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Vascular MRCS B > Arterial > Flashcards

Arterial Flashcards

1
Q

Features of chronic lower limb arterial stenosis or

occlusion

A

● Intermittent claudication

● Rest pain

● Dependent rubor or sunset foot

● Ulceration

● Gangrene

● Arterial pulsation diminished or absent

● Arterial bruit

● Slow capillary refilling

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2
Q

Intermittent claudication

A

Reliably brought on by walking

Not present on fist step (unlike osteoarthritis)

Reliably relieved by rest, standing or sitting within 5 minutes
-lumbar vertebral disc pain or spinal stenosis usually only relieved by sitting and takes >5 minutes

Claudication distance varies little day-to-day
-unlike musculoskeletal pain

Claudication distance is decreased by increasing the work demands and hence oxygen requirements of the muscles affected, e.g. walking up hill, increasing the speed of walking and/or carrying heavy weights,

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3
Q

Most common site of stenosis

A

Superficial femoral artery disease (70%)
-hence majority of caludicants have calf pain

Aorto-iliac disease (30%)

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4
Q

Leriche’s syndrome

A

Aorto-iliac disease causing buttock claudication in association with sexual impotence

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5
Q

Rest pain

A

=anaerobic respiration at rest
=Critical limb ischaemia

Classically improved with standing

Worse when lying flat or limb elevation

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6
Q

Ulceration in CLI

A

painful erosion between toes or as shallow,

non-healing ulcers on the dorsum of the feet, on the shins and especially around the malleoli

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7
Q

Colour of chronic limb ischaemia

A
  • Chronically ischaemic limb tends to equilibrate with the temperature of its surroundings
  • May feel quite warm under the bedclothes.

-Does not produce paralysis and sensation is usually
intact

-Patients with their leg in dependence may have a red swollen foot that may be mistaken for cellulitis by
the unwary clinician.
However, elevation of the limb reveals the severity of the ischaemia, with venous guttering and foot pallor that changes to a red/purple colour when the limb is allowed to hang down again (dependent rubor or the sunset
foot sign)

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8
Q

Arterial bruit

A

=stenosis

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9
Q

Machinery murmur

A

= AV fistula

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10
Q

Loss of pulse on exercise

A

Indicated pulsation from collaterals around an occlusion

As vasodilation occurs below the occlusion and claudication occurs there is a loss of pulse pressure across the collaterals and a loss of pulse

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11
Q

Signs and symptoms of aortoiliac disease

A
  • Claudication in buttocks, thighs and calves]=
  • Femoral and distal pulses absent in both limbs
  • Bruit over aortoiliac region
  • Impotence (Leriche)
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12
Q

Signs and symptoms of iliac obstruction

A
  • Unilateral claudication in the thigh and calf and sometimes the buttock
  • Bruit over the iliac region
  • Unilateral absence of femoral and distal pulses
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13
Q

Signs and symptoms of femoropopliteal obstruction

A

-Unilateral claudication in the calf

-Femoral pulse palpable with absent unilateral
distal pulses

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14
Q

Signs and symptoms of distal obstruction

A
  • Femoral and popliteal pulses palpable
  • Ankle pulses absent
  • Claudication in calf and foot
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15
Q

Ankle-brachial pressure index

A

ABPI

Ratio of systolic pressure at the ankle to that of the ipsilateral arm

Highest pressure in the doralis pedis, posterior tibial or peroneal artery = numerator

Pressure in brachial = denominator

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16
Q

ABPI values

A
  1. 9 - 1.3 = normal
  2. 5 - 0.9 = intermittent claudication
  3. 3 - 0.5 = rest pain

<0.3 = imminent necrosis

> 20% drop post exercise = flow-limiting arterial disease

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17
Q

Duplex

A

Uses b-mode ultrasound and doppler

Cost-effective and non-invasive and in experienced hands as good as angiography

Relatively poor at visualising aortoiliac vessels, particularly in obese patients

