Vascular Pain

VASCULAR
PAIN
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist
Pain is a frequent manifestation of

arterial , venous, or lymphatic
problems
The nature and location of pain

complaints may be virtually
diagnostic of the underlying vascular
condition
Pain's "purpose is to signal the presence

of (and presumably prevent) tissue
damage and, thus, exists as one aspect
of homeostasis
When it becomes chronic, or is a
manifestation of the postoperative
state, is pain unhelpful
Focal pain is noted at the site of injury,

while diffuse pain is more
characteristic of deep structures
Visceral pain is dull, aching, and has

an agonizing, "sickening" component

Radicular pain radiates along peripheral

nerve pathways
Referred pain is perceived at a site
remote from where the noxious
stimulation is actually occurring

Pain can result from

physical stimuli
pressure
puncture
squeeze
tension
heat
cold

Pain can result from

chemical effects
Change in pH
Histamine-like
materials
Serotonin
Bradykinin
Other similar
polypeptides

Large- and medium-sized arteries have

two types of innervation
Afferent (sensory) nerves
Autonomic (sympathetic) nerves

Pain is the primary sensation

transmitted via nociceptive afferents
in arteries and veins
Position, temperature, and other such
sensations do not appear to be
transmitted via the innervation of
blood vessels
Nociceptive stimulation :
o Direct trauma (e.g., an arteriography
needle)
o Stretch (as with balloon dilatation or
stent)
o Shear (as in arterial dissection)
Nociception in large- and mediumsized veins is due to pain

receptors in the venous
adventitia which respond primarily
to stretch (as in venous
distention or engorgement,
perhaps the consequence of
downstream thrombosis or other
obstruction

Sympathetic and sensory fibers enter

the arterial (and venous) adventitia
to form an intrinsic neural network
(adventitial
plexus) mostly composed of sensory
afferents.

From adventitial plexus bundles of

nonmyelinated fibers (mostly
sympathetic) approach the media
("border plexus"), and extensions of
this network ramify within the media
("muscular plexus")

VASCULAR PAIN
SYNDROMES
Pain is a common manifestation of
various vascular disorders
Location, quality, and natural history of
such pain may be crucial to the
diagnosis or treatment of the
condition

Sudden tearing interscapular pain is

virtually diagnostic of an acute type
B thoracic aortic dissection
Mitigation of this pain is a hallmark of
satisfactory "medical management

VASCULAR PAIN
SYNDROMES
Intermittent Claudication
Pain Syndromes Following Stroke
Aortic and Other Large Artery Pain
Rest Pain, Ulcers, and Gangrene
Pain Associated With Venous Disorders
Pain Associated With Diseases Involving
Small Arteries
Pain Associated With Lymphatic Diseases

Pain Associated With Amputation
Intermittent
Claudication
Intermittent claudication is a
condition that is characterized by
pain and lameness during
muscular exercise or during
walking
The most frequent cause is narrowing
of arteries in the lower leg and foot
by arteriosclerosis
most commonly in the

gastrocnemius/soleus
muscle group distal to
atherosclerotic
occlusion of the
superficial femoral
artery, but can also be
seen
in more proximal thigh
muscle groups with
aortoiliac occlusive
disease or in the upper
extremities with
chronic
Claudication of the muscles of

mastication (jaw claudication )is
almost diagnostic of involvement of
the external carotid artery by giant
cell arteritis

The quality and pattern of the pain

associated with intermittent
claudication is stereotypical It is
absent at rest but appears following
muscle exertion of a specific amount,
disappearing quickly following
cessation of exercise

Claudication of arterial insufficiency

i
The pain is :
Localized to the working muscles
Burning or Cramping or Aching
The muscles are not particularly
tender
No distal trophic lesions occur

At the cellular level

Pain likely results from a combination of :
Ischemic neuropathy (particularly of small unmyelinated Adelta
and C sensory fibers)
Localized lactic acidosis (resulting from the anaerobic

metabolism)
Perhaps heightened by elaboration of

substance P


D.D. of Intermittent
claudication
Neurogenic claudication
Venous claudication
Myositis (administration of various statin

Medications)
Neurogenic Claudication
o Pain radiating to both lower extremities at
the posterolateral aspects of the thighs and
legs
o Worse with walking and with lumbar
extension, and is relieved by sitting down
o The pain is often associated with
numbness, and with heaviness or weakness

