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CVS > 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

How do you examine for the aortic pulse?

A

Above umbilicus

Use two hands to feel for pulsation vs expansion

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3
Q

How do you feel for the common femoral artery?

A

Mid-inguinal point, ½ way between Anterior Superior Iliac Spine and pubic symphysis

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4
Q

How do you feel for the popliteal artery?

A

Use both hands to feel deep in popliteal fossa – leg relaxed into your hands

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5
Q

How do you find the posterior tibial pulse?

A

½ way between medial malleolus and achilles tendon

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6
Q

How do you find the dorsalis pedis pulse?

A

Lateral to extensor hallucis longus tendon

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7
Q

What is the cause of CLI (critical limb ischaemia)?

A

Atherosclerotic disease of arteries supplying lower limb

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8
Q

What are the risk factors for CLI?

A

—Male

—Age

—Smoking

—Hypercholesterolaemia

—Hypertension

—Diabetes

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9
Q

What is stage 1 CLA according to the Fontaine classification?

A

Stage I: Asymptomatic, incomplete blood vessel obstruction

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10
Q

What is stage 2 CLA according to the Fontaine classification?

A

Mild claudication pain in limb

Stage IIA:

  • Claudication when walking more than 200m

Stage IIB:

  • Claudication when walking less than 200m
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11
Q

What is stage 3 CLA according to the Fontaine classification?

A

Stage III: Rest pain, mostly in feet

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12
Q

What is stage 4 CLA according to the Fontaine classification?

A

Stage IV: Necrosis and/or gangrene of limb

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13
Q

Which leg does claudication usually impact?

A

Bilateral

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14
Q

What is typical past medical history for CLI?

A

—Other signs of atherosclerosis (MI, Stroke?)

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15
Q

What drug might a CLI patient be taking?

A

control of diabetes, aspirin

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16
Q

What is the significance of a CLA patient occupation?

A

Determines type of treatment

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17
Q

What are the signs of chronic ischaemia on examination?

A

Ulceration

Pallor

Hair loss

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18
Q

What should you feel during examination of CLA?

A

Capillary refill times

Temperature

Pulses

Peripheral sensation (particularly in diabetics)

Start at toes

Always compare sides

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19
Q

How do you auscultate for CLA?

A

Hand held doppler (ultrasound machine)

Listening to dorsalis pedis and posterior ribial pulses

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20
Q

What is the ankle brachial pressure index and what does it indicate?

A
  • Ratio of ankle pressure over brachial pressure
  • When exercising should be greater than 1 since leg muscles need lots of O2 so increased blood flow.
  • At rest ratio should be around 1 less than 1 indicates obstruction of blood flow
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21
Q

What is the buerger’s test?

A

Elevate legs - pallor below 20 degree angle indicates severe ischaemia

Hang feet over edge of bed - slow to regain colour, should progress to Dark red colour (hyperaemic sunset foot).

22
Q

Why does hanging feet over the edge of a bed cause CLI patients’ feet to become hyperaemic?

A

Normally only 1/3 of capillaries are open

In CLI all capillaries are open and autoregulation is lost

23
Q

What is peripheral vascular disease treated the same way as?

A

Should be managed the same way as those with established CHD

24
Q

What is best medical therapy?

A

Antiplatelet

Statin

BP control: Target <140/85

Smoking cessation

Exercise: 150% improvement in walking time – body develops own collaterals with neo-angiogenesis

Diabetic control: 10% of PAD patients are undiagnosed diabetics, Tight glycaemic control prevents microvascular disease

(Statins Inhibit platelet activation and thrombosis, endothelial and inflammation activation, plaque rupture)

25
Q

What type of therapy is best for

  1. Moderate symptoms
  2. Severe symptoms
  3. Critical symptoms
A

Moderate - BMT only

Severe - BMT, angioplasty/stent, surgical bypass

Critical - BMT, angioplasty / stent / endovascular reconstruction / surgical bypass

26
Q

What are the possible imaging investigations for CLI?