High flow= stenosis

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18
Q

Digital subtract percutaneous angiography

A

DSA
-injection of radio-opaque contrast dye into the arterial tree by percutaneous catheter method e,g, seldinger cannulation

Images are obtained and digitalised by computer, removing the extraneous background tissues

Advantages:

  • Provides dynamic arterial flow information
  • Allows endovascular intervention

Disadvantages:

  • Bleeding
  • Haematoma
  • False anuerysm
  • Arterial dissection
  • Thrombosis
  • Renal injury
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19
Q

Non-surgical management of arterial stenosis

A
  • Structured exercise programme of 2 hours per week for >3 months
  • Smoking cessation
  • Weight loss if obese
  • Optimise medical coniditions
  • -Diabetes: metformin
  • -Hypertension: ACE-inhibitors

Atrovastatin (protective independent of serum cholesterol)

Clopidogrel

20
Q

Complications of angioplasty

A

Occurs in ~5%

Haematoma

False aneurysm

Distal embolisation

Thrombosis

Hamper subsequent arterial bypass attempts

21
Q

Miller cuff

A

Vein cuff for PTFE graft at distal anatsomosis

22
Q

Approach for aortobifem bypass

A

Midline approach

-Transverse would divide inferior epigastric artery which are important collaterals in aortic occlusive disease

23
Q

Subclavian steal syndrome

A

In periods of arm activity, reversal of the blood supply to the posterior cerebral circulation via the vertebral artery can result in a wide range of cerebral symptoms, including vertigo, diplopia, dysphagia, dysarthria, visual loss, or syncope

Proximal subclavian stenosis means that during upper limb exercise, there is reversal of flow from vertebral artery to supply upper limb
–> cerebral ischaemia

Caused by:

  • Atherosclerosis
  • Vasculitis
  • Thoracic outlet syndrome (e.g. cervical rib)
  • Complications following aortic coarctation repair
24
Q

Coronary-Subclavian Steal Syndrome

A

Coronary-Subclavian Steal Syndrome occurs in patients who have undergone an Internal Mammary Artery (IMA) Graft. An increase in oxygen demand in the left arm then steals blood from the IMA leading to cardiac ischaemia.

25
Q

Gangrene

A

Gangrene refers to death of macroscopic portions of tissue, which turns black because of the breakdown of haemoglobin and the formation of iron sulphide

26
Q

Definition of acute limb ischaemia

A

Embolic arterial occlusion causing limb-threatening ischaemia requiring urgent intervention

27
Q

6 Ps of acute limb ischaemia

A

Pain

Pallor

Paralysis

Pulsessness

Paraesthesia (actually anaesthesia)

Poikilothermia (Perishingly cold)

28
Q

Treatment of acute limb ischaemia

A

1) 5000 units of IV heparin
- prevent elongation of clot (particularly distal)

2) Analgesia for pain

3) Embolectomy
- Expose vesssel
- Transverse incision proximal to occlusion
- Fogarty catheter to remove embolism
- DSA to demonstrate flow

4) Post-op heparin infusion
- Warfarin bridging

29
Q

Considerations for thrombolysis

A

Acute limb ischaemia in which the occlusion is not causing severe ischaemia

Thrombolysis will take up to 24 hours to achieve clot breakdown

Consists of intra-arterial injection of tissue plasminogen activator

Contraindications: recent stroke, pregnancy, bleeding diathesis, poor outcomes in patients over 80 years old

30
Q

Broad treatment for acute mesenteric ischaemia

A

1) resection of infracted bowel
2) embolectomy of arterial bypass
3) re-look lap at 24 hours +/- further resection

31
Q

Sources of emboli

A

Cardiac

  • AF
  • Left ventricular mural thrombus post MI
  • Vegetation from infective endocarditis