Bicycle test of van

Gelderen
Patient is asked to pedal on a stationary
bicycle
If the symptoms are caused by
peripheral vascular disease, the
patient will experience claudication
if the symptoms are caused by lumbar
stenosis, symptoms will be relieved
when the patient is leaning forward
while bicycling
Lower extremity claudication in

younger individuals
Popliteal entrapment syndrome
Chronic compartment syndrome

Intermittent claudication treatment

Exercise program (Walking)
Smoking
Control lipid profile, diabetes and
hypertension
Antiplatelet therapy (aspirin ,
ticlopidine and clopidogrel )
Cilostazol (and pentoxifylline)
Revascularization
Whose job performance or lifestyle is
compromised by claudication
Who do not have a response to
exercise and pharmacotherapy
The riskbenefit ratio with
revascularization is favorable

Revascularization
Catheter based intervention
Atherectomy
Stenting
Angioplasty
Surgery is the last resort

Endarterectomies on arterial blockages
Arterial bypass
Pain Syndromes
Following
Stroke
Pain is uncommon in association with

(CVA), except for patients whose
cerebrovascular ischemia results from
intracranial hemorrhage or tumor

Stroke survivors sometimes experience

what
appears to be a centrally mediated
pain ipsilateral to the neurologic deficit

Central poststroke pain (CPSP)

Patients suffering from strokes
involving
parts of the thalamus may complain
from motor and sensory
disturbances referred, in general, to
the opposite side of the body
The most frequent and paradoxical
manifestations are spontaneous pain

Thalamic syndrome was later shown to
be one aspect of a pathological
entity known as central pain
CPSP occurs after ischemic or
hemorrhagic stroke
Following thalamic stroke, CPSP is not
uncommon

Sensory abnormalities include
decreased perception of sharpness
and temperature
Pain usually limited to an area

smaller than the area affected by
sensory deficits

Burning or lancinating pain
associated with sensory
abnormalities in the painful region
Allodynia and hyperalgesia
The pain is often constant, but may
paroxysms
Central poststroke pain

(CPSP)
The pain is often worsened by stress
and relieved by relaxation
Pain can causing severe depression


(CPSP)
CPSP is a difficult to treat, and pain
reduction rather than relief has to be
the goal
Conventional analgesics and opioids
have been noted to be ineffective


(CPSP)
Amitriptyline (levels> 300 ngmol/L)
lamotrigine high dose (200 mg/day)
IV lidocaine
Mexiletine (400-800 mg/day)?


(CPSP)
A number of different stimulation
approaches and surgery have been
adopted for treatment of CPSP
Cortical stimulation
Thalamic stimulation



Vascular Pain

Загружено:

Сведения о документе

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Vascular Pain

Загружено:

Авторское право:

Доступные форматы

VASCULAR

Pain is a frequent manifestation of

The nature and location of pain

Pain's "purpose is to signal the presence

Focal pain is noted at the site of injury,

Visceral pain is dull, aching, and has

Dr Mehran Rezvani pain fellowship

Radicular pain radiates along peripheral

Dr Mehran Rezvani pain fellowship

Pain can result from

Dr Mehran Rezvani pain fellowship

Pain can result from

Dr Mehran Rezvani pain fellowship

Large- and medium-sized arteries have

Dr Mehran Rezvani pain fellowship

Pain is the primary sensation

Nociception in large- and mediumsized veins is due to pain

Dr Mehran Rezvani pain fellowship

Sympathetic and sensory fibers enter

Dr Mehran Rezvani pain fellowship

From adventitial plexus bundles of

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Sudden tearing interscapular pain is

Dr Mehran Rezvani pain fellowship

Pain Associated With Lymphatic Diseases

most commonly in the

Claudication of the muscles of

Dr Mehran Rezvani pain fellowship

The quality and pattern of the pain

Dr Mehran Rezvani pain fellowship

Claudication of arterial insufficiency

Dr Mehran Rezvani pain fellowship

At the cellular level

Localized lactic acidosis (resulting from the anaerobic

Perhaps heightened by elaboration of

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship

Bicycle test of van

Lower extremity claudication in

Dr Mehran Rezvani pain fellowship

Intermittent claudication treatment

Dr Mehran Rezvani pain fellowship

Surgery is the last resort

Pain is uncommon in association with

Dr Mehran Rezvani pain fellowship

Stroke survivors sometimes experience

Dr Mehran Rezvani pain fellowship

Central poststroke pain (CPSP)

Central poststroke pain (CPSP)

Central poststroke pain (CPSP)

Pain usually limited to an area

Central poststroke pain (CPSP)

Central poststroke pain

Dr Mehran Rezvani pain fellowship

Central poststroke pain

Dr Mehran Rezvani pain fellowship

Central poststroke pain

Dr Mehran Rezvani pain fellowship

Central poststroke pain

Dr Mehran Rezvani pain fellowship

Dr Mehran Rezvani pain fellowship