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Medico Macha
  • 7/8/2025
Transcript
00:00so let's now talk about arterial disorders and in arterial disorders the first topic which we need
00:13to talk about is acute arterial occlusion now acute arterial occlusion is secondary to an
00:19embolus and the source of this embolus is usually the heart so the source of the embolus is usually
00:27the heart sometimes it can be an aneurysm like an aortic aneurysm can also shower of emboli which can
00:33go distally and block the vessels but usually the source is the heart and what are the keywords which
00:40you should look out for in the question if you're given such a question so you will get keywords like
00:45atrial fibrillation or irregularly irregular heartbeat irregularly irregular heartbeat and this basically
00:55says that because of this irregular heartbeat because of atrial fibrillation there can be
01:03emboli which can form in the heart and they can be showered of distally and they can block the vessel
01:08now because this is acute occlusion there is no time for the formation of collaterals so the clinical
01:15features with which these patients are going to come are six p's and these six p's have been asked
01:21very frequently in the exam so the six p's which you get are pain pallor that means the limb is going
01:28to become white there's going to be parasis there's going to be weakness paresthesias
01:32paresthesias are going to be there poikyothermia poikyothermia is that the limb will become cold
01:39and you can have pulselessness and there can be pulselessness right now one thing which i want to tell
01:49you here that for the sake of remembering i've given six p's and i've given paresthesias but usually
01:55there is complete loss of sensation there is usually complete loss of sensation when there is an acute
02:01embolic block complete loss of sensation is present and pulselessness i want you to know is a late sign
02:10so just don't go by pulselessness you should look at the entire picture in totality and look at these six
02:16signs which are there now when you have a patient with acute arterial occlusion the investigation of
02:23choice in these patients is a duplex scan we've already covered duplex duplex is a doppler with
02:30a b mode ultrasound this is where what will localize the site of block for us now on a duplex scan a normal
02:37vessel has triphasic flow there is triphasic flow this question has been asked in the exam and we've
02:44already discussed in duplex scan it it tells us about the direction of flow it tells us about reflux
02:50those are the things which we'll get to know on a duplex scan and of course we get to know the site
02:55of the block as well now acute arterial occlusion you can see here that this embolus has come all of a
03:01sudden and it has blocked the vessel and because there is no time for the formation of collaterals
03:07the symptoms are severe and dramatic like i've just explained to you so the management or in
03:13these patients the management of acute arterial occlusion now if the patient comes to us early
03:19by early we means if the patient comes within six to eight hours of the onset of pain or the onset of
03:27the emboli then the limb can be salvaged and how do we salvage the limb we can either carry out
03:34thrombolysis right either thrombolysis can be carried out we can use streptokinase or other
03:41thrombolytic agents but the contraindications for thrombolysis are bleeding disorders
03:46are bleeding disorders or if there is a recent stroke these are the complicate contraindications
03:56where thrombolysis cannot be used the other way is to carry out an embolectomy and how do we
04:04carry out an embolectomy we use fogarty's balloons these fogarty's balloons have been asked in the
04:10exam we use fogarty's balloons to carry out embolectomy let me just show you what fogarty's
04:16balloons look like so this is a fogarty's balloons it it is there in the deflated state you pass it
04:22beyond the vessel you can see here we've gone beyond the vessel and then we inflate it when we
04:27inflate it and we pull it back it will pull out the embolus along with it it will pull out the
04:33embolus along with it so this is fogarty's balloons we should always use heparin in these
04:39patients to prevent propagation of the thrombus to prevent propagation of the embolus
04:46we should always use heparin in these patients now like i was telling you the management if the
04:54patient comes early these are the two treatment options which we have but if the patient comes
04:59late to us if the patient comes late to us where gangrene has already set in now when gangrene has
05:08already set in we wait for the line of demarcation to appear and then we need to carry out amputation
05:13then we need to carry out amputation now one more thing which i want you to know now whether you do
05:20thrombolysis or you do embolectomy whether thrombolysis or embolectomy there can be reperfusion
05:27injury when the blood flow is re-established there can be reperfusion injury due to free radicals
