Surgical pathology of the arteries

The pathobiology of atherosclerosis

Cardiovascular disease remains the chief cause of death in the United States and Western Europe, and atherosclerosis, the principal cause of myocardial and cerebral infarction, accounts for the majority of these deaths.

Lack of unanimity about the definition of the histopathological structure of the lesion.

Arteriosclerosis remains the acceptable collective term for what is known popularly as hardening of the arteries.
The World Health Organization gives the definition of atherosclerosis as a variable combination of changes of the intima of arteries consisting of focal accumulations of lipid, complex carbohydrates, blood and blood products, fibrous deposits and calcium deposits associated with medial changes

NORMAL ARTERIAL ANATOMY

Arteries are compliant, distensible structures with a flat internal surface. They consist of three layers; the intima, the media, and the adventitia.

Vasa vasorum, found in the adventitia of larger arteries, provide oxygenation and nutrition to the outer layers of the artery.

HYPERLIPIDAEMIA

A high level of circulating lipoproteins usually results from an increase in their synthesis due to a diet high in saturated fat and/or a genetically determined reduction in their removal from the circulation.
Depending on the type of particles this causes an increase in the concentration of cholesterol and/or triglycerides in the plasma.

Familial hyperlipidaemia is one of the most common inherited conditions, affecting at least 1 in every 500 people in the United Kingdom. In some populations, such as Lebanese and Afrikaaners, the incidence is much higher. It is inherited in an autosomal dominant manner. Conditions which may cause secondary hyperlipidaemia include diabetes mellitus, hypothyroidism, excessive alcohol intake, obesity, nephrotic syndrome, pregnancy, biliary obstruction, myeloma, and intake of drugs such as thiazide, steroids, -blockers, and oral contraceptives.

EPIDEMIOLOGY OF ATHEROSCLEROSIS
Incidence Atherosclerosis and its complications are the leading cause of morbidity and mortality in the Western world, accounting for more than 50 per cent of all deaths.

Over 80 percent of these deaths are due to arteriosclerosis and hypertension combined.

Prevalence Atherosclerosis shows a prevalence of nearly 100 per cent in adults.

The severity of the disease varies from mild to severe when comparisons are made between groups, individuals, and even within individuals. In general, atherosclerosis increases with age, but it is not thought to be an intrinsic biological ageing process as most mammalian species age without spontaneously developing atherosclerosis. Males are affected more frequently than females, but the differences tend to diminish with increasing age: the ratio of affected males to females is 6:1 at ages 35 to 44, but 2:1 in the 65 to 74 age group.

Heredity Heredity influences the severity of atherosclerosis directly by affecting arterial wall structure and function and indirectly through such factors as hypertension, hyperlipidaemia, diabetes, and obesity.

Risk factors Epidemiological studies (such as the Framingham study) show that certain habits, diseases, and lifestyles are more important than others and offer different degrees of risk

It must be realized that advanced atherosclerosis and its clinical complications are uniquely human conditions. It is not possible to follow the progression of atherosclerosis within an individual, and epidemiology has to rely on the assessment of clinical consequences of atherosclerosis, such as myocardial infarction, as they apply to populations. Although these risk factors may be important in the development of these clinical complications; they do not necessarily per se reflect what is going on at the level of the intimal lesion in a single individual.

PATHOLOGY
Types of lesions The lesions seen in atherosclerosis consist of fatty streaks, fibrous plaques, and complicated or advanced plaques.

Patterns of lesion distribution

The abdominal aorta is affected more often than the thoracic aorta.

Atherosclerosis is particularly seen around ostia of branch vessels. It is rare in pulmonary arteries, except in the presence of pulmonary hypertension.

Major anatomical patterns include involvement of coronary arteries, the terminal abdominal aorta and its branches, the innominate, carotid, and subclavian arteries and their branches, and visceral branches of the abdominal aorta including the renal arteries.

