Arterial Diseases of the Limb Flashcards
What causes upper limb vascular disease
Stenosis - atherosclerosis Thrombosis Inflammation Emboli Venous disease
What is collateral circulation
If main vessel occluded collateral takes over
May not be sufficient if high metabolic demand
What does axillary / brachial emboli cause
6P’s
What causes axillary emboli
AF so may have features e.g. syncope
Mural thrombus from LA
What causes arterial occlusion
Atherosclerosis
Trauma is rare
What are the symptoms of arterial occlusion
Claudication
Ulceration
Gangrene
Subclavian steal if proximal
What causes venous thrombosis in upper limb
Pre-exisitng malignancy
Repetitive use
How do you treat
Same as DVT
Gradual onset swelling and discomfort
Sensation and motor = normal
What is cervical rib
Fibrous band arising from 7th cervical vertebrae
Congenital or traumatic
Presents 3rd decade
What are the symptoms
Thoracic outlet syndrome
Absent radial and +Ve Adson if compress subclavian
What is Adson
Flexion away from symptomatic side + traction of symptomatic obliterates radial
How do you treat
Surgery
What causes subclavian steal
Proximal stenosis of subclavian artery
Causes retrograde flow through vertebral or internal thoracic
Decrease through carotid = syncope, dizzy, vertigo
Brain stem ischaemia like Sx
Typically when using arm
>20mmHg pressure difference in arms
How do you Dx and Rx
Duplex and angio
ANgiplasty and stent
What causes peripheral arterial disease / RF
Atherosclerosis = main cause HTN Smoking = strong link Cholesterol DM = atheroma / calcification CKD Stroke / TIA / MI / angina - other arterial disease Previous PCI / CABG
Non modifiable
Male
Age
FH
What is PAD classified into
Intermittent
Acute limb ischaemia
Chronic limb ischaemia - symptomatic
Critical
What are less common causes of peripheral arterial disease
Vasculitis
Buerger’s in young smoker
What is Buerger’s / Thromboanngiits obliterates
Young male smoker
Ischaemia - claudication / ulcers- UL and LL
Superficial thrombilitis
Raynaud’s
What is stage 1 chronic limb ischaemia
Asymptomatic as incomplete obstruction
What is stage 2
Mild intermittent claudication = BMT
- Cramping pain after walking and improved rest
A >200m
B <200m
What is stage 3
Rest pain Particularly at night Patients often hang legs of bed to ease pain If buttock = iliac pain If calf = superficial femoral
What is stage 4
Necrosis
Ulceration
Gangrene
Toes and heels common
What is critical limb ishcaemia
1+ of Rest pain >2 weeks Ulceration Gangrene Requires urgent investigation and investigation
What do you look for in the examination
Ulcers Hair loss Pain Pallor Parathesia Perishingly cold Pulses - popliteal and feet just say present or absent CRT - prolonged Paralysis Aneurysm - aorta Carotid bruit BP both arms Quality - thumbing, normal, weak, absent Size - small, normal, ecstatic, aneurysmal Soft, hard, calcified
How do you investigate PAD
What is 1st line imaging
Other imaging options
H+E Bloods - FBC, U+E, lipid, blood glucose for DM, Thrombophilia screen if <50 ECG for cardiac ischaemia Assess pulses Bueger's ABPI Doppler USS
If stage 3
Arterial Duplex (USS + doppler) = 1st line
MR angiogram if considering intervention
CT angiogram if CI i.e. due to pacemaker (radiation / contrast nephropathy) / or to plan Rx - looks like normal CT
CT / MRI
Digital subtraction angiography (invasive as puncture artery) - X-Ray
What is the ABPI
Ratio of BP in legs (posterior tibial or dorsals pedis) to arms (brachial artery)
Use hand held doppler + BP cuff to get
Should be >8
If <1 = PAD
Won’t work if calcified will be inappropriately high - DM / low sun / 2 PTH / CKD / via D deficiency
What are the stages of PAD related to ABPI
>1 = asymptomatic (0.9-1.2) or calcification - DM / CKD 0.5-0.95 = intermittent claudication / absent distal 0.3-0.5 = severe refer as critical limb ischaemia / Bueger +ve / absent distal / ulceration / rest pain <0.2 = gangrene
What is Buerger’s test
Elevate legs and look at pallor
Go pale at lower degrees <20 = indicate severe ischaemia
>90 = normal
Hang over bed and skin goes bright red due to loss of auto regulation / slow to return = +ve sign
How do you treat PAD
Modify CVS RF If >200 = BMT If <200m = stent / angioplasty If rest pain = urgent referral for stent or surgical bypass Amputation if not possible / gangrene
What does bypass require
Good influx of blood
Conduit vein
Aorta - femoral
Femoral femoral bypass if don’t want to use aorta due to chest
What does BMT involve
Anti-platelet - single clopidogrel > aspirin Statin BP control Stop smoking Exercise - supervised Weight loss Diabetic control Vascular clinic follow up
What is important in the history
Vascular RF
Exercise tolerance
Claduciation pain - effect of incline/. changes
SOCRATES
Any rest pain
Tissue loss - duration / trauma / sensation
What causes acute limb ischamia
Emboli
- Post MI
- Atrial fibrillation
Arterial thrombus from stenosed artery
Rare cause
Trauma
Dissection
What are the symptoms
6P's - Pale - Pulseless - Pain - Paraesthesia - Paralysis - Perishingly cold Always compare to contralateral Irreversible after 6 hours
How do you Dx
Dx = clinical as Ix delays RX History - critical ischaemia / cardiac / onset and duration Bloods ECG Doppler USS - absent CT angio to image
How do you Rx
Discuss with senior
NBM
Analgesia
Anti-coagulate - IV heparin infusion to prevent extension
URGENT surgery - bypass or stent / embolectomy
