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Surgery.(General 2).Vascular > Arterial.4.chronic ischemia ( Definition, Etiology, Clinical picture, GRADING and D.D) > Flashcards

Arterial.4.chronic ischemia ( Definition, Etiology, Clinical picture, GRADING and D.D) Flashcards

1
Q

Definition of chronic lower limb ischaemia

A

It is a slowly progressive gradual decrease in arterial limb perfusion that may affect its function & vitality.
Thus giving enough time for collaterals to develop and, therefore, gangrene does not occur rapidly.

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2
Q

Etiology of chronic L.L ischaemia

A
  1. Above the age of 45 years

2. Below the age of 45 years :

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3
Q

Etiology of chronic L.L ischaemia Above 45 years

A

atherosclerosis is the commonest cause.

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4
Q

Etiology of chronic L.L ischaemia Below the age of 45 years

A
  • Diabetic presenile atherosclerosis.
  • Buerger’s disease.
  • Vasospastic conditions
  • Incomplete recovery after treatment of acute ischemia
  • Aneurysm.
  • Vascular compression : Thoracic outlet syndrome
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5
Q

By far the most frequent cause of chronic L.L ischaemia is

A

Atherosclerosis

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6
Q

Predisposing factors ofAtherosclerosis

A

Major risk factors :

  • Hypertension.
  • Hypercholesterolaemia.
  • Smoking.

Other risk factors :

  • D.M.
  • Obesity.
  • Positive family history.
  • Sedentary or stressful life style.
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7
Q

Clinical picture of chronic L.L ischaemia

A
  • Symptoms

* Examination

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8
Q

Symptoms in Clinical picture of chronic L.L ischaemia

A

1- pain

2- Ischemic foot ulcers and gangrene

3- Symptoms of atherosclerosis elsewhere

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9
Q

pain in Symptoms in Clinical picture of chronic L.L ischaemia

A

A. Intermittent claudications

B. Rest pain

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10
Q

Intermittent claudications in Symptomsin Clinical picture of chronic L.L ischaemia

A
  • Definition
  • Muscles affected
  • Level of obstruction for each affected muscle
  • Boyd’s classification
  • Claudication Distance
  • Claudication Time
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11
Q

Definition of Intermittent claudications in Symptomsin Clinical picture of chronic L.L ischaemia

A

This is a cramp-like pain that is induced by exercise and is relieved by rest.

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12
Q

Muscles affected in Intermittent claudications in Symptomsin Clinical picture of chronic L.L ischaemia

A

Gluteal claudication

Thigh claudication.

Calf claudication

sole claudication

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13
Q

The level of obstruction of Gluteal claudication in Intermittent claudications in Symptomsin Clinical picture of chronic L.L ischaemia

A

Aorto-iliac obstruction

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14
Q

The level of obstruction of Thigh claudication in Intermittent claudications in Symptomsin Clinical picture of chronic L.L ischaemia

A

Ilio-femoral obstruction

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15
Q

The level of obstruction of Calf claudication in Intermittent claudications in Symptomsin Clinical picture of chronic L.L ischaemia

A

Femoro-popliteal obstruction

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16
Q

The level of obstruction of sole claudication in Intermittent claudications in Symptomsin Clinical picture of chronic L.L ischaemia

A

Tibio-peroneal obstruction

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17
Q

Boyd’s classification in Intermittent claudications in Symptomsin Clinical picture of chronic L.L ischaemia

مش مهمة

A
  • Grade I
  • Grade II
  • Grade III
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18
Q

Grade I in Boyd’s classification in Intermittent claudications in Symptomsin Clinical picture of chronic L.L ischaemia

A

The claudication passes off on continuing walking (as the metabolites cause vasodilatation & increases the muscle blood flow).

