Arterial Diseases Flashcards
What is carotid artery disease?
Build up of atherosclerotic plaque in one or both common and internal carotid arteries
Usually asymptomatic but responsible for 10-15% of ischaemic strokes
What is the radiological classification of carotid artery disease?
Mild - <50%
Moderate 50-69%
Severe - 70-99%
Total occlusion
How may Carotid artery disease present?
Focal neurological deficit:
TIA - including amaurosis fugax
Stroke
List some differential diagnosis for carotid artery disease?
- Carotid dissection - often younger then 50 with underlying connective tissue disorder, potentially precipitated by trauma or sudden neck movement
- Thrombotic Occlusion of Carotid artery
- Fibromuscular dysplasia
- Vasculitis
-hypoglycaemia, subdural haematoma
What initial investigation is ordered for a stroke?
Urgent non-contrast CT head
What other investigations would you do for a pt with stroke?
Bloods - FBC, U&Es, Clotting, lipid profile and glucose
ECG - AF
CT head contrast angiography for thrombectomy
How can carotid arteries be screened for after stroke or TIA?
Duplex ultrasound scans
CT angiography
What is the acute management of suspected stroke?
High flow oxygen
Blood glucose optimised
Swallowing screen assessment
Initial management of ischeamic stroke?
IV alteplase, if pt admitted 4.5 hrs of symptom onset and meet inclusion criteria and 300mg aspirin
Initial management of haemorrhaging stroke?
Correct an coagulopathy and referral to neurosurgery
What is the long term management with known stroke or TIA?
Anti-platelet - 300mg aspirin for 2 weeks OD and then clopidogrel 75mg OD
Statin - high dose
Aggressive management of hypertension and DM
Lifestyle
Who should be consider for a carotid endarterectomy (CEA)?
Pt with non-disabling stroke/TIA who have symptomatic carotid stenosis between 50-99%
Complications of stroke?
Dysphagia Seizures Ongoing spasticity Bladder/bowel incontinenece Depression/anxiety Cognitive decline
Definition of AAA?
Dilation of abdominal aorta greater then 3 cm
What are the risk factors of AAA?
Smoking, hypertension, hyperlipideamia, family history and male gender + increasing age
How do AAA present?
Most are asymptomatic and usually incidental finding
But symptomatic present with:
Abdominal pain
Back/loin pain
Distal embolisation
At what age are men invited to national AAA screening (NAAASP)?
65
What is the main differential diagnosis for AAA?
Renal colic
What investigations are appropriate for AAA?
Initial ultrasound scan
Then follow-up CT scan with contrast warranted if threshold of 5.5cm
What is the management of AAA less then 5.5 cm?
- 0-4.4cm - yearly ultrasound
- 5-5.4cm - 3 monthly ultrasound
Optimise CVD risk factors - including statin and aspirin therapy
When is surgery consider in AAA?
AAA >5.5cm
AAA expanding at >1cm/yr
Symptomatic AAA in person who is otherwise fit
What are the two types of surgery for AAA?
Open repair
Endovascular repair (EVAR)
What is a complication of EVAR?
Endoleaks
Often asymptomatic and need monitoring via ultrasound
What is the major complication of AAA?
Rupture
What are less common complications of AAA?
Retroperitoneal leak
Embolisation
Aortoduodenal fistula
What is the management of rupture AAA?
High flow O2, IV access and urgent bloods(FBC, U&Es, clotting) with cross match
Shock should be treated carefully as raising BP may dislodge any clot and make bleeding worse so aim for BP <=100mmHg
If pt unstable immediate open surgical repair
If stable they require CT angiogram to determine whether aneurysm sutible for endovasular repair.
Between which two layers does an aortic dissection occur?
Tunic intima and tunica media
How is acute and chronic aortic dissection distinguished?
Acute <=14 days
Chronic >14 days
Who is more likely to get an aortic dissection?
Men
People with connective tissue disorders
Age 50-70
What are the two types of dissections in aortic dissections?
Anterograde
Retrograde - can cause bleeding into aortic valve and cardiac tamponade
What are the clinical features of aortic dissection?