Can do on table angio +- tPA thrombosis if fails
Amutation if not salvageable
Life-long anti-coagulation required after
What are complications of acute limb ischaemia
Compartment syndrome
What are types of amputation
Hind quarter Hip disarticulation - more trauma / malignancy Transfemoral (above knee) Through knee Transtibial (below knee) - less energy Symes Transmetatarsal Digit
What are reasons for amputation
Bypass / angioplasty not an option
Peripheral vascular disease
Trauma
Malignancy
Who are at risk of needing
DM
Atherosclerosis
Adrenaline large dose = vasoconstriction -> gangrene
Who is at risk of high mortality from amputation
Age Co-morbid CVS disease DM Blood loss / GA Coronary and cerebral artery disease
What are complications of amputation
Stump breakdown Wound infection DVT /PE HAP Phantom limb MI / stroke - optimise CVS / BMT Falls Mortality
What causes stump breakdown
Ischaemia / poor blood - higher amputation may be needed
Infection
Trauma - control falls
Control BG
How do you prevent DVT
LMWH admission to discharge
What do you do if DM of digit
Transmetatarsal as risk other toes will become affected
How do you minimise pain
Neuropathic pain relief
Wound catheter giving LA
Anatomy of LL
Aorta
Common iliac
Internal iliac
External iliac -> superficial femoral at inguinal ligament
Posterior tibial -> dorsalis pedis -> pedal arch
Collateral - profunda femoris, anterior tibial, peroneal
How does DM worsen ulceration
Neuropathy
Microvascular complications
What is claudication
Cramp like pain in back of calfs when blood supply to muscle is reduced
Worse up hills
Relieved by rest
Progressive but reduced by formation of collateral
What do you do before bypass surgery
H+E ECG FBC, U+E, LFT, coag, glucose, G+S CXR PFT / ECHO / myocardial perfusion scan
What are the complications of bypass surgery
MI Infection Pneumonia Stroke Limb loss PE / DVT Graft failure
What arteries affected by PAD
Coronary
Carotid
Peripheral
USS
Dynamic images and flow
1st line if not severe / IC
Non-invasive, no radiation, done at bedside
User dependent
MR angiogram
Contrast safer than CT
Better soft tissue contrast
Not if pacemaker
Less available
CT angiogram
Inject contrast IV Take photos in arterial phas Good resolution Less invasive Radiation, nephrotoxic Can't visualise if calcified Useful if deciding anatomy
Angiogrpahy
X-Ray used Have to puncture artery to inject Can do angioplasty / stent after if vessel found to be stenosed High radiation Nephrotoxic contrast
Angioplasty
Catheter and balloon to open up artery
Only 15% suitable
When is stent used
If multiple
Long stenosis
Failed angio
Embolisation
Fibroid AV Tumour GI bleed Endoleak post EVAR Trauma Varciocele
What can DM cause
Peripheral neuropathy Peripheral vascular disease OM Neuropathic pain Charcot Ulceration
What causes foot ulcers
Ischaemia
Neuropathy
Mixed
What causes neuropathy
Microvascular complication = nerve hypoxia
Hyperglycaemia = affects metabolism
Symptoms of neuropathy
Asymptomatic
Burning pain
Altered temp sensation
Altered touch - allydonia where touch perceived as pain
Autonomic = reduced sweat / loss of auto regulation
Motor = muscle wasting and deformity
Charcot
How do you Dx neuropathy
Regular foot exam
How do you Rx
Footwear
How do you treat diabetic foot
Surgical debridement
Amputation may be needed
What are types of pain people with PVD / DM can present with
Neuropathic
Ischaemic
Intermittent claudication
Neuropathic pain
Foot / shin Tingling / burning Night time worse Exercise better Warm foot Bounding pulse
Ischaemic pain
Foot / calf Aching pain Elevation worsen Hanging foot = better Feet cold Pulsless
Intermittent claudication
Calf / thigh Cramping Exercise worse Rest better Weak or absent pulse
What causes Charcot
DM neuropathy
What is stage 1
Fragmentation Swelling Red Warmth X-Ray shows soft tissue swelling / bony fragmentation / dislocation
What is stage 2
Coalescenece
X-Ray shows healing
Reduced swelling
What is stage 3
Reconstruction
X-Ray shows residual deformity
What is anterior triangle of neck bordered by
SCM
Mandible
Midline
Clavicle
What is posterior triangle of the neck bordered by
SCM
Trapezius
What is the contents of the anterior triangle
Common carotid Internal carotid External carotid Vagus nerve (runs beside CCA) Hypoglossal and accessory nerve
What is the contents of the posterior triangle
Subclavian artery and vein
Brachial plexus
Occipital artery
Nerves
What are the branches of the external carotid
Superior thyroid Acending pharyngeal Lingual Occpital Facial Posterior auricular Maxillary Superficial temporal
What makes up popliteal fossa
Biceps femoral (lateral)
Semimembranous
Plantaris
Gastrocnemius
Contents of popliteal fossa
Sciatic branches into tibial and common fibular
Popliteal vein and artery
Sural nerve
When do you do carotid endarectomy
> 70% stensosis
Symptomatic - Arthrus fujax / TIA / stroke
Why don’t you do angioplasty in carotid
High risk of stroke / emboli
What if you don’t do endarectomy
1 in 5 will have another event
1 in 100 will have stroke due to op
If someone presents with pain down their leg what do you ask
Ask red flag - caudal equina
Weight loss / B symptoms
Surgical Hx
If man has pain in buttocks when walks but no calf what vessel
Iliac
What vessel if calf pain
Femoral
What causes Leriche
Occlusion in distal aorta / iliac
What is the triad
Thigh / buttock claudication
Absent femoral pulses
Male impotence
