Arterial Disease Flashcards by Lisa McCulloch

What are the two main types of arterial limb disease?

intermittent claudication

critical limb ischaemia

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When does intermittent claudication occur?

on exertion / exercise

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When does critical limb ischaemia occur?

on rest

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What symptoms do people with intermittent claudication have?

cramp like muscle pain in the calf, thigh and buttocks

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What age range of people tend to have intermittent claudication?

> 55 years

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What skin and limb problems can result from critical limb ischaemia ?

ulceration

gangrene

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What changes to arteries does diabetes cause?

calcification of the arteries which make them less compliant and therefore the lumen size is smaller

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What two causes can cause intermittent claudication?

atheromatous plaque

diabetes mellitus

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Name three uncommon causes for intermittent claudication

beurgers disease
vasculitis
hyperhomocysteinaemia

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Name three main investigations that should be done for intermittent claudication

Duplex
Magnetic resonance angiogram
Ankle Brachial Pressure Index (ABPI) - ankle/brachial pressure (if below 0.4 then prognosis isn’t good)

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What does PAD mean in terms of intermittent claudication?

peripheral arterial disease

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Are patients with PAD at high risk of developing coronary heart disease?

yes

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What two medications should patients with PAD be prescribed?

anti platelets - aspirin or clopidogrel

statins

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What are anti platelets used for?

to thin the blood and prevent thrombus from forming

decreasing the risk of vessel occlusion

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What are statins used for?

to reduce the LDLs in the blood and hence reducing the risk of atheromatous plaques from forming
also stabilises the plaque

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What three other managements should be done for PAD patients other than medication?

smoking cessation
screen for diabetes/ manage diabetes properly
have good control of BP (high BP can result in an embolism)

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In what two conditions should the ABPI be measured at?

during rest

- during stress

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For PAD patients, a procedure called PTA is available for some patients. What does this procedure involve?

involves using a catheter to increase the diameter of the lumen by inserting a balloon and may include inserting a stent into the vessel to ensure the vessel remains open.

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Can exercise therapy be used to improv the symptoms of intermittent claudication patients?

yes

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How does exercise therapy help intermittent claudication patients?

o improves BP, dyslipidaemia, endothelial function
- if each day they walk slightly further then they can improve their symptoms gradually and increase the distance they are able to walk

What are the risk factors for PAD?

smoking
hypercholesterolaemia
hypertension
lack of exercise
poor diet
diabetes

When should angioplasty (PTA) be offered to patients with PAD?

If symptoms are bad and cannot be improved through other methods
AND
the occlusion/damage is over a short distance

For how long does PTA improve quality of life for?

2 years

When should surgery be considered for PAD patients?

extensive disease which isn’t suitable for PTA
if PTA/stenting has failed
poor quality of life
risk factors are well managed

Is surgery frequently performed for PAD patients?

What are the two main types of modern management and give examples for each?

- secondary prevention smoking cessation control BP and diabetes anti platelets and statins ``` - symptom improvement exercise therapy smoking cessation Pharmacotherapy PTA surgery ```

What four things does statins inhibit ?

- platelet activation and thrombosis - plaque rupturing - endothelium dilation - inflammatory response

What is Dyslipidaemia?

abnormal amounts of lipid in the blood

What ideal BP should PAD patients have?

What % of intermittent claudication patients are suitable for PTA?

~15%

For critical limb ischaemia, does raising the foot increase or decrease the pain for the patient?

increase the pain

Why does raising the foot increase the pain for the patient?

- there is less blood flow able to get to the tissue in the periphery as gravity is no longer acting to pull the blood down - therefore there is more anaerobic respiration and more acid building up in the cells - increases the pain in the leg and feet

For critical limb ischaemia, would appearance would the feet have if they were raised then lowered again?

they would go pale as they were raised as the feet would have less blood flow they would go bright red as they were lowered again as the collaterals would dilate and fill with blood when lowered.

State some methods of secondary prevention for critical limb ischaemia

- smoking cessation - control BP - control diabetes - prescribe anti platelets, ACEI and statins

What are the two options if limb ischaemia is severe and the limb needs to be revascularised?

- surgery (fem-pop bypass) | - angioplasty (PTA)

If limb ishcaemia is very severe what option is there?

- amputation

What is the main complication after surgery for PAD?

How does angioplasty compare to surgery?

PTA - less mortality - faster recovery time - lower reobstruction rate - less durable than surgery

Where are the four sites where patients are amputated?

digital transmetatarsal below knee above knee

What is the difference between acute and chronic limb ischaemia?

acute limb ischaemia has occurred suddenly so there are no collaterals able to carry the blood flow around the occlusion

What is the presentation of acute limb ischaemia ? | 6 signs

``` pain pulseless paraethesia (pins and needles) pallor paralysis perishingly cold ```

What are the two causes of acute limb ischaemia and what are the % of cases?

- embolism (30%) | - in situ thrombosis (60%)

Name four other uncommon causes of acute limb ischaemia

- trauma (leg fracture, dislocation, stab wounds, iatrogenic) - popliteal aneurysm - thoracic dissection - intra arterial drug administration

What examination would you do to determine the severity of the acute limb ischaemia? 4 things

- peripheral pulses present? including above femoral - is sensation or movement restricted or absent in the limb - is atrial fibrillation present? (heart related?) - how long has it lasted?

What are the treatment options for acute limb ischaemia that has been caused by an embolus if the leg is salvageable ?

- if urgent then embolectomy should be performed to remove the embolus - if there is time available then thrombolysis should be administered pain relieve and heparin should also be given ensure the area of ischaemia has been reperfused

What are the treatment options for acute limb ischaemia that has been caused by a thrombosis if the leg is salvageable ?

Angiography should be performed to determine the severity of the occlusion ``` Severity will determine whether - thrombolysis - PTA - by pass is required ```

What are the contradictions for thrombolysis ?

- recent haemorrhage - recent bleed - recent surgery - GI bleed - recent stroke - over 80 years

If acute limb ischaemia has been caused by an embolism, how long does the patient have been the leg is unsalvageable?

6-8 hours