05:33so this reperfusion injury can give rise to swelling of the muscles can give rise to swelling
05:40of the muscles and this can predispose the patient to compartment syndrome it can predispose the patient
05:49to compartment syndrome which is why it is said that if you get a patient with acute arterial occlusion
05:55we should carry out a physiotomy along with embolectomy a physiotomy should be done
06:02a physiotomy should be done along with embolectomy to prevent compartment syndrome
06:08to prevent compartment syndrome and compartment syndrome we've covered at various places it would
06:16have been covered in orthopedics as well in compartment syndrome there is excessive pain
06:21excessive pain which is not relieved by medicines there is pain on passive stretching that is another
06:30sign there's pain on passive stretching and pulsations can be normal so pulsations can be normal
06:40so don't get swayed away if the pulsations are present that does not rule out compartment syndrome
06:46and in these patients who are undergoing an embolectomy or thrombolysis do a prophylactic
06:52fasciotomy to prevent reperfusion injury we've also discussed that when we do a fasciotomy
06:58we go down we incise till the deep fascia so we're going to incise the deep fascia as well
07:04that is an adequate fasciotomy so we can even do an angiography you can see here that this was there
07:12was a patient where this was the blocked area and once an angioplasty has been done then you can see
07:19the blockade has opened up so this can also reveal to us that the blockade has opened up
07:24this was regarding acute arterial occlusion let's move on to chronic arterial occlusion now
07:30now chronic arterial occlusion is because of a thrombus and you can see here in a thrombus
07:36there is so this is gradual occlusion or chronic arterial occlusion is because of a thrombus which
07:44starts here and as the thrombus keeps on increasing in size it will block the vessel but because this
07:52is a gradual process because this is a gradual process what is going to happen collaterals will
08:00form collaterals will form and these collaterals are going to supply below the blocked area as well
08:07so even the area below the block some bit of it will receive supply because of these collaterals
08:14and these collaterals contribute to the distal runoff distal runoff means that even distal to the
08:21side of the block there will be some blood supply which will be coming in now how do these patients with
08:28chronic arterial occlusion present to us so these patients the clinical features of chronic arterial
08:35occlusion these patients are going to come with intermittent claudication intermittent claudication
08:42means that at rest at rest there is adequate blood supply right at rest there is adequate blood supply
08:52which is there but when these patients start exercising or they start walking then the blood supply to the
08:58muscles distal to the block is reduced and these patients are going to come with cramping pain
09:05this is cramping pain after walking a certain distance
09:10after walking a certain distance and this is known as intermittent claudication
09:19this pain is known as the pain of intermittent claudication now as the block as the block
09:27increases the claudication distance will reduce so if the patient initially was able to walk one
09:35kilometer and then get the pain as the block increases the pain will occur at 750 meters and 500
09:42meters then 250 meters eventually the patient will land up with rest pain as well so as the block increases
09:50claudication distance will reduce
09:52eventually the patient lands up with rest pain as the name suggests this is pain at rest and it is
10:02worse at night it is worse at night it is worse at night and the patient gets some relief
10:09the patient gets some relief when he hangs his leg down when he hangs leg down that is when he's going to get
10:21some relief this is what you need to elicit in the history as well if you get a patient of arterial
10:27occlusion or gangrene you should ask this finding that do you have pain at rest also is it relieved
10:33when you hang your leg down these are questions which you should ask in the history as well
10:38now there is a boyd's classification for claudication which you should know about this boyd's classification
10:46also you should know once an mcq has been asked and also this is asked in the viva this is for
10:52claudication pain on walking but pain reduces as the patient continues to walk so as the patient
10:59continues to walk substance p which is potassium which is causing the pain that gets diluted off and
11:05the pain will reduce so that is class one where there is pain but as the patient keeps on walking pain
11:11will reduce class two is there's pain on walking but the patient continues to walk despite the pain
11:18patient continues to walk despite the pain class three is pain forces the patient to stop and the
11:27patient has to take some rest and class four is rest pain which i've told you is worse at night
