Dr.Dinesh.M.Gunasagar Professor of Surgery J.J.M.M.C Davangere

1. Dr. Dinesh. M.G
Professor of Surgery
J.J.M.M.C.
Davangere

2. Atherosclerosis
 Atherosclerosis is a disease of large and medium sized
muscular arteries with sub-intimal deposition of
atherosclerotic plaque consisting of lipids, smooth muscle cells,
macrophages, cholesterol, calcium and cellular debris resulting in
arterial stenosis or block
 This results in tissue ischaemia or infarction distally

3. Atherosclerosis
 Atherosclerotic plaques are more at the regions of
branching of arteries
 Stenosis more than 40% is critical, may cause atrophy of
tunica media leading to dilatation(aneurysm)
 Common arteries involved are
 Coronary arteries
 Infrarenal abdominal aorta
 Iliofemoral arteries
 Carotid bifurcation
 Popliteal arteries
 Mesenteric arteries

4. Atherosclerosis

5. Atherosclerosis
 Abdominal aorta
 Carotid bifurcation

6. Atherosclerosis-Risk factors
Definitive
• Hypercholesterolaemia and
hyperlipidaemia
• Cholesterol > 200mg%
• High LDL > 100mg%
• Low HDL < 35mg%
• Smoking
• Hypertension
• Diabetes mellitus
Relative
• Age-elderly
• Males
• Hypertriglyceridaemia
• Sedentary life, obesity
• Family history

7. Atherosclerosis-clinical features
 Common after 50 years of age
 Males>Females, Positive family history for
atherosclerosis
 Smoking, hypertension, diabetes and raised cholesterol
levels
 Arterial wall thickening
 Thrill or bruit over carotid, femoral, renal arteries
 Features of ischaemia in the limb
 Claudication
 Ulceration or gangrene of parts of limb
 Feeble or absent pulsations
 Transient ischaemic attacks, chest pain, sudden black out,
post prandial abdominal pain or altered renal function

8. Atherosclerosis-Investigations
 Blood sugar
 Fasting lipid profile
 ECG
 Echocardiogram
 Tread mill test
 Ultrasound abdomen
 Duplex scanning of suspected arteries
 Angiogram showing site, extent & percentage of block and
collaterals
 DSA
 CT angiogram
 MR angiogram

9. Atherosclerosis-Management
 Risk factor modification
 Drugs
 Aspirin, clopidogrel, atorvostatin, cilastazol, pentoxyphylline
 Percutaneous transluminal angioplasty(PTA)
 Surgeries
 Thrombectomy, endarterectomy, profundaplasty
 Arterial by pass using reverse saphenous vein graft
 By pass grafts:
 CABG(Coronary Artery Bypass Graft)
 Aortofemoral,
 Iliofemoral,
 Femoropopliteal etc
 Amputations if limb is gangrenous

10. Atherosclerosis
 Percutaneous transluminal angioplasty

11. Atherosclerosis
 Percutaneous transluminal angioplasty

12. Atherosclerosis
 Percutaneous transluminal angioplasty and atherectomy

13. Atherosclerosis
 Bypass grafts
Coronary Artery Bypass Graft(CABG) Aortoiliac bypass

15. Aneurysm
 Abnormal permanent dilatation of localised segment of
artery
 Diameter is more than 50% of normal
 Atherosclerosis is most common cause(90%)
 Types
 True : contains all three layers of artery
 False : contains single layer of fibrous tissue as a wall

16. Aneurysm-types
1. Fusiform
2. Saccular
3. Dissecting

17. Aneurysm-Aetiology
Acquired
 Degenerative: Atherosclerosis
 Traumatic
 Infective
 Mycotic
 Syphilitic
 Collagen diseases like Marfan’s syndrome, Polyarteritis
nodosa etc.
Congenital
 Berry aneurysm occurring in arteries of circle of Willis

18. Aneurysm
Sites of aneurysm
 Aorta
 Femoral
 Popliteal
 Subclavian
 Cerebral, renal, mesenteric, splenic arteries

19. Aneurysm
Complications of aneurysm
 Thrombosis and distal ischaemia
 Embolism and acute arterial occlusion
 Pressure effects
 On bone(erosion)
 Skin
 Veins (oedema)
 Nerves( pain, paraesthesia)
 Stomach(erosion leading to haematemesis)
 Oesophagus (dysphagia)
 Rupture and haemorrhage
 Infection of aneurysm

20. Aneurysm-clinical features
 Pulsatile swelling
 Thrill & bruit
 Distal oedema due to venous compression
 Altered sensation due to compression of nerves
 Erosion into bones, joints, trachea or oesophagus
 Embolism resulting in gangrene of toes, digits
Investigations
 Duplex scanning
 Angiogram( CT, MRI, DSA)
 Blood sugar, lipid profile, echocardiography

21. Aneurysm-Treatment
 Reconstruction of artery using arterial graft
 Arterial endoaneurysmorrhaphy
 Therapeutic embolisation
 Clipping of aneurysm
 Endovascular graft

22. Aneurysm
Open & Endovascular repair

24. Carotid body tumour
 Also known as Potato tumour, Chemodectoma, Non
chromaffin paraganglioma
 Arises from carotid body located at the bifurcation of
common carotid artery

25. Carotid body tumour
 Usually benign or locally
malignant. Occasionally
lymphatic spread occurs
 Well encapsulated, hard
creamy yellowish tumour
 Not hormonally active
Clinical features
 Usually unilateral in middle
age
 Firm pulsatile swelling(75%)
in the region of carotid
bifurcation
 Head ache, neck pain,
syncope, dysphagia

26. Carotid body tumour
Investigations
 Duplex scanning
 Carotid angiogram
 CT scan, MRI, MR
angiography

27. Carotid body tumour-Treatment
 Excision followed by vascular graft if necessary

29. Varicose veins
 Dilated, tortuous , elongated veins in the leg of long or short
saphenous system
 Caused by incompetence of valves of main segment or
perforators

30. Varicose veins

31. Varicose veins
Aetiology
 Primary
 Congenital weakness of wall of veins or absence of valves
 Prolonged standing
 Congenital AV malformation
 Secondary
 Pregnancy
 Pelvic tumours
 Traumatic arteriovenous fistula

32. Varicose veins-clinical features
 Dull ache in calf in the
evening
 Bleeding
 Eczema
 Pigmentation
 Varicose ulcer

33. Varicose veins
Signs
 Brodie-Trendelenburg test for SFJ and perforator incompetence
 Triple tourniquet test
 Perthe’ test for patency of deep veins
Complications
 Haemorrhage
 Pigmentation, eczema and ulcer
 Periosteitis
 Equinus deformity
 Thrombophlebitis

34. Varicose veins
Investigations
 Duplex scanning of leg veins
Treatment
 Elastic stockings
 Injection sclerotherapy for
below knee varicosities
 Juxtafemoral ligation of great
saphenous
vein(Trendelenburg’s
operation)
 Stripping of veins
 Subfascial perforator ligation
 Endovenous laser ablation

35. Varicose veins
Endovascular laser treatment

36. Thank you