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CVS > Arterial Diseases of the Limb > Flashcards

Arterial Diseases of the Limb Flashcards

1
Q

What causes upper limb vascular disease

A 
Stenosis - atherosclerosis 
Thrombosis
Inflammation
Emboli
Venous disease
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2
Q

What is collateral circulation

A

If main vessel occluded collateral takes over

May not be sufficient if high metabolic demand

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3
Q

What does axillary / brachial emboli cause

A

6P’s

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4
Q

What causes axillary emboli

A

AF so may have features e.g. syncope

Mural thrombus from LA

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5
Q

What causes arterial occlusion

A

Atherosclerosis

Trauma is rare

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6
Q

What are the symptoms of arterial occlusion

A

Claudication
Ulceration
Gangrene
Subclavian steal if proximal

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7
Q

What causes venous thrombosis in upper limb

A

Pre-exisitng malignancy

Repetitive use

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8
Q

How do you treat

A

Same as DVT
Gradual onset swelling and discomfort
Sensation and motor = normal

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9
Q

What is cervical rib

A

Fibrous band arising from 7th cervical vertebrae
Congenital or traumatic
Presents 3rd decade

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10
Q

What are the symptoms

A

Thoracic outlet syndrome

Absent radial and +Ve Adson if compress subclavian

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11
Q

What is Adson

A

Flexion away from symptomatic side + traction of symptomatic obliterates radial

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12
Q

How do you treat

A

Surgery

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13
Q

What causes subclavian steal

A

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

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14
Q

How do you Dx and Rx

A

Duplex and angio

ANgiplasty and stent

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15
Q

What causes peripheral arterial disease / RF

A 
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

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16
Q

What is PAD classified into

A

Intermittent
Acute limb ischaemia
Chronic limb ischaemia - symptomatic
Critical

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17
Q

What are less common causes of peripheral arterial disease

A

Vasculitis

Buerger’s in young smoker

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18
Q

What is Buerger’s / Thromboanngiits obliterates

A

Young male smoker
Ischaemia - claudication / ulcers- UL and LL
Superficial thrombilitis
Raynaud’s

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19
Q

What is stage 1 chronic limb ischaemia

A

Asymptomatic as incomplete obstruction

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20
Q

What is stage 2

A

Mild intermittent claudication = BMT
- Cramping pain after walking and improved rest
A >200m
B <200m

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21
Q

What is stage 3

A 
Rest pain 
Particularly at night 
Patients often hang legs of bed to ease pain
If buttock = iliac pain
If calf = superficial femoral
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22
Q

What is stage 4

A

Necrosis
Ulceration
Gangrene
Toes and heels common

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23
Q

What is critical limb ishcaemia

A 
1+ of
Rest pain >2 weeks
Ulceration
Gangrene
Requires urgent investigation and investigation
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24
Q

What do you look for in the examination

A 
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
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25
Q

How do you investigate PAD

What is 1st line imaging

Other imaging options

A 
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

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26
Q

What is the ABPI

A

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

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27
Q

What are the stages of PAD related to ABPI

A 
>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
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28
Q

What is Buerger’s test

A

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

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29
Q

How do you treat PAD

A 
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
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30
Q

What does bypass require

A

Good influx of blood
Conduit vein
Aorta - femoral
Femoral femoral bypass if don’t want to use aorta due to chest

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31
Q

What does BMT involve

A 
Anti-platelet - single clopidogrel > aspirin
Statin 
BP control
Stop smoking
Exercise - supervised
Weight loss
Diabetic control
Vascular clinic follow up
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32
Q

What is important in the history

A

Vascular RF
Exercise tolerance
Claduciation pain - effect of incline/. changes
SOCRATES
Any rest pain
Tissue loss - duration / trauma / sensation

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33
Q

What causes acute limb ischamia

A

Emboli
- Post MI
- Atrial fibrillation
Arterial thrombus from stenosed artery

Rare cause
Trauma
Dissection

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34
Q

What are the symptoms

A 
6P's
- Pale
- Pulseless 
- Pain
- Paraesthesia
- Paralysis 
- Perishingly cold 
Always compare to contralateral
Irreversible after 6 hours
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35
Q

How do you Dx

A 
Dx = clinical as Ix delays RX
History - critical ischaemia / cardiac / onset and duration
Bloods 
ECG 
Doppler USS - absent 
CT angio to image
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36
Q

How do you Rx

A

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

37
Q

What are complications of acute limb ischaemia

A

Compartment syndrome

38
Q

What are types of amputation

A 
Hind quarter
Hip disarticulation - more trauma / malignancy 
Transfemoral (above knee) 
Through knee
Transtibial (below knee) - less energy
Symes
Transmetatarsal
Digit
39
Q

What are reasons for amputation

A

Bypass / angioplasty not an option
Peripheral vascular disease
Trauma
Malignancy

40
Q

Who are at risk of needing

A

DM
Atherosclerosis
Adrenaline large dose = vasoconstriction -> gangrene

41
Q

Who is at risk of high mortality from amputation

A 
Age
Co-morbid
CVS disease
DM
Blood loss / GA
Coronary and cerebral artery disease
42
Q

What are complications of amputation

A 
Stump breakdown
Wound infection
DVT /PE
HAP
Phantom limb
MI / stroke - optimise CVS / BMT
Falls
Mortality
43
Q

What causes stump breakdown

A

Ischaemia / poor blood - higher amputation may be needed
Infection
Trauma - control falls
Control BG