11:33and it's slightly relieved when the patient hangs his leg down this is the boyd's classification you can
11:40also have a fontaine and rutherford classification for claudication but what has been mainly asked is the
11:47boyd's classification so only if you're preparing for the super speciality exam or the inicc exam then
11:54try to remember the details of fontaine and rutherford otherwise only boyd is good enough for your exam
12:00now one more thing which you need to remember is that you can sometimes have a patient of
12:09neurogenic claudication or osteoarthritis also walk into the surgery opd and your professor will ask you
12:17how will you differentiate intermittent claudication from neurogenic claudication from osteoarthritis so
12:26these are the three things where there can be some confusion and you need clinical points to
12:31differentiate them so intermittent claudication i'm saying vascular claudication which we've been talking
12:37about so vascular claudication the pain is going to come after walking a certain distance after walking
12:47a certain distance that is when this pain will come neurogenic claudication on the other hand
12:55varies with posture varies with posture and this is the pain which occurs when there's lumbar canal
13:04stenosis so when the nerves are compressed lumbar canal stenosis nerves are compressed and this can
13:11give rise to shooting pain around the along the leg and this pain is relieved pain is relieved when
13:19patient bends forward when patient bends forward this pain is relieved okay so this is neurogenic
13:30claudication osteoarthritis pain is worse worse pain on taking the first step on taking first step that is
13:44when the patient will have worse pain so this is how clinically we can differentiate these three
13:49conditions and you should know it for your exam as well now we discuss the six Ps in acute arterial
13:56occlusion in chronic arterial occlusion in chronic arterial occlusion because you have collaterals
14:03because you have collaterals you need to know that pain is felt in the muscle group pain is felt in the
14:16muscle group below the block distal to the block right below the block and the most common site where
14:24the pain is felt is the calf because you have the femoral artery which is commonly involved so mostly
14:31pain is felt in the calf now symptoms depending on the site of the block this is very very important
14:38because this iotoiliac obstruction that is larynx syndrome has been asked many times in the exam now if there's iotoiliac
14:48obstruction then there is going to be claudication in the gluteal region so gluteal claudication
14:57is the earliest finding of larynx syndrome this question has been asked many times in the exam
15:03the earliest finding of larynx syndrome or aotoiliac block is gluteal claudication
15:07there can be absence of pulses there can be bruy over the aotoiliac region and there can be importance
15:15in males this is another thing which has been asked in the exam so this is larynx syndrome which you
15:21should know if there is iliac obstruction then there will be claudication in the thigh and the calf
15:26sometimes the buttock and there'll be unilateral absence of pulsations if there is femoral
15:32pulpitial obstruction there will be claudication in the calf calf is the most common site where there
15:38is claudication pain felt femoral pulses are palpable but distal pulses are absent and if there's distal
15:45obstruction then you will have claudication in the foot or the calf this is for distal obstruction
15:52so depending on the site claudication can be felt in the muscle group below the block
16:00the other clinical features and chronic arterial occlusion so sensation is intact sensation is intact
16:10the temperature equilibration is intact so there in acute arterial occlusion the limb was becoming cold
16:21and it was unable to equilibrate with the ambient temperature but here sensations are also intact
16:28and temperature temperature equilibration is also intact in chronic arterial occlusion
16:36also these patients can present with an arterial ulcer arterial ulcer i've discussed in the common
16:43ulcer module in detail about arterial ulcerations so arterial ulcerations you'll get absent pulsations
16:51you will get absent pulsations there'll be shiny skin there'll be shiny skin loss of hair
17:02and you will get a punched out ulcer and you will get a punched out ulcer and there can be gangrenous
17:09changes surrounding the ulcer as well so this is what an arterial ulcer looks like for more details you
17:16should also see the common ulcer module where i've also covered diabetic ulcers in great detail now
17:24again in these patients the investigation of choice is a duplex scan or a doppler scan investigation of
17:31choice is a duplex scan or a doppler scan this is what a doppler handheld doppler machine looks like
17:39also we should investigate also we should investigate the patient for cardiac
17:46problems as cardiac problems can coexist with arterial or peripheral arterial disease as well
