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Systems: Cardiovascualar AB > Arterial Disease of the Limbs: Presentation, Investigation and Therapy > Flashcards

Arterial Disease of the Limbs: Presentation, Investigation and Therapy Flashcards

1
Q

What pulse points should be examined?

A
  • Aorta
  • Common femoral artery
  • Popiteal artery
  • Posterior tibial pulse
  • Dorsalis pedis
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2
Q

Pulse point: aorta

A

Above the umbilicus. Use 2 hands to feel for pulsation vs expansion

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3
Q

Pulse points: common femoral artery

A

Mid-ingual point, 1/2 between the anterior superior iliac spine and the pubic symphysis

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4
Q

Pulse points: popiteal artery

A

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

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5
Q

Pulse points: posterior tibial pulse

A

1/2 way between the medial malleolus and the Achilles tendon

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6
Q

Pulse points: dorsalis pedis

A

Lateral to the extensor halluces longus tendon

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7
Q

What are the risk factors for CLI?

A
  • Male
  • Age
  • Smoking
  • Hypercholesterolemia
  • Hypertension
  • Diabetes
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8
Q

What is the pathophysiology of CLI?

A
  • Atherosclerotic disease of the arteries supplying the lower limb
  • Less commonly vasculitis, Buerger’s disease
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9
Q

What does CLI follow the same disease process as?

A
  • Coronary atherosclerosis

- Carotid atherosclerosis

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10
Q

What are the Fontaine classifications of symptoms?

A
  • Stage I
  • Stage IIA
  • Stage IIB
  • Stage III
  • Stage IV
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11
Q

Fontaine classification: stage I

A

Asymptomatic, incomplete blood vessel obstruction

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12
Q

Fontaine classification: stage IIA

A

Claudication when walking a distance of greater than 200m

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13
Q

Fontaine classification: stage IIB

A

Claudication when walking a distance of less than 200m

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14
Q

Fontaine classification: stage III

A

Rest pain, mostly in feet

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15
Q

Fontaine classification: stage IV

A

Necrosis and /or gangrene of the limb

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16
Q

What may there be history of?

A
  • Claudication
  • Rest pain
  • Tissue loss
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17
Q

What must be considered during the history when making a diagnosis?

A
  • Risk factors
  • PMH
  • DH
  • SH
  • OH
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18
Q

What details about any claudication should you find out?

A
  • Exercise tolerance
  • Effect of incline
  • Change over time
  • Relieved by rest?
  • Location
  • Type of pain
  • Bilateral?
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19
Q

What details about any rest pain should you find out?

A
  • Type of pain

- Relieving factors

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20
Q

What details about ant tissue loss should you find out?

A
  • Duration
  • History of trauma
  • Peripheral sensation
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21
Q

What should you look for on examination of both legs?

A

Signs of chronic ischaemia:

  • Ulceration
  • Pallor
  • Hair loss
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22
Q

What should you feel for on examination of the legs?

A

Start at toes, compare both sides:

  • Cap refill
  • Temp
  • Pulses (start at aorta)
  • Peripheral sensation
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23
Q

How should auscultation be carried out?

A

Hand held doppler

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24
Q

What should be ausculatated?

A
  • Dorsalis pedis

- Posterior tibial pulses

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25
Q

What special tests should be carried out on examination?

A
  • Ankle brachial pressure index

- Buerger’s test

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26
Q

What is the ankle brachial pressure index?

A

Ankle pressure divided by the brachial pressure

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27
Q

What are the clinical statuses on the ankle brachial pressure index?

A

-Symptom free: 1+
-Intermittent claudication: 0.95-0.5
-Rest pain: 0.5-0.3
Gangrene and ulceration: <0.2

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28
Q

How is Buerger’s test performed?

A
  • Elevate legs (pallor, Bueger’s angle< 20 degrees severe ischaemia)
  • Hang feet over the bed (slow to regain colour, dark red colour)
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29
Q

How many capillaries are normally open?

A

1/3

30
Q

What causes hyperaemic sunset foot?

A

CLI autoregulation is lost causing all capillaries to open

31
Q

What is involved in best medical therapy?

A
  • Antiplatelet
  • Statin
  • BP control
  • Smoking cessation
  • Exercise
  • Diabetic control
32
Q

What do antiplatelets do?

A

Reduce risk of requiring revascularisation as well as reducing CV and all cause mortality

33
Q

What do statins do?

A

Inhibits platelet activiation and thrombosis, endothelial and inflammation activation, plaque rupture

34
Q

What is the target BP?

A

<140/85

35
Q

What does smoking cessation lead to?

A

Excess risk of CV disease diminishes within 4-6yrs

36
Q

What does exercise lead to?

A

150% improvement in waling time

37
Q

What does diabetic control lead to?

A

10% of PAD are undiagnosed diabetics. Tight glycaemic control prevents microvascular disease

38
Q

How should those with mild to moderate symptoms be managed?