44
Q

How do you prevent DVT

A

LMWH admission to discharge

45
Q

What do you do if DM of digit

A

Transmetatarsal as risk other toes will become affected

46
Q

How do you minimise pain

A

Neuropathic pain relief

Wound catheter giving LA

47
Q

Anatomy of LL

A

Aorta
Common iliac
Internal iliac
External iliac -> superficial femoral at inguinal ligament
Posterior tibial -> dorsalis pedis -> pedal arch
Collateral - profunda femoris, anterior tibial, peroneal

48
Q

How does DM worsen ulceration

A

Neuropathy

Microvascular complications

49
Q

What is claudication

A

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

50
Q

What do you do before bypass surgery

A 
H+E
ECG
FBC, U+E, LFT, coag, glucose, G+S
CXR
PFT / ECHO / myocardial perfusion scan
51
Q

What are the complications of bypass surgery

A 
MI
Infection
Pneumonia
Stroke
Limb loss
PE / DVT
Graft failure
52
Q

What arteries affected by PAD

A

Coronary
Carotid
Peripheral

53
Q

USS

A

Dynamic images and flow
1st line if not severe / IC
Non-invasive, no radiation, done at bedside
User dependent

54
Q

MR angiogram

A

Contrast safer than CT
Better soft tissue contrast
Not if pacemaker
Less available

55
Q

CT angiogram

A 
Inject contrast IV
Take photos in arterial phas
Good resolution
Less invasive
Radiation, nephrotoxic
Can't visualise if calcified
Useful if deciding anatomy
56
Q

Angiogrpahy

A 
X-Ray used 
Have to puncture artery to inject
Can do angioplasty / stent after if vessel found to be stenosed
High radiation
Nephrotoxic contrast
57
Q

Angioplasty

A

Catheter and balloon to open up artery

Only 15% suitable

58
Q

When is stent used

A

If multiple
Long stenosis
Failed angio

59
Q

Embolisation

A 
Fibroid
AV
Tumour
GI bleed
Endoleak post EVAR
Trauma
Varciocele
60
Q

What can DM cause

A 
Peripheral neuropathy
Peripheral vascular disease
OM
Neuropathic pain
Charcot
Ulceration
61
Q

What causes foot ulcers

A

Ischaemia
Neuropathy
Mixed

62
Q

What causes neuropathy

A

Microvascular complication = nerve hypoxia

Hyperglycaemia = affects metabolism

63
Q

Symptoms of neuropathy

A

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

64
Q

How do you Dx neuropathy

A

Regular foot exam

65
Q

How do you Rx

A

Footwear

66
Q

How do you treat diabetic foot

A

Surgical debridement

Amputation may be needed

67
Q

What are types of pain people with PVD / DM can present with

A

Neuropathic
Ischaemic
Intermittent claudication

68
Q

Neuropathic pain

A 
Foot / shin
Tingling / burning
Night time worse
Exercise better
Warm foot
Bounding pulse
69
Q

Ischaemic pain

A 
Foot / calf
Aching pain
Elevation worsen
Hanging foot = better
Feet cold
Pulsless
70
Q

Intermittent claudication

A 
Calf / thigh
Cramping
Exercise worse
Rest better
Weak or absent pulse
71
Q

What causes Charcot

A

DM neuropathy

72
Q

What is stage 1

A 
Fragmentation
Swelling
Red
Warmth
X-Ray shows soft tissue swelling / bony fragmentation / dislocation
73
Q

What is stage 2

A

Coalescenece
X-Ray shows healing
Reduced swelling

74
Q

What is stage 3

A

Reconstruction

X-Ray shows residual deformity

75
Q

What is anterior triangle of neck bordered by

A

SCM
Mandible
Midline
Clavicle

76
Q

What is posterior triangle of the neck bordered by

A

SCM

Trapezius

77
Q

What is the contents of the anterior triangle

A 
Common carotid 
Internal carotid 
External carotid 
Vagus nerve (runs beside CCA)
Hypoglossal and accessory nerve
78
Q

What is the contents of the posterior triangle

A

Subclavian artery and vein
Brachial plexus
Occipital artery
Nerves

79
Q

What are the branches of the external carotid

A 
Superior thyroid
Acending pharyngeal
Lingual
Occpital 
Facial 
Posterior auricular
Maxillary
Superficial temporal
80
Q

What makes up popliteal fossa

A

Biceps femoral (lateral)
Semimembranous
Plantaris
Gastrocnemius

81
Q

Contents of popliteal fossa

A

Sciatic branches into tibial and common fibular
Popliteal vein and artery
Sural nerve

82
Q

When do you do carotid endarectomy

A

> 70% stensosis

Symptomatic - Arthrus fujax / TIA / stroke

83
Q

Why don’t you do angioplasty in carotid

A

High risk of stroke / emboli

84
Q

What if you don’t do endarectomy

A

1 in 5 will have another event

1 in 100 will have stroke due to op

85
Q

If someone presents with pain down their leg what do you ask

A

Ask red flag - caudal equina
Weight loss / B symptoms
Surgical Hx

86
Q

If man has pain in buttocks when walks but no calf what vessel

A

Iliac

87
Q

What vessel if calf pain

A

Femoral

88
Q

What causes Leriche

A

Occlusion in distal aorta / iliac

89
Q

What is the triad

A

Thigh / buttock claudication
Absent femoral pulses
Male impotence

CVS (30 decks)

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