17:55now by using the doppler and by measuring the blood pressure we can also measure one very important
18:01thing here and that is abpi abpi is super important for the exam this is ankle brachial pressure
18:08index this is ankle brachial pressure index is abpi and ankle brachial pressure index is defined as
18:20reading of maximum systolic bp maximum systolic bp in the ankle at the ankle divided a maximum systolic bp in
18:35the arm so that is your ankle brachial pressure index and you have to take multiple readings and you
18:42will take the maximum value of the ankle divided by maximum value of the arm and that's how you will
18:47get the reading of ankle brachial pressure index now what all does this ankle brachial pressure index
18:52signify to us if the reading is between 0.9 to 1.3 this is according to the latest bailey and subiston
19:01i'm telling you the latest values 0.9 to 1.3 is considered as normal less than 0.9 is when intermittent
19:10claudication starts less than 0.9 is when intermittent claudication is going to start in these patients
19:17less than 0.5 you will get rest pain and less than 0.3 is critical limb ischemia this value has also been
19:26asked this is critical limb ischemia where necrosis is imminent where imminent necrosis is there necrosis
19:35can occur below 0.3 also you should know that sometimes you can get a high value of abpi as well
19:43and high value of abpi is seen in patients with calcified vessels it is seen in patients with
19:49calcified vessels and this is usually seen in patients with diabetes or chronic kidney disease
19:54so these values of abpi you should remember for the exam as they've been asked frequently there
20:01are certain other points which i want you to remember which have been written in both bailey
20:04and subiston regarding ankle brachial pressure index so patients who have abpi less than 0.5 are twice
20:12most likely to deteriorate that means the disease is more likely to progress if the abpi is less than 0.5
20:20gradually decreasing abpi is a sign of imminent limb loss in patients where resting abpi is normal but
20:30arterial compromise is suspected then we should do post-exercise abpi this is a very important
20:37statement so in normal people in normal people like us after exercise after exercise
20:47abpi will increase abpi will increase abpi is going to increase but in patients with rate limiting
20:58arterial disease in patients with rate limiting arterial disease abpi will fall and this can predict
21:10that these patients will develop major arterial issues in the future so wherever you have a doubt
21:17whether arterial problems are there or not you do post exercise abpi and if there's a fall in abpi of
21:23more than 20 percent that means the patient has arterial problems and one final thing which you should know for
21:31every 0.1 decrease in abpi below 0.9 the risk of cardiac mortality goes up by 10 percent so every time 0.1
21:43value reduces below 0.9 then the risk of cardiac mortality goes up by 10 percent so these are some
21:51important points regarding abpi which you should know now i told you about duplex scan being the
21:58investigation of choice but in obese patients in obese patients it is difficult to visualize the iliac
22:10block and that is why in these patients we can use an mr angio or we can use digital subtraction
22:20angiography so digital subtraction angiography is also coming up in a big way to identify arterial
22:27blockade as you can get reconstructed images where they tell you where exactly the site of the block
22:33is so this is regarding the workup of a patient with chronic arterial occlusion now the two main
22:40causes of chronic arterial occlusion which we need to discuss for the exam are burges disease and
22:46atherosclerosis so we need to discuss the differences of burges and atherosclerosis these are frequently asked in
22:52the exam now burges now burges is commonly seen in the third or the fourth decade of life this is
23:05commonly seen in the fourth third or fourth decade of life and males are more commonly affected than
23:11females whereas atherosclerosis usually starts in the fifth decade of life and beyond and equal male to
23:17female incidence is seen here now burges disease smoking is the main risk factor smoking is the main
23:25risk factor for burges disease for atherosclerosis both in pathology and in medicine you've read about
23:32the multiple risk factors for atherosclerosis so i'm not going to enumerate all of them you can have
23:38smoking alcohol type a personality multiple other risk factors have been covered in medicine and pathology
23:45now burges disease again lower limb is more commonly affected than the upper limb that is the same case
23:54in atherosclerosis as well lower limb is more commonly affected than the upper limb burges disease
24:00involves the artery vein and nerve all three structures artery vein and nerve all three structures are involved
24:08and another name is thromboangitis obliterence is thromboangitis obliterence right here you can get