Pathogenesis of atherosclerosis

Multiple theories of atherogenesis have been proposed

Obliterative atheromatous disease

Aortoiliac disease

The infrarenal aorta and iliac arteries are among the most common sites of chronic atherosclerotic occlusive disease in patients with symptomatic arterial insufficiency of the lower extremities. Proper management of patients with aortoiliac disease requires an understanding of the various clinical presentations, the typical patterns of commonly associated infrainguinal arteriosclerotic disease, the incidence of coexistent cardiopulmonary disease, and the variety of surgical techniques available for therapeutic intervention.
Proper patient selection, with careful history taking and physical examination, well accepted and standardized indications for surgery, appropriate preoperative testing and perioperative monitoring techniques, and use of appropriate procedures for each individual patient will usually result in a favourable clinical result with a low risk.

CLINICAL PRESENTATION

The initial manifestation of aortoiliac occlusive disease is intermittent claudication of the lower extremities, usually the buttock, hip, thigh, and calf muscle groups. The claudication is often more disabling than that associated with isolated femoropopliteal disease due to the larger number of muscle groups affected in more proximal occlusive disease.

In addition to intermittent claudication, male patients with aortoiliac disease may present with the classic triad of diminished femoral pulses, lower extremity claudication, and impotence, known as the Leriche syndrome.

The symptoms experienced by an individual patient depend upon the distribution and severity of the occlusive process.

When disease is confined to the aortic bifurcation and the common iliac arteries (type 1 disease), limb-threatening ischaemia is rare and the symptoms are limited to claudication.

Numerous pathways of collateral circulation are often found in patients with type I disease, and these may result in only mild to moderate claudication, even when the aortoiliac segment is completely occluded.

DIAGNOSIS

The clinical diagnosis of symptomatic aortoiliac disease is usually accurately established on the basis of a complete history and physical examination. Claudication occurring in the proximal muscle groups of the lower extremity, occurrence of the pain after walking a predictable distance, relief of the pain with only several minutes rest, and impotence in male patients is the classic description. Physical examination will often reveal auscultable bruits over the lower abdomen and the femoral regions. Femoral and distal pulses are usually diminished or absent and, in patients with more severe or type III disease, dependent rubor, elevation pallor and trophic skin changes may be seen in the feet and lower legs.

Laboratory assessment of vascular patency, particularly good quality preoperative arteriography, sometimes including pressure measurements allows accurate assessment of the adequacy of aortoiliac inflow.

Claudicatory symptoms must also be differentiated from non-vascular causes of lower extremity pain such as radicular pain caused by nerve root irritation from spinal stenosis (pseudoclaudication) or intervertebral disc herniation.
These patients will often describe pain induced by simply standing as well as on walking, and this history will help distinguish these patients from claudicants. Patients with pseudoclaudication often need to sit or lie down in order to relieve the pain as opposed to simply stopping walking. A careful history may reveal the sciatic distribution of the pain, suggesting its true aetiology.

OPERATIVE INDICATIONS

It is generally agreed that limb-threatening ischaemia, clinically defined by the presence of untreated rest pain, ischaemic ulceration, or frank gangrene, will usually require major amputation; these signs and symptoms are, therefore, clear-cut indications for arterial reconstruction. In this patient population there are few contraindications to surgery, since revascularization by some means can usually be accomplished with morbidity and mortality rates equivalent to or lower than those associated with major amputations. Age is rarely, if ever, a contraindication. If direct aortoiliac reconstruction is deemed too great a risk, high-risk patients with multiple associated medical problems may be candidates for alternative techniques for lower extremity revascularization, such as extra-anatomical bypass, percutaneous transluminal angioplasty, atherectomy, or a combination of such procedures.

The need for surgical intervention must be dictated by the circumstances of each individual patient.
Incapacitating claudication that prevents the patient from earning a living or that has a significant negative impact on the patient's desired lifestyle is generally considered an indication for surgery, provided that the patient is not at high risk for surgical complications, does not have a limited life expectancy secondary to associated medical problems, and has a generally favourable distribution of disease for correction. Patients with stable claudication will often experience significant improvement in their symptoms following conservative measures such as abstinence from smoking and pursuit of a daily exercise protocol, with weight reduction if appropriate. Surgical intervention should only be considered if these conservative treatments fail to improve the claudication.