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19
Q

Grade II in Boyd’s classification in Intermittent claudications in Symptomsin Clinical picture of chronic L.L ischaemia

A

The pain persists but does not force the patient to stop

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20
Q

Grade III in Boyd’s classification in Intermittent claudications in Symptomsin Clinical picture of chronic L.L ischaemia

A

The pain increases & forces the patient to stop

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21
Q

Claudication Distance in Intermittent claudications in Symptomsin Clinical picture of chronic L.L ischaemia

A
  • Definition

* Meaning of Crippled claudication

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22
Q

Definition of Claudication Distance in Intermittent claudications in Symptomsin Clinical picture of chronic L.L ischaemia

A

It’s the distance that after which the patient complains of pain

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23
Q

Meaning of Crippled claudication in Claudication Distance in Symptoms in Intermittent claudicationsin Clinical picture of chronic L.L ischaemia

A

If claudication distance < 150m

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24
Q

Claudication Time in Intermittent claudications in Symptomsin Clinical picture of chronic L.L ischaemia

A

Is the time that the patient can walk on a treadmill until he complains of pain.

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25
Q

Rest pain in Symptoms in Clinical picture of chronic L.L ischaemia

A
  • Definition
  • Pathogenesis
  • The reason why It’s more severe at night
  • Handling
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26
Q

Definition of Rest pain in Symptoms in Clinical picture of chronic L.L ischaemia

A

It is severe burning pain in the toes & dorsum of the foot.

Partially relieved by putting the leg below the level of the heart.

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27
Q

Pathogenesis of Rest pain in Symptoms in Clinical picture of chronic L.L ischaemia

A

It is due to cutaneous nerve ischaemia.

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28
Q

The reason why It’s more severe at night in Rest pain in Symptoms in Clinical picture of chronic L.L ischaemia

A

because the warmth of the limb during sleep increases the metabolic demands while the blood supply cannot cope with these increased requirements

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29
Q

Handling Rest pain in Symptoms in Clinical picture of chronic L.L ischaemia

A

Many of these miserable patients spend the night sitting on a chair

or hanging the leg over the side of the bed

& rubbing the dorsum of the foot in an attempt to relieve the pain.

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30
Q

Ischaemic foot ulcers and gangrene in Symptoms in Clinical picture of chronic L.L ischaemia

A
  • Definition
  • Pathogenesis
  • Morphology
  • End stage
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31
Q

Definition of Ischaemic foot ulcers and gangrene in Symptoms in Clinical picture of chronic L.L ischaemia

A
  • Very painful Ulcers “except if associated with severe neuropathy”
  • Occur at or between the toes & on the dorsum of foot
  • In severe ischaemia
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32
Q

Pathogenesis of Ischaemic foot ulcers and gangrene in Symptoms in Clinical picture of chronic L.L ischaemia

A

May be related to minor trauma to pressure areas.

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33
Q

Morphology of Ischaemic foot ulcers and gangrene in Symptoms in Clinical picture of chronic L.L ischaemia

A
  • Starts as a small superficial ulcer & slowly gets deeper & larger.
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34
Q

End stage of Ischaemic foot ulcers and gangrene in Symptoms in Clinical picture of chronic L.L ischaemia

A

The end stage of ischaemia is dry gangrene with black mummified skin and tissues.

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35
Q

Ischaemic foot ulcers and gangrene is very painful except if

A

associated with severe neuropathy

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36
Q

Symptoms of atherosclerosis elsewhere in Symptoms in Clinical picture of chronic L.L ischaemia

A

May be present as

  • Angina pectoris.
  • History of cerebral stroke.
  • Transient ischaemic attacks
37
Q

Leriche syndrome

A

A triad of

impotence
Buttock and thigh claudication
Absent bilateral femoral pulse

38
Q

the reason why impotence occurs with leriche syndrome

A

due to diminished blood supply in the internal iliac arteries

39
Q

Examination in Clinical picture of chronic L.L ischaemia

A
  • General

* Local

40
Q

General Examination in Clinical picture of chronic L.L ischaemia

A

Pulse all over the body except L.L

41
Q

Local Examination in Clinical picture of chronic L.L ischaemia

A

I- INSPECTION

II- PALPATION

III- AUSCULTATION

IV. SPECIAL TESTS

42
Q

INSPECTION in Local Examination in Clinical picture of chronic L.L ischaemia

A
  • Trophic changes

* Colour changes

43
Q

Trophic changes in INSPECTION in Local Examination in Clinical picture of chronic L.L ischaemia