24:20superficial thrombophlebitis also in addition to you can get superficial thrombophlebitis in these patients
24:28you can get neuropathy in these patients and of course there can be arterial blockade as well
24:35in atherosclerosis only the artery is involved here now two things which govern the difference in
24:43presentation and difference in management of these two conditions so you should know burges the spread
24:49is distal to proximal the spread is distal to proximal spread and it involves the small to medium sized
24:57vessels small to medium vessels are involved whereas atherosclerosis is proximal to distal spread
25:07is proximal to distal spread and it involves the large to medium sized vessels large to medium
25:16vessels are involved in atherosclerosis now in burges disease if you do angiography you will get
25:24cockscrew collaterals so if angiography is done you will get cockscrew collaterals this you should
25:31know for your exam cockscrew collaterals are seen here cockscrew collaterals are seen if angiography
25:40is done in burges disease this is an image of a patient with burges disease you can see it involves
25:45the distal vessels so that is why the toes are the ones which become gangrenous first so you can see
25:52here in burges disease now let's talk about the management of these two conditions so the management
25:58of burges and atherosclerosis the management of burges disease first thing is to prevent the patient
26:05from smoking right so it's to stop smoking otherwise the disease will keep on progressing now this might seem
26:12like an easy task but trust me this is the most difficult task in a patient with burges disease
26:18and i clearly remember a patient when i was in first year that was the time when the patient first had
26:26his digits amputated of one of the limbs because of burges disease three days after the procedure he was
26:34caught smoking outside the ward by the time i was in final year he lost digits of his other leg
26:42as well in first year of my senior residency two of his fingers had to be amputated of one hand and
26:50finally in third year of senior residency the fingers of the other hand were also amputated
26:57even after this you know whenever he used to come to the opd the attendants used to tell us
27:03that he used to force them to put the cigarette in his mouth so even without the digits he used to ask
27:08attendants to put the cigarette in his mouth that's how difficult it is for these patients to give up
27:14smoking so these patients have to give up smoking and we can use medicines in these patients so i told
27:22you about pentoxifilin pentoxifilin can be used in these patients like it was being used in venous ulcers as
27:30well and this reduces the viscosity improves the micro perfusion so pentoxifilin has a role
27:39conservative amputations should be done in these patients with burges disease
27:44i will tell you about conservative amputations we'll discuss in detail now no bypass or
27:53no bypass grafting is possible in patients with burges disease why because it is involving small to
28:02medium vessels the caliber is very small and if we draw a simple diagram here you can see here
28:13we can see here that on this side is burges disease right so burges is involving these very
28:20small vessels and it is spreading from distal to proximal so even if i have to do a bypass there is no
28:29distal target vessel because the target vessel is already thrombosed so no bypass grafting because small
28:38vessels are involved and there is no distal target vessel because the disease spreads from distal to
28:44proximal proximal there is no distal target vessel in these patients so in these patients we can carry out
28:54lumbar sympathectomy to reduce the pain we can carry out lumbar sympathectomy
29:04lumbar sympathectomy can be done to reduce the pain in these patients and lumbar sympathectomy is only
29:11done when there is rest pain it is contraindicated in intermittent claudication it is contraindicated
29:20in intermittent claudication so lumbar sympathectomy is only done when the patient has rest pain and it
29:27is contraindicated in intermittent claudication now why is it contraindicated in intermittent claudication
29:34because what lumbar sympathectomy does is that it causes cutaneous vasodilation it causes cutaneous
29:40vasodilation and by causing cutaneous vasodilation, it is basically stealing blood or shunting
29:48blood from the muscles, blood from the muscles, right?
29:54So when there is rest pain, the muscles are already dead, right?
29:58So to save the cutaneous supply, we can steal blood from whatever little blood is going
30:03in the muscles, it can go to the skin and it will reduce the pain for the patient.
30:09But in intermittent claudication, the muscles are still active.
30:12And if you steal blood from the muscles, you are basically precipitating rest pain, right?
30:18The patient who could walk say 100 meters now can't even walk that much because you've
30:23stolen all the blood from the muscles and given it to the cutaneous circulation.