PREOPERATIVE EVALUATION

Preoperative evaluation of the patient with aortoiliac disease routinely includes assessment of the patient's cardiac, pulmonary, and renal function. Myocardial infarction is the cause of more than 50 per cent of the perioperative deaths in patients undergoing peripheral vascular surgery, and the detection and management of coronary disease is, therefore, important. Traditional clinical cardiac risk assessment may be difficult in the patient awaiting peripheral vascular surgery who, due to claudication, leads a sedentary lifestyle: the absence of a cardiac history cannot safely be assumed to imply the absence of severe coronary disease.

Angiographic evaluation

If clinical evaluation indicates the need for revascularization and if the patient is a reasonable surgical candidate, angiography is the next stop in the evaluation. The angiogram should not be used as a diagnostic tool: clinical evaluation, history, and physical examination, often aided by non-invasive vascular laboratory testing, is usually sufficient to diagnose the problem and to determine the need for intervention. The angiogram is used to provide the anatomical details the vascular surgeon needs to select the appropriate operative approach. It may also be used to determine whether the atherosclerotic lesions may be amenable to some form of endovascular procedure such as percutaneous transluminal balloon angioplasty or atherectomy.

SURGICAL TREATMENT OF AORTOILIAC DISEASE

Direct aortoiliac reconstruction with an aortobifemoral bypass using a prosthetic graft represents the most definitive and durable means of revascularization. In a small selected group of endarterectomy may be appropriate. patients, direct aortoiliac

Extra-anatomical procedures or combination procedures using both endovascular techniques and extra-anatomical bypass, are applicable for patients considered to be too high a risk for direct repair. Proper selection of the relevant procedure depends upon critical analysis of three factors: the patient's general condition, the extent and the distribution of the atherosclerotic disease seen on the arteriogram, and the vascular surgeon's own experience and preference.

Aortoiliac endarterectomy

Aortoiliac endarterectomy may be used in those patients with truly localized (type I) disease. The advantages of this technique include the reduced risk of infection of the arterial reconstruction since no prosthetic material is used, a reduced incidence of wound complications since no groin incisions are needed, and establishment of antegrade inflow into the hypogastric arteries, potentially improving vasculogenic impotence in men more reliably than is the case with aortofemoral bypass. At present, these advantages over prosthetic grafting are rather minimal and the issue of improved potency is unproven. Careful patient selection is required for this approach.

Aortobifemoral bypass grafting

Aortofemoral bypass grafting is the preferred method of treatment of most patients with symptomatic aortoiliac disease.
Initial graft patency rates approach 100 per cent, the 5-year patency rate exceeds 80 per cent, and the 10-year patency rate approaches 75 per cent.

ENDOVASCULAR TECHNIQUES

These techniques include intra-arterial thrombolytic therapy for native occlusive lesions, transluminal balloon angioplasty, laser or thermal assisted balloon angioplasty, and atherectomy. Long-term follow-up of results of many of these techniques should be restricted to the high-risk patient felt to be unsuitable for standard aortobifemoral bypass. Long-term patency and relief of ischaemic symptoms following percutaneous transluminal angioplasty for local iliac disease produces results equivalent to those of surgical treatment in patients with limited disease, and its advantages in terms of cost and morbidity are obvious.

Femoral and distal arteries

INTRODUCTION

Obliterative atheromatous disease of the femoral and distal arteries does not exist in isolation but is part of a widespread vascular pathology; the cardiac, cerebral, and less commonly the mesenteric and renal circulations may be affected The plaque may ulcerate, leading to superimposed thrombosis which organizes and enlarges, further narrowing the vessel and causing turbulent flow. Turbulence accelerates the process leading to occlusion of the vessel.

The natural history of infrainguinal arterial disease is not a simple steady deterioration towards amputation; it is more often characterized either by stable intermittent claudication or even by symptomatic improvement as collateral channels enlarge.

PRESENTATION AND CLASSIFICATION

The three cardinal features of peripheral lower limb ischaemia are intermittent claudication, rest pain, and gangrene, representing an increasing degree of severity of ischaemia. Intermittent claudication is a cramp caused by inadequate oxygenation of muscle. It is initiated by walking and relieved by rest; generally the calf muscles are most affected. Claudication distance remains roughly the same unless the underlying condition deteriorates, although the symptom is more pronounced on hurrying or going uphill.