A

CT/MRA

Digital subtraction angiogram (angiography)

Duplex - (ultrasonography where structure or architecture of body part is captured and flow or movement of a structure is visualised)

27
Q

What are the advantages and disadvantages of Duplex?

A

Advantages:

Dynamic – assess flow as well as anatomy

No radiation/contrast

Disadvantages:

Not good in abdomen (iliacs)

Operator dependent, time consuming

28
Q

What are the benefits of CT/MRA

A

Advantages:

Detailed – allows treatment planning

First line according to NICE

Disadvantages:

Uses Contrast and Radiation

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

29
Q

What are the possible conduits for surgical bypass?

A

Reversed saphenous vein

30
Q

What does surgical bypass require?

A

Inflow

A conduit

Outflow

31
Q

Why is an autologous conduit better than a synthetic one?

A

Synthetic has higher risk of infection

32
Q

What are the general risks / complications of surgical bypass?

A

Bleeding

wound infection

pain

scar

DVT/PE

MI

stroke

death (2%)

33
Q

What are the technical risks / complications of surgical bypass?

A

Damage to nearby vein, artery, nerve, distal emboli, graft failure (stenosis, occlusion)

34
Q

What is reintervention rate for surgical bypass?

A

18 – 39% (higher if smoking)

(18.3-38.8%)

35
Q

What are 5 year patency rates of surgical bypass?

A

45-73%

36
Q

What are the types of amputation from the hip down?

A
37
Q

Which type of amputation requires more energy?

BKA or AKA (above or below the knee amputation)

A

—63% higher in BKA

—117% higher in AKA

38
Q

What are the different ways an embolus can arise?

A

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

Trauma

Dissection

Acute aneurysm thrombosis

39
Q

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

A

Lets you know the likely prognosis

40
Q

What are the 6 P’s of presentation?

A

—Pain

—Pallor

—Perishingly cold

—Paraesthesia

—Paralysis

—Pulseless

—Compare to contralateral limb

41
Q

What is compartment syndrome?

A

Swelling or bleeding occurs within a compartment

Fascia doesn’t stretch, increases pressure on capillaries, nerves, and muscles

Blood flow to muscle and nerve cells is disrupted

Without steady O2 and nutrient supply, nerve and muscle cells can be damaged

42
Q

In this case what causes the acute compartment syndrome?

A

After surgeon repairs damaged blood vessel that has been blocked for several hours.

Rise in creatine kinase - risk of renal failure since creatine is massive

43
Q

What is management of acute limb ischaemia?

A

ECG, bloods, nil by mouth

Analgesia

Anticoagulate (heparin - allows chance of blood getting through occlusion)

44
Q

What is management of a salvagable limb in ALI management?

A

Embolus - embolectomy

Thrombus - Endovascular: mechanincal thrombectomy/thrombolysis or open embolectomy +/- bypass

45
Q

What type of anaesthetic is used for embolectomy?

A

General or local

46
Q

What is the likely cause for ALI?

A

—30% embolic, 60% thrombosis in situ

47
Q

When does irreversible muscle ischaemia occur?

A

In 6-8 hours

48
Q

What is the pathophysiology of diabetic foot disease?

A

Microvascular peripheral artery disease

Peripheral neuropathy – lost sensation in foot – more likely chance of trauma

Mechanical imbalance – lost proprioception and walk differently – pressure points different and damaged

Susceptibility to infection

49
Q

How do you ensure footcare of a diabetic?

A

Always wear shoes

Check fit of footwear

Check pressure points of foot regularly

Prompt and regular wound care

50
Q

What is diabetic foot management?

A
  • Prevention
  • Good wound care
  • Tracking infection (lymphangitis or cellulitis)– consider systemic antibiotics
  • Investigate for osteomyelitis, gas gangrene, necrotising fasciitis
  • Revascularisation
  • Disease is very distal – attempt distal crural angioplasty / stent
  • Distal bypass
  • Amputation

CVS (26 decks)

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