Aneurysms
-Trash foot

Atherosclerotic plaques

  • thrombosis at site
  • emboli from site

Parasitic

Mycotic

Air

  • central venous access
  • head and neck injury / surgery

Fat

  • trauma
  • intramedullary nailing / fracture fixation
32
Q

Indications for amputation

A

Dead limb
● Gangrene

Deadly limb
● Wet gangrene
● Spreading cellulitis
● Arteriovenous fistula
● Other (e.g. malignancy)

‘Dead loss’ limb
● Severe rest pain with unreconstructable critical leg ischaemia
● Paralysis
● Other (e.g. contracture, trauma)

33
Q

Long posterior flap

A

Oldest of the below-knee approaches

  • Popular as relatively simple
  • Tibial tuberosity identified and a distance 10 cm measured distally and marked with a sterile marker pen; this is the anterior landmark
  • Circumference is measured at this landmark with a long suture tie and this length divided into two thirds
  • The suture is centred over the anterior landmark so that there is one-third either side. = posterior limit of transverse incision
34
Q

Indications for repair of abdominal aortic aneurysm

A

Symptomatic

Asymptomatic and 5.5 cm or larger

Asymptomatic, larger than 4.0 cm and has grown by more than 1 cm in 1 year.

35
Q

Monitoring abdominal aneurysm growth

A

> 5.5cm: 2ww referral to vascular centre

3 - 5.4cm: 12 ww to vascular centre

  1. 0 - 4.4cm: scan every 2 years
  2. 4 - 5.4cm: scan every 3 months
36
Q

Risk factors for abdominal aortic aneurysm

A

COPD

PAD/ CVD

European

FHx

HTN

Increased cholesterol

Smoking

37
Q

Definition of aneurysm

A

Vessel more than 50% increase in size

Dilatation of localised segments of the arterial system of increased by 50% of original size

38
Q

Ectatic vessels

A

Dilatation of vessels but <50% increase

39
Q

Location of abdominal aortic aneurysms

A

95% are infra-renal

40
Q

Complications of amputation

A

Immediate
-Haemorrhage

Early

  • Haematoma
  • Infection (gas gangrene secondary to faecal contamination in above-knee)
  • Wound dehiscence
  • Gangrene of flaps
  • DVT, PE

Late

  • Pain
  • -unresolved infection such as sinus, osteitis,
  • -bone spur
  • Phantom limb pain (give amitriptyline and gabapentin)
  • Ulceration of the stump
41
Q

Management of ruptured abdominal aortic aneurysm

A

● Early diagnosis (abdominal/back pain, pulsatile mass, shock)

● Immediate resuscitation (oxygen, intravenous replacement therapy, central line)

● Maintain systolic pressure, but not >100 mmHg, consider permissive hypotension

● Urinary catheter

● Cross-match 6 units of blood

● Rapid transfer to the operating room

42
Q

Complications of AAA repair

A

Cardiac

  • ischameia
  • infraction

Respiratory

  • atelectasis
  • HAP

Colonic ischaemia
-~10%, usually resolved without intervention

Renal failure

Neurological
-spinal cord ischaemia
impotence

Aortoduodenal fistula
-think if meleana or haematemesis in months/years post AAA repair

Prosthetic graft infection

43
Q

Buerger’s disease

A

Thromboangiitis obliterans

Consists of occlusive disease of small and medium sized arteries, thrombophlebitis of superficial veins, and raynaud’s syndrome
-e.g. plantar, tibial, radial

Often only one or two of the features present

Occurs in male smokers, <30 years

Smoking cessation halts progression but does not reverse damage

44
Q

Cystic myxomatous degeneration

A

Jelly-like cystic material around arteries such as politeal

Causes claudication from compression

Treatment is by removal of material +/- resection of artery and bypass

45
Q

Acrocyanosis

A

Often confused with Raynaud’s

Young female patients with chillblains and dusky hand

Not episodic, not painful

Vascular MRCS B (9 decks)

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