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Cardiovascular > Abdominal Aorta and Acute Limb Threat > Flashcards

Abdominal Aorta and Acute Limb Threat Flashcards

1
Q

What is an aneurysm?

A

A dilatation of a vessel by more than 50% of its normal diameter

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2
Q

What is the normal aortic diameter?

A

1.2-2.0 cm

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3
Q

What are the 2 types of aneurysm?

A

True aneurysm

False aneurysm

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4
Q

What is a true aneurysm?

A

Involves all 3 layers of the vessel wall

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5
Q

What is a false aneurysm?

A

There is a breach in the vessel wall (surrounding structures act as vessel wall)

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6
Q

What is the morphology of aneurysms?

A

Saccular
Fusiform
Mycotic (arises secondary to an infectious precess involving all 3 layers of the artery)

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7
Q

What is the pathogenesis of AAA?

A

Medial degenration - the regulation of elastin/collagen is impaired and to the vessel walls become weaker
Aneurysmal dilatation, increase in aortic wall stress and progressive dilatation

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8
Q

What are the risk factors to developing an AAA?

A 
Age
Gender
Smoking
Hypertension 
Atherosclerosis
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9
Q

What is the presentation of AAA?

A

75% are asymptomatic
Symptomatic: pain (mimic renal colic), “trashing” (clot in the lumen that can travel down to the arteries in the toes)
Rupture

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10
Q

What is the presentation of a ruptured AAA?

A

Sudden onset epigastric/central pain
May radiate to back
Mimic renal colic
Collapse

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11
Q

What are the examination findings of a ruptured AAA?

A 
May look "well"
Hypo-hypertensive 
Pulsatile, expansile mass +/- tender 
Transmitted pulse
Peripheral pulses
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12
Q

When should the surgeons intervene with an AAA?

A

If it is symptomatic

If asymptomatic: if the AAA is >5.5 cm AP diameter or it is expanding - >1cm/year

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13
Q

How is an AAA imaged?

A

Duplex ultrasound - can give AP diameter and if there is involvement with iliac arteries
CT scan - IV contrast. Gives aneurysm morphology (shape, size, iliac involvement, management planning, allows to see ruptured AAA)

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14
Q

How can an AAA be repaired openly?

A

Open repair - laparotomy, clamp aorta and iliacs and place a dacron graft. Once graft is placed need to fold aneurysm sac over it to prevent bowl perforations or infections

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15
Q

How can an AAA be repaired with a stent?

A

Endovascular aneurysm repair (EVAR)

Excludes the AAA from inside the vessel. Inserted via peripheral artery. X-ray guided. Requires life-long follow up

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16
Q

What is acute limb ischaemia?

A

Sudden loss of blood supply to a limbs - occlusion of a native artery or bypass graft

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17
Q

What can cause a sudden occlusion of an artery?

A 
Embolism - usually from heart 
Atheroembolism 
Arterial dissection 
Trauma
Extrinsic compression - tumour
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18
Q

What are the clinical features of acute limb ischaemia?

A 
Pain
Pallow 
Perishingly cold 
Paraesthesia
Paralysis
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19
Q

What type of pain is associated with acute limb ischaemia?

A

Severe, sudden onset, resistant to analgesia

Calf/muslce tenderness with right (woody) compartment indicated muscle necrosis

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20
Q

What type of pallor is associated with acute limb ischaemia?

A

Limb initially white with empty veins
Later, capillaries fill with stagnated de-oxygenated blood giving a mottled effect (blanching mottling = salvageble if prompt revascularisation)
Arteries distal to occlusion fill with propogated thrombus with ruputre of capillaries (non-blanching mottling = irreversible ischaemia)

21
Q

What is paraesthesia?

A

Sensorimotor deficit are indicative of muscle and nerve ischaemia

22
Q

How is acute limb ischaemia managed?

A 
ABC - resucuitate and investigate
FBC, U/E's, CK, Coag +/- troponin
ECG - MI, dysrhythmia
CXR - underlying malignancy 
Anticoagulate - stops propogation of thrombus 
May improve perfusion
23
Q

When is arterial imaging required in acute limb ischaemia?

A

If there is no prior history of claudication
The cause for embolism is known
Full complement of contra-lateral pulses

24
Q

What is performed on the limb if it is salveagable?