30:27That is why it is contraindicated in intermittent claudication.
30:32Now lumbar sympathectomy can either be done via the surgical method, can be done via the
30:37surgical method or it can now be done via chemical lumbar sympathectomy, which can be done under
30:43radiological guidance.
30:46So you don't need to operate these patients.
30:48Under radiological guidance, we can do chemical sympathectomy in these patients as well.
30:52When we are doing surgical sympathectomy, please remember that the most common structure which
30:58can be mistaken for the lumbar sympathetic chain, most common structure which can be mistaken
31:03for the sympathetic chain is the genitofemoral nerve, is the genitofemoral nerve.
31:13And this question has been asked in the exam.
31:16So by mistake, if you cut the genitofemoral nerve, the patient's symptoms will not subside.
31:22Patient will keep on having the same symptoms.
31:24Now, when we are doing a lumbar sympathectomy, when we are doing a lumbar sympathectomy, so
31:30you know there is L1, L2, L3, L4 ganglions are there.
31:37But if bilateral lumbar sympathectomy is being done, L1 ganglion on one side needs to be saved.
31:46L1 ganglion needs to be saved on one side, otherwise this will give rise to impotence.
31:57Otherwise, it gives rise to impotence in males, that is why L1 ganglion needs to be saved on
32:02one side.
32:03This is a very important statement which you should remember if bilateral lumbar sympathectomy
32:07is being done.
32:08One final thing which you should know, omentoplasty has no role in patients with Burja's disease.
32:15Omentoplasty has no role now.
32:18In earlier times what was done was that the omentum was taken out through a small opening
32:23and it was brought right down till the leg.
32:27And they thought that because omentum has good blood supply, it will share its blood supply
32:31with the limb.
32:32But the surgery turned out to be a failure, so no omentoplasty.
32:36In Burja's disease, we ask the patient to stop smoking, lumbar sympathectomy can be done
32:40when there is rest pain and conservative amputations need to be done.
32:44That is the management of a patient with Burja's disease.
32:48On the other hand, what is the management of atherosclerosis?
32:52So, we discussed atherosclerosis is going to involve these bigger vessels.
32:56And when atherosclerosis is involving the bigger vessels, the management in these patients
33:01can either be angioplasty, can either be angioplasty and stenting and if angioplasty or stenting
33:11does not work out, then in these patients we can do bypass grafting.
33:16Then we can do bypass grafting.
33:18So, these days, angioplasty and stenting is the first-line treatment.
33:24This is the first-line treatment in patients with atherosclerotic peripheral arterial disease.
33:30We do angioplasty and stenting.
33:33And angioplasty, the balloon is inflated for 30 seconds and then it is deflated.
33:39Successful for iliac and femoropoplatial.
33:42But the results below knee are less successful.
33:47That is why below knee grafts are preferred whereas above knee angioplasty and stenting
33:53has shown good results.
33:56The complications of angioplasty and stenting, there can be bruising, bleeding, hematoma
34:00and thrombosis can be there.
34:04If of course there is failure after angioplasty and stenting, then you have to carry out an
34:09open bypass grafting.
34:11You can see here, you can see the stent which has been placed and after placing the stent,
34:16you can see that the blood supply to that area has increased.
34:20Now, bypass grafting.
34:22I told you bypass grafting will be done.
34:24If stenting does not work out, then we will do bypass grafting.
34:29Now, if the block is in the aortic bifurcation, okay, so laryk syndrome, like we discussed laryk
34:35syndrome, iotoiliac block.
34:38Supposing the block is here, so it is an iotoiliac block or laryk syndrome, here what do we do?
34:48Here in these patients, we will have to carry out an iotobifemoral graft, right?
34:57Because we will have to do grafting on both the sides.
35:00So, we will have to do iotobifemoral graft here.
35:06Iotobifemoral graft and this graft is above the inguinal ligament.
35:11It is a suprainguinal graft.
35:13So, we have to carry out an iotobifemoral graft and the best graft material, the best graft
35:20material to carry out this is Dacron.
35:24So, Dacron is the graft material used for grafts above the inguinal ligament and that is
35:29what we will do here.