A

BMT only

39
Q

How should those with sever symptoms be managed?

A
  • BMT
  • Angioplasty/stent
  • Surgical bypass
40
Q

How should those with critical symptoms be managed?

A
  • BMT

- Angioplasty/stent/endovascular reconstruction/surgical bypass

41
Q

What imaging should be carried out in the investigation?

A
  • Ultrasound

- CT

42
Q

What are the advantages of ultrasound?

A
  • Dynamic

- No radiation/ contrast

43
Q

What are the disadvantages of ultrasound?

A
  • Not good in the abdomen

- Operator dependent, time consuming

44
Q

What are the advantages of CT?

A
  • Detailed- allows treatment planning

- First line according to NICE

45
Q

What are the disadvantages of CT?

A
  • Contrast and radiation

- Can overestimate calcification, difficulty in low flow states

46
Q

How can iliac occlusion be bypassed?

A
  • Iliac angioplasty and crossover graft
  • Aortaobifemoral bypass graft
  • Axillobifemoral bypass graft
47
Q

What does surgical bypass require?

A
  • Inflow
  • A conduit
  • Outflow
48
Q

What can be used as conduits for surgical bypass?

A
  • Autologous (vein from legs, arm)

- Synthetic (PFTE/Dacron)

49
Q

What general complication risks are there with surgical bypass?

A
  • Bleeding
  • Wound infection
  • Pain
  • Scar
  • DVT
  • PE
  • MI
  • CVA
  • LRTI
  • Death
50
Q

What technical complication risks are there with surgical bypass?

A
  • Damage to vein
  • Damage to artery
  • Damage to nerve
  • Distal emboli
  • Graft failure
51
Q

What types of amputation may be performed if perfusion to the leg is lost?

A
  • Hindquarter (v rare)
  • Hip disarticulation (v rare)
  • Above knee
  • Through knee
  • Below knee
  • Symes (v rare)
  • Transmetatarsal
  • Digit
52
Q

What do amputees need to regain during rehabilitation?

A
  • Mobility

- Energy requirements

53
Q

How does the energy requirements differ fro BKA and AKA?

A
  • BKA: 63% increase

- AKA: 117% increase

54
Q

Emboli

A

A blood clot, air bubble, piece of fatty deposit or other object which has been carried in the bloodstream to lodge in a vessel and cause an embolism

55
Q

Thrombus

A

A blood clot formed in situ within the vascular system of the body and impeding blood flow

56
Q

What is the pathophysiology of ALI?

A
  • Arterial embolus (MI, AF, proximal atherosclerosis)
  • Thrombosis (usually thrombosis of a previously diseased artery)
  • Trauma
  • Dissection
  • Acute aneurysm thrombosis
57
Q

What should be discussed when taking the history of someone presenting with ALI?

A
  • History of CLI
  • Risk factors for CLI
  • Cardiac history
  • Onset/ duration of symptoms
  • Functional status/ SH
58
Q

What are the 6 Ps in the presentation of ALI?

A
  • Pain
  • Pallor
  • Perishingly cold
  • Paralysis
  • Pulseless
  • Paraesthesia
59
Q

What can cause compartment syndrome?

A
  • Muscle ischaemia
  • Inflammation
  • Oedema
  • Venous obstruction
60
Q

What is there a risk of in compartment syndrome?

A

Renal failure (myoglobulinaemia)

61
Q

What is there a is in in compartment syndrome?

A

Creatinine kinase

62
Q

What is the presentation of compartment syndrome in the leg?

A

Tense, tender calf

63
Q

How should ALI be managed?

A
  • ECG
  • Bloods
  • Nil by mouth
  • Analgesia
  • Anticoagulate
64
Q

How can embolectomy be carried out?

A
  • Under GA

- Under LA

65
Q

When does irreversible muscle ischaemia occur?

A

6-8 hrs

66
Q

What is the mortality rate of ALI?

A

22%

67
Q

What percentage of diabetics will develop a foot ulcer in their lifetime?

A

15%

68
Q

What is the pathophysiology of diabetic foot disease?

A

s-Microvascular peripheral artery disease

  • Peripheral neuropathy
  • Mechanical imbalance
  • Susceptibility to infection
69
Q

What footcare should diabetics have?

A
  • Always wear shoes
  • Check fit of footwear
  • Check pressure points/ plantar surface of foot regularly
  • Prompt and regular wound care of skin breaches
70
Q

How can diabetic foot disease be managed?

A
  • Prevention
  • Good wound care
  • Tracking infection
  • Investigate for osteomyelitis, gas gangrene, necrotising fasciitis
  • Revascularisation
  • Amputation
71
Q

What revascularisation techniques can be used in diabetic foot disease management?

A
  • If the disease is very distal then attempt distal crural angioplasty/ stent
  • Distal bypass

Systems: Cardiovascualar AB (42 decks)

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