HISTORY TAKING IN FELLOWSHIP EXAM

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MANIFESTATIONS OF VASCULAR DISEASES

• Prof. Hasan Ali Al Zahrani, FRCS
• Professor of Surgery,
• Consultant Vascular Surgeon
• King Abdulaziz University, Jeddah
• (www.profzahrani.com)

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Arterial Problems

• 1. Aneurysms
• - AAA
• - peripheral
• 2. Limb ischaemia
• - acute
• - chronic
• 3. Vasculitis
• - Types
• - Thromboangitis obliterans
• 4. Carotid artery disease
• 5. D.M. foot

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Venous Problems

• Varicose veins
• D.V.T. postphlebitic limb
• Leg ulcers

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Others

• Vascular malformations
• Angioaccess
• Thoracic Outlet Syndrome
• Vascular Trauma

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Aneurysms

• Definition
• Localized dilatation of an artery
• or vein
• The commonest is AAA
• Rare in veins
• Usually due to ATO

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• Symptoms
• Most are asymptomatic
• Intermittent claudication
  (if there is occlusive disease)
• Trash foot or blue toes syndrome (if
  embolizing)
• Severe abdominal and/or back pain (if
  leaking)
• Shock (if ruptures)

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• Signs
• Pulsating epigastric mass AAA
• Pulsating iliac mass - ? Iliac
• Examine other arteries 5-10 associated
  aneurysms
• Abd. tenderness
• Shock

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Acute Limb Ischaemia

• Sudden cessation of blood flow to lower or less
  frequently upper limb which is usually due to
  embolism or trauma and less frequently due to
  thrombosis.

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A.L.I.

• Causes
• Embolism
• a. Cardiac very common
• - A.F.
• - M.I. in I.H.D.
• - Rh. H. D
• - Others
• b. Non-cardiac
• - atheromatous plaques
• - aneurysm
• - trauma

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A.L.I.

• Thrombosis
• a. Acute or chronic (? I.C.)
• b. Aneurysms
• c. Severe D.V.T. (P.C.D.)

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A.L.I.

• Symptoms Signs
• The 5 Ps
• Coldness
• Poor capillary refilling
• Rigor (late signs)
• Examine other pulses
• Heart examination

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A.L.I.

• Investigation
• C.W. Doppler
• Duplex scan
• Arteriography (in selected cases)
• ECG, CXR, Echo

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A.L.I.

• Management
• Aim to minimize the time lag to less than 8 hours
• Establish the underlying cause
• Heparin infusion
• Surgical embolectomy
• Fibrinolytic therapy
• ? Primary amputation

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Chronic Limb Ischaemia (C.L.I.)

• Affects usually the lower limbs
• Usually due to atherosclerosis
• Common in D.M. patients
• Symptoms and signs depend on the site of
  occlusion.

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Chronic Limb Ischaemia (C.L.I.)

• Symptoms
• Intermittent claudication -
• cramping pain affecting usually the
  calf muscles which comes with exercise and
  relieved by rest. (? Distance, radiation)
• Rest pain-
• severe burning pain affecting the
  forefoot, coming at rest and relieved by hanging
  the leg beside the bed
• Impotence - Leriches Syndrome

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Chronic Limb Ischaemia (C.L.I.)

• Signs
• Ulceration - painful, no bleeding
• Pallor, Buergers test, rubor or dependency,
  capillary re-perfusion
• Cyanosis, coldness, trophic changes
• Examination of pulses
• Listen for bruits

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(C.L.I.)

• Investigations
• General including - R.B.S., lipids, CXR, ECG
• Specific-
• A/B index, toe pressure
• Duplex scan
• MRA, C.T. angio,.
• Angiogram

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(C.L.I.)

• Indications for surgery
• Disabling I.C.
• Critical ischaemia- I.R.P., ulcer
• Impotence
• ? Progressive disease

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(C.L.I.)

• Medical- Anti-platelets
• Control D.M., hyperlip., high B.P.
• Stop smoking
• Reduce weight and diet
• ? Pentoxyfylline
• Endovascular and surgical -
• P.T.A. ? stenting
• bypass
• endartrectomy
• amputation

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Vasculitis

• Definition
• A group of vascular inflammatory
• disorders sharing immune-mediated
• reactions but with distinctive clinical
• picture, e.g.
• Thromboangitis obliterans
• P.A.N., G.C.A., etc.

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• Buergers Disease (T.A.O.) -
• Vasculitis of small and medium-sized
• veins and arteries affecting mainly young
• and middle-aged males who smoke
• heavily.
• Its aetiology in unknown.

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• Buergers Disease (cont) -
• Management
• Diagnosis (including diff. Diag.)
• Stop smoking
• Vasodilators
• Sympathectomy
• Bypass
• Amputation

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Carotid Artery Disease (CAD)

• Symptoms
• TIA
• PRIND
• Amurosis fugax
• Stroke
• Blindness
• Signs
• Carotid bruit
• Neurological deficits

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C A D

• Diagnosis
• Duplex scan
• MRA
• CT
• Carotid angio

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C A D

• Management
• Medical
• - Antiplatelets
• - Anticoagulants
• - Control risk factors
• Carotid Endartrectomy
• ?? Angioplasty

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D M F

• High incidence of D.M. in S.A.
• The most common indication for amputation
• Factors
• Ischaemia 40
• Neuropathy 60
• Infection 90

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D M F

• Diagnosis -
• For Infection -
• - CBC, culture, x-ray of foot
• For Ischaemia -
• - Toe pressure, Duplex scan, Angio
• For Neuropathy-
• - EMG

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D M F

• Prevention -
• Management -
• Medical
• - control of D.M. hyperlipidaemia
• - antibiotics
• - Antiplatelets
• 2. Surgical
• - Debridement drainage
• - Vascular reconstructive procedure
• - Skin grafting
• - Amputation

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Thank You !!!