A

A. Cutaneous changes :

B. Loss of subcutaneous fat

C. The muscles become wasted.

44
Q

Cutaneous changes in Trophic changes in INSPECTION in Local Examination in Clinical picture of chronic L.L ischaemia

A
  • Loss of skin appendages as hairs, sebaceous & sweat glands.
  • The skin becomes dry.
  • The nails become brittle, deformed & Iose their luster.
  • Ischaemic ulcers with punched out edge.
45
Q

Loss of subcutaneous fat in Trophic changes in INSPECTION in Local Examination in Clinical picture of chronic L.L ischaemia

A

The skin becomes thin and the toes become tapered.

46
Q

Colour changes in INSPECTION in Local Examination in Clinical picture of chronic L.L ischaemia

A
  • Pallor
  • Cyanosis and rubor
  • a Fixed black colour of dry gangrene is present in some cases.
47
Q

Pathogenesis of Pallor in Colour changes in INSPECTION in Local Examination in Clinical picture of chronic L.L ischaemia

A

due to decreased blood flow into the skin.

48
Q

Cyanosis and rubor in Colour changes in INSPECTION in Local Examination in Clinical picture of chronic L.L ischaemia

A
  • Pathogenesis

* Morphology

49
Q

Pathogenesis of Cyanosis and rubor in Colour changes in INSPECTION in Local Examination in Clinical picture of chronic L.L ischaemia

A

due to stagnation of blood in the markedly dilated capillaries under the effect of accumulated vasodilator metabolites

50
Q

Morphology of Cyanosis and rubor in Colour changes in INSPECTION in Local Examination in Clinical picture of chronic L.L ischaemia

A

The colour of blood is at first red but it later becomes blue due extraction of oxygen by the tissues

Rubor “rubber colour” is reversible as it increases with dependency & disappears (foot becomes pale) with elevation.

51
Q

rubor indicates

A

severe ischaemia

52
Q

Rubor vs redness

A

Redness : normal healthy limb irreversible color

Rubor : Reversible with elevation

53
Q

Palpation in Local Examination in Clinical picture of chronic L.L ischaemia

A
  • Temperature changes

* Absent or weak pulsations

54
Q

Temperature changes in Palpation in Local Examination in Clinical picture of chronic L.L ischaemia

A

Expected finding

unexpected finding

55
Q

Expected finding in Temperature changes in Palpation in Local Examination in Clinical picture of chronic L.L ischaemia

A

Some degree of coldness will be detected in the ischaemic limb up to a level below but near that of obstruction

56
Q

unexpected finding in Temperature changes in Palpation in Local Examination in Clinical picture of chronic L.L ischaemia

A

limb may be falsely warm in

  • it was kept under clothes
  • there’s infection
  • previous sympathectomy
57
Q

Absent or weak pulsations in Palpation in Local Examination in Clinical picture of chronic L.L ischaemia

A
  • Expected finding
  • Normal Variation
  • Disappearing pulse
58
Q

Expected finding in Absent or weak pulsations in Palpation in Local Examination in Clinical picture of chronic L.L ischaemia

A

The pulses distal to the site of occlusion will be absent or weak.

59
Q

Normal Variation in Absent or weak pulsations in Palpation in Local Examination in Clinical picture of chronic L.L ischaemia

A

The dorsalis pedis artery is absent in 10% of individuals.

The posterior tibial pulse is absent in 2% of individuals.

60
Q

Disappearing pulse in Absent or weak pulsations in Palpation in Local Examination in Clinical picture of chronic L.L ischaemia

A

ln patients with early ischaemia, pulsation may be felt distal to the obstruction due to collaterals

Ask the patient to exercise his limb to the point of pain the pulse will disappear due to pooling of blood in the muscles.

