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02. Cardiovascular System > Arterial Disease of the Limbs - Presentation, Investigation & Therapy > Flashcards

Arterial Disease of the Limbs - Presentation, Investigation & Therapy Flashcards

1
Q

Name the arteries

A
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2
Q

<p>How do you examine for the aortic pulse?</p>

A

<p>——Above the umbilicus. Use two hands to feel for pulsation vs expansion</p>

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3
Q

<p>How do you feel for the common femoral artery?</p>

A

<p>—Mid-inguinal point, ½ way between the Anterior Superior Iliac Spine and the pubic symphysis</p>

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4
Q

<p>How do you feel for the popliteal artery?</p>

A

<p>—Use both hands to feel deep in the popliteal fossa – leg relaxed into your hands</p>

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5
Q

<p>How do you find the posterior tibial pulse?</p>

A

<p>—: ½ way between the medial malleolus and the achilles tendon</p>

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6
Q

<p>How do you find the dorsalis pedis pulse?</p>

A

<p>Lateral to the extensor hallucis longus tendon</p>

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7
Q

<p>What is the cause of CLI (critical limb ischaemia)?</p>

A

<p>—Atherosclerotic disease of the arteries supplying the lower limb</p>

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8
Q

<p>What are the risk factors for CLI?</p>

A

<p>—Male</p>

<p>—Age</p>

<p>—Smoking</p>

<p>—Hypercholesterolaemia</p>

<p>—Hypertension</p>

<p>—Diabetes</p>

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9
Q

<p>What is stage 1 CLA according to the Fontaine classification?</p>

A

<p>—Stage I: Asymptomatic, incomplete blood vessel obstruction</p>

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10
Q

<p>What is stage 2 CLA according to the Fontaine classification?</p>

A

<p>—Mild claudication pain in limb</p>

<p>—Stage IIA: Claudication when walking a distance of greater than 200 meters</p>

<p>—Stage IIB: Claudication when walking a distance of less than 200 meters</p>

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11
Q

<p>What is stage 3CLA according to the Fontaine classification?</p>

A

<p>—Stage III: Rest pain, mostly in the feet</p>

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12
Q

<p>What is stage 4CLA according to the Fontaine classification?</p>

A

<p>—Stage IV: Necrosis and/or gangrene of the limb</p>

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13
Q

<p>Which legdoes claudication usually impact?</p>

A

<p>Bilateral</p>

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14
Q

<p>What is typical past medical history for CLI?</p>

A

<p>—Other signs of atherosclerosis (MI, Stroke?)</p>

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15
Q

<p>What drug might a CLI patient be taking?</p>

A

<p>control of diabetes, aspirin?</p>

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16
Q

<p>What is the significance of a CLA patient occupation?</p>

A

<p>Determines the type of treatment</p>

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17
Q

<p>What are the signs of chronic ischaemia on examination?</p>

A

<p>Ulceration</p>

<p>Pallor</p>

<p>Hair loss</p>

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18
Q

<p>What should you feel during examination of CLA?</p>

A

<p>Capillary refill times</p>

<p>Temperature</p>

<p>Pulses</p>

<p>Peripheral sensation (particularly in diabetics)</p>

<p></p>

<p>STARTING AT TOES AND ALWAYS COMPARING SIDES</p>

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19
Q

<p>How do you auscultate for CLA?</p>

A

<p>Hand held doppler (ultrasound machine)</p>

<p></p>

<p>Listening to the dorsalis pedis and the posterior ribial pulses</p>

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20
Q

<p>What is the ankle brachial pressure index and what does it indicate?</p>

A

<p>Ratio of ankle pressure over brachial pressure</p>

<p></p>

<p>When exercising should be greater than one since leg muscles need lots of O2 so increased blood flow.</p>

<p></p>

<p>At rest the ration should be around 1 less than 1 indicates obstruction of blood flow</p>

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21
Q

<p>What is the buerger's test?</p>

A

<p>Elevate legs - pallor below a 20 degree angle indicates severe ischaemia</p>

<p>Hang feet over the edge of the bed - slow to regain colour, should progress to—Dark red colour (hyperaemic sunset foot).</p>

22
Q

<p>Why does hanging feet over the edge of a bed cause CLI patients' feet to become hyperaemic?</p>

A

<p>Normally only 1/3 of the capillaries are open. In CLI all capillaries are open and autoregulation is lost</p>

23
Q

<p>What is peripheral vascular disease treated the same way as?</p>

A

<p>Should be managed the same way as those with established CHD</p>

24
Q

<p>What is best medical therapy?</p>

A

<p>—Antiplatelet</p>

<p>—Statin: Inhibits platelet activation and thrombosis, endothelial and inflammation activation, plaque rupture</p>

<p>—BP control: Target <140/85</p>

<p>—Smoking cessation</p>

<p>—Exercise: 150% improvement in walking time – body will develop own collaterals with neo-angiogenesis</p>

<p>—Diabetic control: 10% of PAD patients are undiagnosed diabetics. Tight glycaemic control prevents microvascular disease</p>

25
Q

<p>What type of therapy is best for</p>

<ol> <li>Moderate symptoms</li> <li>Severe symptoms</li> <li>Critical symptoms</li></ol>

A

<p>Moderate - BMT only</p>

<p>Severe -BMT, angioplasty/stent, surgical bypass</p>

<p>Critical -BMT, angioplasty / stent / endovascular reconstruction / surgical bypass</p>