Rest pain occurs when the blood supply is so poor that tissue perfusion is inadequate even at rest. The pain classically affects the toes or forefoot (the most distal part of the limb) although in severe cases it may involve the whole foot or calf. It is usually first noticed in bed, when the patient is horizontal, the beneficial effect of gravity is removed and the foot is warmed, thereby increasing metabolism.

ASSESSMENT

Assessment must establish the degree of ischaemia, whether it requires treatment and, if so, the most appropriate treatment. History and examination will usually identify the presence or absence of vascular disease and suggest its severity. Skin temperature, pallor on elevating the limb followed by dependent rubor, and the absence of pulses are particularly important features. The palpation of pulses should give the surgeon a rough idea of the site of arterial occlusion. More exact assessment requires a Doppler ultrasound probe and sphygmomanometer cuff to measure the highest opening systolic pressure of the three ankle arteries

The standard imaging technique is angiography Radiographs are exposed after injection of radio-opaque contrast medium into the arterial tree through a fine catheter inserted via the femoral artery in the groin. Current techniques using non-ionic contrast media and narrow gauge catheters are safe, though invasive, and the angiogram remains the investigation of choice.

Computerized(digital subtraction) angiography may be used as an adjunct to the basic conventional technique to highlight areas of special interest

It must be stressed that angiography should only be performed if intervention is intended.

It allows an assessment of whether intervention is technically feasible and enables the most appropriate form of treatment to be chosen. The appearance of the aorta and iliac vessels is checked to confirm that there is no impairment of inflow to the leg.
The sites of stenosis and occlusion in the leg arteries themselves are noted, and patency of the distal arteries (outflow) assessed.

MEDICAL TREATMENT

Medical treatment may be indicated when the disease is not of sufficient severity to warrant operation (including angioplasty); when operation is impossible, inappropriate, or unsuccessful; or as an adjunct to operation. Several general measures are applicable to all patients whether or not they have surgery, for instance weight reduction in the obese, correction of anaemia or polycythaemia, treatment of hyperlipidaemia, and control of diabetes. The judicious treatment of heart failure and hypertension may also improve perfusion, but -blocking drugs should be avoided as they may further compromise a diseased peripheral circulation.

Smoking is the most important correctable risk factor. Stopping smoking may be the only treatment that many patients require; claudication not infrequently improves spontaneously. Stopping smoking may not reduce atheroma that is already present, but continuation of smoking leads to an increased deposition and compromises the development of a collateral circulation. Smoking increases the risk of amputation and the incidence of graft occlusion after surgery.

Exercise is the other arm of effective conservation treatment: it may double the distance that can be walked before pain occurs in up to 80 per cent of patients. It has been suggested that selective exercise of those muscles which are most ischaemic produces the best results. Even rest pain may benefit from exercise, and it is prudent to recommend that patients exercise to the limit of comfort.

INDICATIONS FOR INTERVENTION Subclinical disease

In a patient with unilateral symptoms it is not unusual to find angiographic evidence of early disease on the contralateral side. It is not yet known whether intervention for early asymptomatic disease confers benefit over a conservative policy and intervention in this group should occur only in the confines of a clinical trial addressing this question.

Intermittent claudication

Intermittent claudication represents the middle Any decision to intervene must take into account the possibility that spontaneous improvement may occur, especially if smoking is stopped and exercise adopted. Symptomatic improvement is especially likely within the first 6 months after onset of claudication. Consideration should be given to the degree to which the patient's lifestyle is affected and the hazard to life and limb that the proposed intervention might pose.

Rest pain and critical ischaemia

Rest pain or critical ischaemia despite appropriate medical management requires intervention if at all possible.
Revascularization should generally be attempted if angiography and/or pulse generated run-off indicate that percutaneous transluminal angioplasty or reconstructive surgery is feasible.

