Table Of ContentProblems
•
In
Peripheral
Vascular Disease
Problems in Practice Series
PROBLEMS IN ARTHRITIS AND RHEUMATISM - D. N. Golding
PROBLEMS IN CARDIOLOGY - C. F. P. Wharton
PROBLEMS IN GASTROENTEROLOGY - M. Lancaster-Smith and K. Williams
PROBLEMS IN GERIATRIC MEDICINE - A. Martin
PROBLEMS IN GYNAECOLOGY - E. P. W. Tatford
PROBLEMS IN OPHTHALMOLOGY - M. G. Glasspool
PROBLEMS IN OTOLARYNGOLOGY - P. Ratnesar
PROBLEMS IN PAEDIATRICS - J. Hood
PROBLEMS IN PERIPHERAL VASCULAR DISEASE - P. E. A. Savage
PROBLEMS IN RESPIRATORY MEDICINE - P. Forgacs
PROBLEMS IN SOCIAL CARE - R. Corney
SERIES INDEX VOLUME
Problems in Practice Series
Series Editors: ].Fry K.G.D.Williams M.Lancaster-Smith
Problems
•
In
Peripheral
Vascular Disease
P.E.A.Savage
MS,FRCS
Consultant General and Vascular Surgeon
Queen Marys Hospital,Sidcup,Kent
MT
PREss LIMITED
International Medical Publi hers
To
A.L.S.
Published by
MTP Press Limited
Falcon House
Lancaster, England
Copyright © 1983 P.E.A. Savage
Softcover reprint of the hardcover 1st edition 1983
First published 1983
All rights reserved. No part of this publication
may be reproduced, stored in a retrieval
system, or transmitted in any form or by any
means, electronic, mechanical, photocopying,
recording or otherwise, without prior
permission from the publishers.
British Library Cataloguing in Publication Data
Savage, Peter E.A.
Problems in peripheral vascular disease
-(Problems in practice)
1. Peripheral vascular diseases 2. Ischaemia
1. Title II. Series
616.1'31 RC694
ISBN-13: 978-94-011-6650-8 e-ISBN-13: 978-94-011-6648-5
001: 10.1007/978-94-011-6648-5
Butler & Tanner Ltd, Frome and London
Contents
Preface
7
Series Foreword f.P.Horder GEE 9
1 Arterial occlusive disease 11
Presentation - Examination and risk factors - Investi-
gations - Vasoactive drugs - Surgical treatment
2 The surgical treatment of 19
intermittent claudication
Assessment - Aortoiliac disease - Femoropopliteal re-
construction
3 The critically ischaemic limb 25
Definition - Clinical features - Management - Results
4 When should arteries be dilated? 29
Percutaneous trans luminal angioplasty - Technique -
Indications
5 Acute ischaemia and arterial embolism 33
Thrombosis - Embolism - Clinical features - Manage-
ment
6 Amputation in peripheral vascular disease 39
Indications - Technique - Results - Rehabilitation
7 What is Buerger's disease? 45
Clinical features - Prognostic factors - Management
8 Aneurysms 49
Pathogenesis - Aortic aneurysms - Surgery of leaking
aortic aneurysms - Dissecting aortic aneurysms
5
Problems in peripheral vascular disease
9 What about sex, doctor? 55
Physiology - Vasculogenic impotence - Prevention of
impotence - Surgical treatment of vasculogenic
impotence
10 Vascular surgery of the intestinal tract 59
Anatomy - Pathology - Chronic intestinal ischaemia -
Acute intestinal ischaemia
11 Raynaud's what? 63
Physiology - Raynaud's syndrome - Raynaud's disease
- Raynaud's phenomenon - Assessment and investi-
ation - Treatment
12 The diabetic foot 69
Pathophysiology - Clinical presentation - Assessment
- Management
13 Lumbar canal stenosis 75
Cauda equina syndrome - Anatomy - Clinical features
- Diagnosis - Treatment
14 Varicose veins 77
Anatomy - Physiology - Classification - Assessment -
Management - Recurrent varicose veins - Superficial
thrombophlebitis - Restless leg syndrome
15 Compression sclerotherapy for varicose veins 87
Patient selection - Injection technique - Complications
16 Venous thromboembolism 93
Pathogenesis - Prevention of deep vein thrombosis
(DVT) - Clinical features of DVT - Management of DVT
- Recurrent DVT - Pulmonary embolism
17 The post-thrombotic syndrome 103
Clinical features - Venous outflow obstruction -
Venous reconstructive surgery
18 Leg ulcers 107
Aetiology - Clinical features - Diagnosis - Manage-
ment
Index 113
6
Preface
In writing this short monograph on 'Problems in Peripheral
Vascular Disease', I have tried to steer a course between a
simplistic dogmatic approach more appropriate to an under
graduate text, and a detailed specialist treatise of interest only to
vascular surgeons.