Tearing chest pain radiating to the back - may be subtle
Most common signs - tachycardia, hypotension, new aortic regurgitation murmur or signs of end-organ hypo perfusion.
What are the differential diagnosis for aortic dissection?
MI
PE
Pericarditis
MSK pain
Which two systems classify aortic dissections anatomically?
DeBakey
Stanford
What are the risk factors for aortic dissection?
Hypertension Atherosclerotic disease Male gender Connective tissue disorder Biscuspid aortic valve
What investigations should be performed for suspected aortic dissection?
Baseline bloods (FBC, U&Es, LFTs, troponin, coagulation) with cross match of a least 4 units ABG, ECG
CT angiogram to diagnose, could also use trans oesophageal ECHO
What is the management for aortic dissections?
A-E assessment - O2, IV access, fluid resuscitation(caution)
Type A Stanford - surgically - worse prognosis if untreated
Type B - Medically
Life-long antihypertensives, surveillance imaging
What does surgery involve for type A Stanford aortic dissections?
Removal of ascending aorta and replacement with synthetic graft. May require aortic valve repair and re-implantation of add it all branches of aorta.
When does a type B stanford aortic dissection require surgical intervention?
Rupture
Renal,visceral or limb ischemia
Uncontrolled hypertension
What is the most common complication of a chronic type B Stanford aortic dissection?
Aneurysm
Name some complications of aortic dissections?
Aortic rupture Aortic regurgitation MI Cardiac tamponade Stroke or paraplegia
In which pts can using an ABPI be problematic?
Pts with oedema, ulcers/fibrosis/scaring, calcium in wall of arteries
Leads to false reading
If ABPI is not reliable then what can be done instead?
Lift pts leg and measure height at which sound on Doppler disappears and convert to mmHg - this is called pole test
What does the buerger test look for examination?
Critical ischaemia
What is the normal ABPI?
0.8-1.1
What is intermittent claudication?
Pain on walking, comes on quicker when walking fast and worse when walking uphill
Pain relieved on rest/standing still
What is rest pain?
Severe pain when going to bed often in the foot and have to get out of bed and walk around. This is sign of critical ischaemia
What is the difference between pain felt on spinal stenosis and intermittent claudication?
Pain not relieved by standing alone in spinal stenosis but my be relived by rest
Leaning forward may help in spinal stenosis
Spinal stenosis affects both legs usually
What are the levels of intermittent claudication?
Mild : walking distance >300m, single stenosis
Moderate : walking stenosis 100-200m, severe stenosis/occlusion
Severe : walking distance 50-100m, occlusion
Rest pain : block at two levels - Occlusion + severe stenosis/occlusion
What are the different scenarios for PVD?
Infrarenal aorta - younger pts, slight weakness in legs when walking
Iliac disease - common iliac - buttock pain, external iliac - thigh pain
Femoropopliteal disease - calf pain
Run-off disease - changes in foot - usually seen in diabetes and hard to treat
How does diabetic foot disease present?
Neuropathic pain - shooting/burning pain in feet
Toenail infection - acute paronychia
Interdigital infection - begins and fungal and develops to bacteria
Pressure ulcer - MT head, Dorsal PIP joint, tips of toes - rubbing on shoes due to subluxation
Charcot mid foot deformity ulcer - losses sensation, planter arch can collapse
Heel linear fissure ulcer - dry skin due to autonomic neuropathy
Wet gangrene/deep planter space infection
What are some components of diabetic foot disease?
Reduced immune function
Sensory/autonomic/motor neuropathy
Peripheral vascular disease - accelerated atherosclerotic, calcium deposits
Endothelial dysfunction
What is the treatment for diabetic foot disease?
Optimise glycemic control - BM<10 Drain pus & debride necrotic tissue Appropriate antibiotics Stop smoking Cardio protective medications Offload pressure areas Debride osteomyelitis bone Revascularistion - critical ischaemia Podiatry follow up
What is acute limb ischaemia?
Sudden decrease in limb perfusion the threatens the viability of the limb
What are the three main aetiologies of acute limb ischaemia?