ALTERNATIVES TO SURGERY

Percutaneous transluminal angioplasty is a radiological technique in which a guidewire is introduced percutaneously through the common femoral artery to lie within a stenosis. A catheter with a balloon at its end is introduced over the guidewire and the balloon is inflated within the narrowed segment

Today the technique is regularly applied to the femoropopliteal segment and to many sites other than the leg

OPERATIVE TECHNIQUES AND GRAFT MATERIALS

The choice of operation for patients with occlusive disease of the lower limb arteries depends on the site of the occlusion(s), the availability of a suitable graft, and the experience of the operator. Although a variety of local bypasses or patch angioplasties may occasionally be desirable, by far the most common procedure is a bypass from the common femoral artery to a distal vessel; this is usually the popliteal artery-either above or below knee level-but it may also be to the tibioperoneal trunk or to any of the three (crural) vessels of the lower leg. The rationale is to transport blood around an occluded segment while avoiding operative trauma to collaterals.

When available, the autogenous long saphenous vein is the best graft material for femorodistal bypass .
However, this vein may be too small in calibre, thrombosed, markedly varicose, or may have been removed surgically in the past. It is common for the vein to be assessed visually at the time of operation, but it is possible to assess the usefulness of the long saphenous vein before surgery, either by duplex ultrasound scanning or by saphenography.

If the vein is inadequate it may be necessary to use a graft of synthetic material, the most popular of which is expanded polytetrafluoroethylene (PTFE) . This inert substance has considerable resistance to thrombosis.

When a graft of any type is inserted it is good practice to ensure at the end of the operation that the anastomoses, especially the distal one, are technically satisfactory and that flow through the graft is adequate to maintain patency. Several techniques are available.

peroperative Doppler ultrasonography

peroperative angiography

angioscopy which is now becoming increasingly popular in major vascular centres

ANEURYSMS AORTA

DEFINITION

an abnormal dilatation of an artery or vein, and the application of this general principle to the abdominal aorta has seldom presented any problems in routine clinical practice. The universal use of abdominal ultrasound as a basic diagnostic tool has recently highlighted the need for a more precise definition to allow appropriate diagnosis of the many marginal aortic dilatations, or small aneurysms, which are now being discovered.

An aortic aneurysm is present when the maximum external diameter of the aorta either (1) is at least 4.0 cm; or (2) exceeds the diameter of the adjacent aorta by at least 0.5 .

CLINICAL PRESENTATION

The majority of abdominal aortic aneurysms are asymptomatic and are often discovered incidentally. The patient may notice a pulsatile epigastric mass for the first time typically while lying relaxed in bed or his bath. Large aneurysms in thin patients are readily detected on routine abdominal examination, but most are now discovered by ultrasonography or abdominal radiography performed to investigate unrelated symptoms.

Symptoms and signs of aortic rupture

Typically, rupture of an abdominal aortic aneurysm produces the sudden unheralded onset of severe central abdominal and lumbar back pain. Some patients may have experienced dull back pain of lesser severity for hours or days before, due to acute aneurysm expansion immediately prior to rupture. The lumbar pain may be worse on one side, commonly the left, because of the direction in which the retroperitoneal haematoma spreads.

Other early symptoms and signs depend on the volume of acute blood loss. Once the posterior peritoneum is breached, the patient will rapidly bleed to death into the peritoneal cavity, and most immediate deaths are due to intraperitoneal rupture. Survival after rupture depends on an intact posterior peritoneum, tissue tamponade, and early emergency surgery. When the connective tissue tamponade provided by the retroperitoneum is very effective, or the leak is small, only modest haemorrhage may occur, and these patients can survive long journeys to hospital and several days before exsanguinating haemorrhage occurs.

The self-selection of such patients for transfer to distant tertiary referral centres may be partly responsible for the superior results of some units. In most cases, tamponade is less effective and arrests acute haemorrhage only when assisted by hypotension secondary to blood loss. These patients exhibit pallor, sweating, tachycardia, and anuria, and transfusion alone by raising the blood pressure will result in further haemorrhage. Immediate surgery to clamp the aorta above the site of rupture offers the only chance of survival.

MANAGEMENT

Symptomatic abdominal aortic demand urgent or early treatment.

aneurysms

usually

The extent of preoperative investigation, assessment, and medical treatment may therefore need to be curtailed and the patient prepared for surgery as well as possible in the time available.
The most immediate need for surgery arises in the patient with a ruptured aneurysm, and this is contrasted below with management of the asymptomatic patient.

The management of other symptomatic presentations of the disease will fall somewhere between these two extremes, depending on how compelling the need for surgery.