A

Embolectomy
Fasciotomies
Thrombolysis

25
Q

What is performed if the limb is not salveagable?

A

Palliation

Amputation

26
Q

What are the different types of diabetic foot problems?

A

Diabetic neuropathy
Peripheral vascular disease
Infection

27
Q

What does diabetic foot problems lead to?

A

Tissue ulceration
Necrosis
Gangrene
May result in limb amputation

28
Q

What is the strongest risk for limb loss?

A

Diabtetes

29
Q

What can be the source of sepsis in diabetic foot sepsis?

A

Simple puncture wound
Infection from the nail plate or inter-digital space
Neuro-ischaemic ulcer (occurs on areas of increased pressure i.e. under the metatarsal heads)

30
Q

What are the compartments of the foot?

A

Plantar fascia, metatarsal bones, interosseous fascia

Infection will track in the soft tissues into the rigid compartment

31
Q

What are the clinical findings of diabetic foot sepsis?

A 
Swollen affected digit
Swollen forefoot
Tenderness
Ulcer with pus extruding 
Erythema, may track up the limb 
Patches of rapidly developing necrosis 
Crepitus in the soft tissues of the foot 
Pedal pulse may or may not be present
32
Q

How is diabeteic foot sepsis managed?

A

Appropriate antibiotics should be administered at the earliest opportunity
Rapid surgical debridement of infected tissue
Remove all infected tissue, leave the wound open to encourage drainage

33
Q

What are the types of antibiotics that may be administered in diabetic foot sepsis?

A

Gram positive cocci (S.Aureus + streptococcus)
Gram -ve bacilli (E.coli, Klebsiella, enterbacteria, proteus, pseudomonas)
Anaerobes (bacteroides)

34
Q

How can diabetic foot problems be prevented?

A

Adequate education, foot assessment (diabetic foot clinic, podiatrist) and pressure offloading footwear

35
Q

What are the branches off the abdominal aorta?

A

Coeliac axis
Superior mesenteric
Right renal
Inferior mesenteric

36
Q

What arteries are contained within the pelvic structure?

A

Common iliac, internal iliac, external iliac

37
Q

What arteries are contained within the thigh?

A

Common femoral, deep femoral and superficial femoral

38
Q

What arteries are contained within the lower leg and foot?

A

Popliteal, anterior tibial, tibioperoneal trunk, posterior tibial, peroneal

39
Q

What is intermittent claudication?

A

“angina for the leg”

Insufficient blood reaches the muscle when exercising

40
Q

How is claudication diagnosed?

A

Ankle brachial pressure index (ABPI)
Ankle pressure (mmHg)/Brachial pressure (mmHg)
Duplex ultrasound scanning

41
Q

What is the range of values for a normal, claudication and severe ABPI?

A 
Normal = 0.9 - 1.2 
Claudication = 0.4 - 0.85 
Severe = 0- 0.45
42
Q

What is a invasive investigation of claudication?

A

Magnetic resonance angiography (MRA)
CT angiography
Catheter angiography

43
Q

How is lower limb ischaemia treated?

A

Slowing progression: SMOKING CESSATION, lipid lowering, antiplatelets, hypertension, diabetes, life style issues

44
Q

How can claudication symptoms be improved?

A 
Realistic expectations
Consent
Exercise training
Drugs
Angioplasty 
Surgery
45
Q

What different types of surgery can be performed to improve the symptoms of claudication?

A

Endarterectomy (improves inflow)

Bypass (outflow) - anatomic, extra-anatomic (prosthetic, vein)

46
Q

What are the different types of bypass that can be performed to improve the symptoms of claudication?

A

Iliac angioplasty and crossover graft
Aortobifemoral bypass graft
Axillobifemoral bypass graft

47
Q

What are the risk factors for amputation in critical limb ischaemia?

A

Smoking
Diabetes
Hypertension
Raised cholesterol

48
Q

What are the symptoms of critical limb ischaemia?

A

Pain at rest
Strong analgesia
Worse at night
Helped by sitting

49
Q

What can be seen in the clinical examination of a critially ischaemic limb?

A 
Cool to touch 
Absence of peripheral pulses 
Shiny 
Pale
Loss of hair
Ulcers

Cardiovascular (27 decks)

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