Embolisation - most common, source may be AF, post-MI, mural-thrombus, AAA or prosthetic valve.
Thrombus in situ - plaque ruptures
Trauma - compartment syndrome
What are the 6Ps of acute limb ischaemia?
Pain Pallor Pulselessness Parasthesia Perishingly cold Paralysis
What is a sensitive sign for embolitic occlusion in acute limb ischaemia?
Normal, pulsatile contralateral limb
What is the clinical categories for acute limb ischaemia?
Rutherford classification:
I-viable
IIA-marginally threatened
IIB-immediately threatened
III-irreversible
What are the differential diagnosis for acute limb ischaemia?
Critical chronic limb ischaemia
Acute DVT
Spinal cord or peripheral nerve compression
What investigations would you do in acute limb ischaemia?
Routine bloods - groups and save, thrombophila screen (if <50yrs without known risk factors)
ECG
Doppler ultrasound
CT angiography - GOLD STANDARD
CT ateriogram - if limb consider salvageable
What is the time when irreversible limb damage starts to occur in acute limb ischaemia?
6 hours
What is the initial management of someone with acute limb ischaemia?
High flow 02
IV access - therapeutic dose heparin or bolus dose then heparin infusion
What is the conservative management for acute limb ischaemia?
Consider in Rutherford 1 and 2a
Prolonged course of heparin + regular assessment to determine effectiveness through APPT and clinical review
What are the surgical options for acute limb ischaemia cause by embolisation?
Embolectomy
Local intra -arterial thrombolysis
Bypass surgery
What are the surgical options for acute limb ischaemia if cause is thrombotic disease?
Local intra-arterial thrombolysis
Angioplasty
Bypass surgery
What options are available for irreversible acute limb ischaemia?
Urgent amputation
Palliative approach
What is some with acute limb ischaemia at risk of after surgery?
Ischemia reperfusion syndrome
What is the long term management for acute limb ischemia after treatment?
Reduce CVD risk factors
Treat underlying cause for limb ischemia E.g AF
Anti-platelet agent
If amputation has occurred- OT, Physio + long term rehabilitation plan
What is involved in reperfusion injury after an acute limb ischaemia?
Compartment syndrome Damaged muscle cells release: K+ ions H+ ions Myoglobin - AKI
What is an early symptom of chronic limb ischaemia?
Intermittent claudication and walking a fixed distance (claudication distance)
What is the Fontaine classification of chronic leg ischaemia?
Stage I - asymptomatic
Stage II - intermittent claudication
Stage III - ischaemic rest pain
Stage IV - ulceration or gangrene or both
What is leriche syndrome?
Peripheral arterial disease affecting the aortic bifurcation- specifically presents with buttock/thigh pain and associated erectile dysfunction.
How is critical limb ischaemia defined?
Ischaemia rest pain greater then 2 weeks
Presence of ischaemic lesions or gangrene
ABPI <0.5
What are the differential diagnosis for a patient with chronic limb ischaemia?
Spinal stenosis
Acute limb ischaemia
What are the investigations for chronic limb ischaemia?
ABPI - quantify severity Doppler ultrasound CT angiography or MR angiography Cardiovascular risk assessment If under 50 do thrombophila screen
What is the medical management for chronic limb ischaemia?
Lifestyle advice Statin therapy Anti-platelet therapy Optimise diabetes control Supervised exercise programme
When can surgical intervention be offer in chronic limb ischaemia?
When risk factor modification has been discussed
Supervised exercise has failed to improve symptoms
Any pt with critical limb ischaemia
What are the surgical options for chronic limb ischaemia?
Angioplasty
Bypass grafting
Combination of two
Amputation for severe cases
What are complications of chronic limb ischaemia?
Sepsis - infected gangrene
Acute-on-chronic ischaemia
Amputation
Reduced mobility and quality of like
What is the immediate management for some who has had a open AAA?
ICU
What are the complication after an AAA open repair?
Most commonly cardiac event
Haemorrhage, resp failure, renal failure, embolisation, ureteric injury, impotence, graft infection