Carotid artery

INTRODUCTION

Atheromatous disease at the origin of the internal carotid artery is a significant cause of strokes. Its recognition as a cause of neurological symptoms is important, for it may be amenable to surgical correction by carotid endarterectomy. The usual indication for carotid endarterectomy is a transient ischaemic attack, although it may be performed in patients with an evolving stroke, a completed stroke, or an asymptomatic tight carotid artery stenosis.

Atheromatous plaques form at the carotid bifurcation, and especially in the carotid sinus. The lesion in the internal carotid artery is restricted in most instances to the origin of the artery and the carotid sinus, the artery distal to the lesion and the common carotid artery proximal to the lesion being relatively normal. The plaque may ulcerate, giving rise to thrombus formation in the bed of the ulcer or, if the plaque eventually produces a tight stenosis of the artery origin thrombus may form at the stenosed area of the plaque . If thrombus is dislodged it will pass downstream, either to the retinal arteries via the ophthalmic artery or to the cerebrum via the middle cerebral artery, giving rise to a transient ischaemic attack, a complete stroke, amaurosis fugax, or a retinal infarct.

CLINICAL PRESENTATION AND DIFFERENTIAL DIAGNOSIS

Symptoms of transient ischaemia in the carotid artery territory reflect its distribution to the eye and the anterior two-thirds of the brain. The most common symptoms are weakness, numbness, and clumsiness of the limbs, especially the arm, contralateral to the side of the lesion, or loss of vision on the side of the lesion (amaurosis fugax). The patient characteristically describes the loss of vision as being as if a blind had been pulled down (occasionally across) and as vision returns, usually in a few minutes, the blind retreats in the opposite direction. Dysphasia associated with a transient ischaemic attack is also common, especially if the left hemisphere is involved in a right-handed person.

INVESTIGATION

The gold standard has always been carotid angiography with the addition of CT scanning or magnetic resonance imaging (MRI) of the brain in recent years.
However, the risk of a stroke being precipitated by angiography is between 1 and 4 per cent when this is performed for extracerebrovascular disease.

MANAGEMENT OF CAROTID DISTRIBUTION TRANSIENT ISCHAEMIC ATTACKS

INDICATIONS FOR CAROTID ENDARTERECTOMY

Vertebrobasilar, subclavian, and innominate arteries

Arterial emboli: limbs

DEFFINITION AND AETIOLOGY

An embolus consists of undissolved material which is carried in the circulation and impacts in a blood vessel, usually blocking it. The most common source of arterial embolism is the left atrium in atrial fibrillation, accounting for two-thirds of all cases. Thrombus forms because of stasis in the enlarged and fibrillating atrium, and fragments detach to enter the arterial circulation Thrombi can also form on the damaged endocardium of the left ventricle after myocardial infarction, and arrhythmias cause these to detach and embolize.

SITES AFFECTED BY EMBOLI

Emboli usually lodge at the bifurcations of arteries, because the diameter of each major branch is less than that of the main branching vessel.

CLINICAL ASSESSMENT Diagnosis of embolism causing acute ischaemia of a limb The clinical features are best remembered as the six P pain, pallor, pulselessness, paraesthesiae, paralysis, and perishing cold.

The onset of symptoms caused by an embolus is sudden, with pain and pallor occurring first. Colour change is variable and depends on the amount of collateral blood flow. If there are no established collaterals the extremity is white, sometimes with a bluish tinge. If some blood flow is maintained a pink colour remains, but capillary return is slower than normal. The more profound the ischaemia, the sooner paraesthesiae will be followed by anaesthesia. Loss of sensation is a serious sign and an indication for urgent treatment to restore blood flow. Paralysis is also a sign of advanced ischaemia.

Pulses distal to the occlusion are lost, while immediately proximal to the occlusion the pulse may be enhanced due to the high resistance caused by obstruction. Acute ischaemia due to an embolus is a clinical diagnosis and special tests should not be necessary, but Doppler ultrasound investigation confirms absent or poor blood flow signals in the distal arteries, and the systolic pressure is unrecordable or low. An arteriogram is not necessary in the presence of an obvious embolic source (for example atrial fibrillation) and clear evidence of a sudden arterial occlusion, but angiography is worthwhile if there is any doubt about the diagnosis