Although arterial surgery has been performed for centuries,
the main indications in the past were to deal with the effects of
trauma and aneurysm formation. The development of arterio
graphy and the ability to see arterial blocks and stenoses allowed
surgeons to carry out increasingly sophistidated operations for
an enlarging range of pathological conditions. Even today,
arterial surgery continues to develop, and although we are often
dealing with the 'surgery of ruins', a successful outcome is just
as rewarding for surgeon and patient alike.
In this book I have also included a discussion on venous
problems including a note about recent developments in direct
surgery of the deep veins of the lower limb which could be a re
warding field of endeavour for the vascular surgeon.
The original descriptions by Buerger and Raynaud are taken
from 'Classic Descriptions of Disease' by Ralph H. Major. While
reviewing my own surgical practice, I have had the pleasure of
reading once again the publications of H.H.G. Eastcott (arterial
surgery), J.T. Hobbs (varicose veins), G.L. Hill (Buerger's
disease), Adrian Marston (intestinal ischaemia), Martin
Bimstingl (vasospastic disorders) and C.H. Hawkes (lumbar
canal stenosis).
To my registrar, Mr F. Massouh FRCS, I extend my thanks
for the trouble he has taken in reading the draft manuscript and
7
Problems in peripheral vascular disease
for making many valuable suggestions. My secretary, Mrs
Sharon Hartman, has typed the manuscript with her usual
patience and skill.
P.E.A. Savage
Sidcup, 1982
8
Series Foreword
This series of books is designed to help general practitioners. So
are other books. What is unusual in this instance is their collec
tive authorship; they are written by specialists working at
district general hospitals. The writers derive their own experi
ence from a range of cases less highly selected than those on
which textbooks are traditionally based. They are also in a good
position to pick out topics which they see creating difficulties
for the practitioners of their district, whose personal capacities
are familiar to them; and to concentrate on contexts where
mistakes are most likely to occur. They are all well-accustomed
to working in consultation.
All the authors write from hospital experience and from
the viewpoint of their specialty. There are, therefore, matters
important to family practice which should be sought not within
this series, but elsewhere. Within the series much practical and
useful advice is to be found with which the general practitioner
can compare his existing performance and build in new ideas
and improved techniques.
These books are attractively produced and I recommend
them.
J.P. Horder CBE
Past President, The Royal College
of General Practitioners
9
~
Arterial occlusive disease
Presentation - Examination and risk factors - Investigations -
Vasoactive drugs - Surgical treatment
The clinical features of arterial insufficiency in the lower limb
are reflected by the relative needs of various tissues for oxygen
and nourishment. Exercising muscle, being the most active
metabolic tissue in a limb, registers its relative anoxia by stimu
lating pain receptors. This pain is brought on by exercise and re
lieved by rest. As the degree of ischaemia increases, the claudi
cation distance becomes shorter until the patient suffers from
continuous pain at rest. Progressive arterial insufficiency even
tually leads to deterioration in skin nutrition with ulceration.
The death of skin and deeper structures in the foot and leg is
followed by infection and gangrene.
Presentation
Presenting A patient may consult his family doctor with three main peri
complaint pheral vascular problems: an acute arterial occlusion (Chapter
5), a chronic arterial occlusion which has progressed to the stage
at which viability of the limb is precarious (Chapter 3) and a
chronic vascular insufficiency causing intermittent claudi
cation.
Intermittent Although there are a number of causes for pain in the lower
claudication limb, pain in a muscle group brought on by exercise and com
pletely relieved by rest is the classical presentation of inter
mittent claudication. Claudication may affect the muscles of the
11