26
Q

<p>What are the possible imaging investigations for CLI?</p>

A

<p>Duplex (ultrasonography wherestructure orarchitectureof the body part is captured and flow or movement of a structure is visualized)</p>

<p>CT/MRA</p>

<p>Digital subtraction angiogram (angiography)</p>

<p></p>

27
Q

<p>What are the advantages and disadvantages of Duplex?</p>

A

<p>Advantages:</p>

<p>—Dynamic – assess flow as well as anatomy</p>

<p>—No radiation/contrast</p>

<p></p>

<p>Disadvantages:</p>

<p>—Not good in the abdomen (iliacs)</p>

<p>—Operator dependent, time consuming</p>

28
Q

<p>What are the benefits of CT/MRA</p>

A

<p>Advantages:</p>

<p>—Detailed – allows treatment planning</p>

<p>—First line according to NICE</p>

<p></p>

<p>Disadvantages:</p>

<p>Uses Contrast and Radiation</p>

<p>—Can overestimate calcification, difficulty in low flow states (difficult if there is terrible heart failure and the contrast can’t really reach the feet)</p>

<p></p>

29
Q

<p>What are the possible conduits for surgical bypass?</p>

A

<p>Reversed saphenous vein</p>

<p></p>

30
Q

<p>What does surgical bypass require?</p>

A

<p>Inflow</p>

<p>A conduit</p>

<p>Outflow</p>

31
Q

<p>Why is an autologous conduit better than a synthetic one?</p>

A

<p>Risk of infection is worse</p>

32
Q

<p>What are the general risks / complications of surgical bypass?</p>

A

<p>Bleeding, wound infection, pain, scar, DVT, PE, MI, stroke, death (2%)</p>

33
Q

<p>What are the technical risks / complications of surgical bypass?</p>

A

<p>Damage to nearby vein, artery, nerve, distal emboli, graft failure (stenosis, occlusion)</p>

34
Q

<p>What is reintervention rate for surgical bypass?</p>

A

<p>18.3 – 38.8% (higher if smoking)</p>

35
Q

<p>What are 5 year patency rates of surgical bypass?</p>

A

<p>45-73%</p>

36
Q

What are the types of amputation from the hip down?

37
Q

<p>Which type of amputation requires more energy?</p>

<p>BKA or AKA (above or below the knee amputation)</p>

A

<p>—63% higher in BKA</p>

<p>—117%higher in AKA</p>

38
Q

<p>What are the different ways an embolus can arise?</p>

A

<p>MI, AF, proximal atherosclerosis (not DVT/PE these are linked to venous disease)</p>

<p>Trauma</p>

<p>Dissection</p>

<p>Acute aneurysm thrombosis</p>

39
Q

<p>What is the point in finding out the onset/duration of symptoms?</p>

A

<p>Lets you know the likely prognosis</p>

40
Q

<p>What are the 6 P's of presentation?</p>

A

<p>—Pain</p>

<p>—Pallor</p>

<p>—Perishingly cold</p>

<p>—Paraesthesia</p>

<p>—Paralysis</p>

<p>—Pulseless</p>

<p></p>

<p>—Compare to contralateral limb</p>

41
Q

<p>What is compartment syndrome?</p>

A

<p>Compartment syndrome develops when swelling or bleeding occurs within a compartment. Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged.</p>

42
Q

<p>In this case what causes the acute compartment syndrome?</p>

A

<p>This may occur after a surgeon repairs a damaged blood vessel that has been blocked for several hours.</p>

<p>Rise in creatine kinase - risk of renal failure since creatine is amssive</p>

43
Q

<p>What is management of acute limb ischaemia?</p>

A

<p>ECG, bloods, nil by mouth</p>

<p>Analgesia</p>

<p>Anticoagulate (heparin - allows chance of blood getting through occlusion)</p>

44
Q

<p>What is management of a salvagable limb in ALI management?</p>

A

<p>If embolus - embolectomy</p>

<p>If thrombus - Endovascular :mechanincal thrombectomy/thrombolysis or open embolectomy +/- bypass</p>

<p></p>

45
Q

<p>What type of anaesthetic is used for embolectomy?</p>

A

<p>General or local</p>

46
Q

<p>What is the likely cause for ALI?</p>

A

<p>—30% embolic, 60% thrombosis in situ</p>

47
Q

<p>When does irreversible muscle ischaemia occur?</p>

A

<p>In 6-8 hours</p>

48
Q

<p>What is the pathophysiology of diabetic foot disease?</p>

A

<p>Microvascular peripheral artery disease</p>

<p>—Peripheral neuropathy – they lose sensation of their foot – more likely chance of trauma</p>

<p>—Mechanical imbalance – lose proprioception and walk differently – pressure points different and now damaged</p>

<p>—Susceptibility to infection</p>

49
Q

<p>How do you ensure footcare of a diabetic?</p>

A

<p>Always wear shoes</p>

<p>Check fit of footwear</p>

<p>Check pressure points of foot regularly</p>

<p>Prompt and regular woundcare</p>

50
Q

<p>What is diabetic foot management?</p>

A

<p>—<u>Prevention</u></p>

<p><u>—Good wound care</u></p>

<p><u>—Tracking infection</u> (lymphangitis or cellulitis)– consider systemic antibiotics</p>

<p><u>—Investigate</u> for osteomyelitis, gas gangrene, necrotising fasciitis</p>

<p><u>—Revascularisation</u></p>

<p>—Disease is very distal – attempt distal crural angioplasty / stent</p>

<p>—Distal bypass</p>

<p><u>Amputation</u></p>

02. Cardiovascular System (72 decks)

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