61
Q

Auscultation in Local Examination in Clinical picture of chronic L.L ischaemia

A

A systolic bruit may be heard over the Common femoral artery

62
Q

clinical picture of advanced “critical” lower limb ischaemia (pre-gangrene)

A
  1. rest pain
  2. ischaemic foot ulcers
  3. color changes
63
Q

Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A
  • Test for the capillary circulation
  • Buerger’s angle
  • Harvey’s venous refilling time
  • Guttering of veins
64
Q

Test for the capillary circulation in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

Procedures:

Normal finding

Abnormal finding

65
Q

Procedures of Test for the capillary circulation in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

If one presses over the tip of the toe, it becomes pale.

Once the pressure is released, the colour returns.

66
Q

Normal finding of Test for the capillary circulation in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

Normal capillary refill is < 2 seconds.

67
Q

Abnormal finding of Test for the capillary circulation in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A
  • Sluggish capillary circulation.
  • Advanced ischemia.
  • Established gangrene.
68
Q

Sluggish capillary circulation in Abnormal finding of Test for the capillary circulation in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

In an ischaemic limb the return of colour is slow

69
Q

Advanced ischemia in Abnormal finding of Test for the capillary circulation in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

If the return of colour is delayed to above 30 seconds

70
Q

Established gangrene in Abnormal finding of Test for the capillary circulation in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

if there’s failure of blanching

71
Q

pathogenesis of failure of blanching in Established gangrene in Abnormal finding of Test for the capillary circulation in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

thrombosis of vessels and within few hours it will be black

72
Q

Buerger’s angle in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A
  • Procedures:

* Abnormal Findings

73
Q

Procedures of Buerger’s angle in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

The patient lies supine and the limb is gradually elevated.

The angle at which blanching of the toes occurs is called Buerger’s angle.

74
Q

Abnormal Findings of Buerger’s angle in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A
  • The smaller the angle at which blanching occurs, the more severe the ischaemia is.
  • Advanced ischaemia.
75
Q

Advanced ischaemia in Abnormal Findings of Buerger’s angle in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

If < 20 degree

76
Q

Harvey venous refilling time in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

Procedures:

Normal findings

Abnormal findings

77
Q

Procedures of Harvey venous refilling time in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A
  • With the patient supine, the limb is elevated to right angle until all veins empty.
  • It is then brought down to the horizontal position “some prefer to Lower the limb below the level of the bed
78
Q

Normal findings of Harvey venous refilling time in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

Normally the veins fill in 10-15 seconds

79
Q

Abnormal findings of Harvey venous refilling time in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A
  • Chronic ischaemia

* Advanced ischaemia.

80
Q

Chronic ischaemia in Abnormal findings of Harvey venous refilling time in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

Venous refilling is delayed to above 30 seconds

81
Q

Advanced ischaemia in Abnormal findings of Harvey venous refilling time in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

Venous refilling is delayed to above 2 minutes:

82
Q

Guttering of veins in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A
  • Normal finding

* Abnormal finding

83
Q

Normal finding of Guttering of veins in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

Veins of a normal foot are full when the patient is lying horizontal & collapse when the foot is raised above the level of the heart.

84
Q

Abnormal finding of Guttering of veins in Special tests in Local Examination in Clinical picture of chronic L.L ischaemia

A

With severe chronic ischaemia, guttering of veins occurs with 10-15 degree Iimb elevation.

85
Q

GRADING Of CHRONIC L.L ISCHEMIA : Fontain’s staging:

A

Grade I : Asymptomatic.

Grade II : IIa : Mild claudication. IIb : Crippled claudication .

Grade III : Rest pain.

Grade IV: Ischemic foot ulcers or gangrene.

86
Q

D.D OF CHRONIC L.L ISCHEMIA

A

I- D.D of claudication pain:

II. D.D of rest pain

87
Q

D.D of claudication pain in D.D OF CHRONIC L.L ISCHEMIA

A
  1. Venous claudication of chronic ilio-femoral DVT :Associated with varicosities with intact arterial pulses
  2. Neurogenic pain: Prolapsed disc: Pain starts by the 1st of walking
  3. Osteoarthrosis :Pain is located at the joints with intact arterial pulses
88
Q

D.D of rest pain in D.D OF CHRONIC L.L ISCHEMIA

A

Burning pain of peripheral neuropathy.

Surgery.(General 2).Vascular (16 decks)

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