35:31Now, the second situation is that there is a block in the, if supposing there is a block
35:40in the iliac artery, if there is a single iliac artery which is blocked, right?
35:45Then we can either do iotofemoral or iliofemoral.
35:49So, this graft will either be, so if there is an iliac block, we will again do either iotofemoral
35:59or iliofemoral grafting would be done and again Dacron will be the graft material which
36:08will be used because this is above the inguinal ligament.
36:11This is done for iliac block.
36:13Now, if the block is more distal to this, if the block is in the femoral artery, then
36:18what do we do?
36:19So, here, now if the block is in the femoral artery here, so this is our femoral block which
36:30is there.
36:31Now, if there is a femoral block, we will have to do an iliopopleteal graft, okay?
36:36We will have to do an iliopopleteal graft.
36:39So, femoral block, we will have to do iliopopleteal graft and predominantly this graft is going to
36:45be below the inguinal ligament.
36:47This graft is going to be below the inguinal ligament.
36:50So, when infrainguinal grafting is done, the best graft material for infrainguinal grafts
36:56is reverse saphenous vein.
36:59Is reversed saphenous vein graft, right?
37:05It is a reverse saphenous vein graft and I will show you a video of how this saphenous
37:12vein is harvested.
37:14So, this is the reverse saphenous vein graft which is the best graft material for infrainguinal
37:19grafts.
37:20The best synthetic graft material.
37:24Now, best synthetic graft material here is PTFE but please remember that reverse saphenous
37:30vein is better than PTFE.
37:31So, there are two questions, don't get confused, best overall is reverse saphenous vein but
37:37the best synthetic graft material here is PTFE.
37:40So, let me show you this quick video of how this saphenous vein is harvested and what are
37:46the precautions which we need to take.
37:48So, I have already told you about the surface marking for the great saphenous vein.
37:52It lies just anterior to the medial malulus and whenever we have to harvest the great saphenous
37:57vein and where do we need the great saphenous vein?
38:00We can use it for infrainguinal grafting like I have just told you in this module and this
38:05great saphenous vein can also be used for coronary artery bypass grafting, right?
38:11So, we make an incision all along the great saphenous vein and then we dissect the vein.
38:15You can see here we dissect the vein and I told you below the knee it is closely associated
38:21with the saphenous nerve.
38:23So, we have to be careful that we don't injure the saphenous nerve.
38:26Now, once we have dissected the entire vein, we are going to cannulate the vein and then
38:31we cut the vein and we will have the entire graft with us.
38:36Now, when we are doing grafting, we usually reverse the vein so that the valves don't interfere
38:41in the circulation.
38:43So, this was the management of Burgess disease and atherosclerosis and we have spoken about
38:47acute arterial occlusion and chronic arterial occlusion.
38:50We have discussed that if we don't intervene on time or if the patient comes late, the patient
38:55is going to develop gangrene.
38:57Gangrene is when there is microscopic and macroscopic death of tissue.
39:03Microscopic and macroscopic death of tissue.
39:08That is gangrene.
39:12And gangrene can either be dry gangrene or it can be wet gangrene.
39:16Let me show you the images and then we will talk about the differences.
39:20This is a very common short note which is asked in the college exams where they ask you
39:23the differences between dry and wet gangrene.
39:26So, this you can see is dry gangrene.
39:28This was a patient with Burgess disease.
39:30You can see the line of demarcation is very well present there and this appears as desiccated,
39:36dried up, shriveled up skin.
39:37Wet gangrene, on the other hand, the line of demarcation is not very well marked and you
39:42can see oozing, you can see infection actively present in a patient with wet gangrene.
39:49Now, dry gangrene is a desiccated tissue by gradual slowing of blood and there is a good
39:56line of demarcation.
39:58Now, this line of demarcation is the difference between, is the juncture between dead and living,
40:06dead and living tissue, it is the junction between dead and living tissue, it is lined by
40:12granulation tissue, it is lined by granulation tissue and this line of demarcation is very
40:21sensitive to touch, right?
40:23It is very sensitive or there is hyperesthesia which is present here.
