
2.3.3.(Status of limb)
2.3.3.1 acute ischaemia
2.3.3.1.1. Thrombolysis
Thrombolysis
(revascularisation)
severe ischaemia thrombolysis
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)
- paralysis
2.3.3.2
(intermittent claudication)
aortoiliac
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
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
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
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
(Angiogram)
Angiogram
Angiogram Iodine Iodine
MRA
X ray
Angiogram
MRA
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
Angioplasty
2.4.1.3. Bypass Surgery
(conduit)
Bypass surgery
1. intermittent claudication
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
Axillofemoral bypass
axillofemoral bypass
Femorofemoral bypass
2.4.1.4 amputation
1. Digital amputation Ray
amputation
2. Transmetatarsal amputation metatarsal
Stroke MI
intermittent claudication critical limb ischaemia
(gangrene, ulcer) 2% critical limb ischaemia
50% 5
Bypass Surgery
(distal anastomosis)
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
(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
, ,
,
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.