40:28So, there is good line of demarcation in dry gangrene and if a bony, if the bone is also
40:36involved, then the stump is conical.
40:39Why?
40:40Because bone has better blood supply.
40:42So, the bone line of demarcation will be more distal than the line of demarcation over
40:47the skin and the muscle.
40:49The bone line of demarcation will be more distal.
40:52Wet gangrene can occur when there is venous blockade or super added infection.
40:57So, this is another question which can be asked in the exam.
41:00Can a dry gangrene be converted into a wet gangrene?
41:04Absolutely.
41:05If there is super added infection, a dry gangrene can get converted into wet gangrene as well.
41:11There is a poor line of demarcation and there is infection which can extend to the neighboring
41:16tissue and the line of demarcation can be more proximal, right?
41:21If there is infection, even the block might be distal but because of infection, the line
41:26of demarcation might be more proximally placed.
41:29So, these are the differences between dry and wet gangrene which you should know about.
41:35Now, when there is gangrene, we have to carry out amputation and the indications of amputation,
41:41you can remember them as dead, deadly and damn nuisance.
41:49That's how we were taught in the exam or that is how we were taught in college.
41:56Dead means the gangrene has set in.
41:59Dead means there is gangrene.
42:01Deadly means if there is gas gangrene which can spread to the rest of the body as well.
42:08If there is a sarcoma which is involving the limb, if there is cancer involving the limb,
42:14that is a deadly limb, okay?
42:16That is a deadly limb and damn nuisance is when there are contractures which have developed
42:21in the limb which don't enable the patient to walk properly or they are causing a lot
42:26of pain to the patient or there are multiple sinuses or fistulae which are formed or there
42:34is deformity which is not enabling the patient to be ambulatory, these are the indications
42:39when you have to amputate the limb.
42:43So, we'll talk about certain points regarding amputation.
42:48This has been covered by Dr. Abbas in orthopedics as well but I will tell you the points which
42:52have been mentioned in Bailey so that you're all sorted for your surgery exam.
42:56Of course, I wanted to share this image of Oscar Pistorius, he was a double amputee, both
43:02baloney amputation and he was one of the fastest blade runners.
43:07So, these new blade prostheses are used these days and these patients can run very well and
43:14he had an excellent career in front of him but unfortunately he was convicted for murdering
43:22his girlfriend and he's currently in jail but I just wanted to show this picture that
43:28these patients even after double amputations can still have a functionally active life.
43:36So, the key points which have been written in Bailey regarding amputation, when there is
43:40diabetes mellitus, local amputation of the digits should be done and we should do conservative
43:45amputations.
43:46If the metatarsophalangeal joint is involved, then ray excision should be carried out.
43:54Transmetatarsal amputation, when several toes are involved, like in cases of Burgers or
44:00diabetes, if several toes are involved, then we can do a transmetatarsal amputation.
44:06Below knee amputation preserves the knee and this gives the best chance of walking.
44:12This gives the best chance of walking, so you should know this, below knee and above
44:17knee heals well, the flaps heal well.
44:21Now, this is the amputation stump below the knee, you should know that it should be not
44:27less than 8 cm below knee.
44:29This question has been asked in the exam.
44:32The amputation stump should be not less than 8 cm.
44:35Ideally, it should be 10 to 12 cm so that a good prosthesis can fit there, right?
44:41So, why do we want this much length?
44:42So, that a good prosthesis can fit there.
44:46There are two ways to do a baloney amputation.
44:49More commonly, we do a long posterior flap or the other one is a skew flap.
44:55Now, long posterior flap is more popular and the anterior mark is 10 cm below the tibial
45:02tibial tibia.
45:03The anterior mark is 10 cm below the tibial tibia.
45:06So, here you can see the marking for below knee amputation.
45:10You can see a long posterior flap.
45:12This is how the amputation is done and this is how it heals up.
45:15A long posterior flap, you can see the posterior skin coming forward.
45:19This is the more popular type of flap which is made during amputation.
45:24For above knee amputation, not less than 20 cm length should be there for the prosthesis
45:30to fit in, right?
45:32So, these points you should remember for the exam.