Cardiovascular pathology 3 (2) Flashcards
What is a thrombus ?
solid mass formed from the constituents of blood which is found within the vascular system
Where can a thrombus be found?
Blood vessels or the heart
What causes a thrombus to from ?
change to Virchow’s triad
what is Virchow’s triad ?
Stasis (change in flow), endothelial damage (change in wall structure) and hypercoagulability (change in contents of the blood).
Describe the formation of a thrombus in the arteries
Arterial thrombosis is mainly caused by the rupture of an atheroma plaque which is an example of endothelial damage. Endothelial damage however can be caused by other things such as high cholesterol, smoking, trauma and hypertension. When a atheroma ruptures it causes a thrombus (mainly platelets and fibrin and is therefore white in colour) to form on the surface and this happens through the activation of the clotting cascade (See diagram). Lines of Zahn will then develop, where a thrombus causes a layer of clot to form which then causes a layer of thrombus to form etc.
What can the consequences of a arterial thrombus be ?
This thrombus can then embolise to the coronary vessels to cause a acute coronary syndrome or to the brain to cause a ischemic stroke.
Describe the clotting cascade
Damage occurs to the tissue.
Through a series of steps a clotting factor is produced which converts prothrombin to thrombin which then converts fibrinogen to fibrin
Describe thrombus in the veins
Venous thrombosis is mainly caused by a change in the stasis or hyperstability of the blood. Stasis/flow is altered when there is immobility i.e. when you are bed bound or on a long haul flight. Hypercoagulability can be caused by pregnancy, cancer, sepsis or genetics. In the veins the stasis or hypercoagulability result in a clot forming (mainly fibrin and red blood cells which is red in colour). Venous thrombosis often occurs in the deep veins of the legs and is called DVT. These clots can then embolise and often goes to the lungs and causes a PE. Some thrombus don’t embolise however some will resolve themselves or with medication or they will become organised and shrink over time.
Examples of things which cause stasis
immobility i.e. when you are bed bound or on a long haul flight.
Examples of things which cause hypercoagubility
pregnancy, cancer, sepsis or genetics.
What are the outcomes of venous thrombosis ?
These clots can then embolise and often goes to the lungs and causes a PE.
Some thrombus don’t embolise however some will resolve themselves or with medication
or they will become organised and shrink over time.
Describe normal flow through a vessel
laminar where the cells move in the centre of the vessel and the plasma flows around it.
What is blood flow controlled by ?
changing the pressure gradient, the resistance, the velocity and the compliance
What are the two main ways in which blood flow can be unusual
The first is stasis where there is stagnation of the blood flow i.e. the blood flows slowly (lack of movement due to sitting too long or not moving i.e. after an operation or in a aeroplane etc). The second is where there is turbulent blood flow i.e. flow is forceful and unpredictable.
What is a thromboembolism ?
When a thrombus or clot embolises
Name some other things which can cause an embolism
Fat gas tumours bone marrow foreign bodies parts of the trophoblast etc from the baby in pregnancy
How does fat cause embolism ?
Embolisms can be beads of fat caused when there are bone fractures and fat from the bone enters to the blood and causes confusion (if it enters the brain) or can lodge go to the kidneys or the skin.
How does gas cause embolism ?
Embolism can also be beads of gas. This is commonly caused when a driver rise to the surface to quickly and it causes N2 bubbles to form and lodge in the capillaries, this is called decompression sickness. Gas embolise can also be caused by injury to the head and neck, from surgery or from CV lines
How does bone marrow cause an embolism ?
Bone marrow can embolise after a bone fracture or even after CPR
Describe embolism in pregnancy
. In pregnant ladies an embolism is also caused when part of the Trophoblast from the baby, some Amniotic fluid embolism or foetal skin cells and keratin from the baby get into he maternal circulation.
What are the signs and symptoms of arterial thrombosis ?
Sudden onset
Signs of embolism i.e. strokes, ACS etc
What are the signs and symptoms of venous thrombosis ?
Slow onset
Signs of embolism i.e. PE
Evidence of DVT i.e. unilateral limb swelling, persistent discomfort, calf tenderness and to a lesser extent warmth, redness, prominent collateral veins and unilateral pitting oedema
What investigations should be carried out into thrombosis ?
The wells score
A D-dimer blood test
What is D-Dimer ?
the breakdown product of cross linked fibrin produced during fibrinolysis
What is fibrinolysis ?
The bodies natural process of trying to break down a clot
What other things can cause an elevated D-Dimer?
trauma, cancer sepsis, bleeding surgery
What should you do if the D-Dimer results are positive ?
An ultrasound
How can you be sure a patient does not have a Thrombus or embolism ?
Negative wells score and negative d-dimer
Describe the summary of the investigations for thrombosis and embolism ?
Do History Wells score and D-dimer test
if Wells and D-dimer are negative then not diagnosis
If both are positive do a compression ultrasound to confirm diagnosis
What is the wells score ?
-
How is thrombosis treated ?
Preventative: Prophylaxis before surgery, compression socks, encourage mobility.
Arterial thrombosis - Antiplatelet and anticoagulant therapy
Venous thrombosis - Anticoagulants.
Vascular surgery can also be offered for massive DVTs.
Treatment of the consequences.
What is chronic heart disease?
Dysfunction heart
What are the names of the two types of chronic heart failure ?
LVSD or HRrEF Left ventricular systolic dysfunction.
HRpEF left ventricular diastolic dysfunction
What is LVSD
Failure to pump
What is left ventricular diastolic dysfunction ?
Failure to fill with blood
What can cause left ventricular diastolic dysfunction ?
Thickening of heart muscle wall
What is a common consequence of having chronic left side heart failure ?
The failure of the left-hand side of the heart to function normally causes a build of blood trying to get into he heart and so there is a build up of blood in the lungs
What causes chronic heart failure ?
. Causes of chronic heart disease can be almost anything which causes a structural change to the heart. Common only, ischemic heart disease, valvular heart disease, hypertension and arrhythmias (commonly AF).
How is chronic heart failure classified ?
Using the new York association classification
What does the new York association classification system say ?
-
Risk factors for chronic heart failure
hypertension, MI, family history, alcohol, diabetes , being post partum, lyme’s disease
Signs and symptoms of chronic heart failure
Breathlessness which is worse on excretion,
cough sometimes with frothy white/pink sputum,
fatigue,
fluid retention i.e. oedema,
reduced exercise capacity,
raised JVP,
orthopnoea (shortness of breath which is worse when lying down),
Displaced apex beat,
paroxysmal nocturnal dyspnoea where patients wake up in the night with severe SOB and cough.
Bibasal capitations and crackles.
What is paroxysmal nocturnal dyspnoea?
Paroxysmal nocturnal dyspnoea is due to the
- fluid position in the lungs when lying down,
- the less responsive respiratory centres and
- the reduction in adrenaline when asleep.
How is chronic heart failure investigated ?
Cardiac function test (A BNP blood test)
Echocardiogram
ECG
Other tests that you could do to investigate chronic heart failure further
LVEF
coronary angiogram
What is a BNP blood test ?
A BNP blood tests which looks at amino acid peptides. It is released when there is a change in pressure in the heart. It can be done bedside and is cheap. An elevated BNP would suggest heart failure and the higher the BNP the greater the severity of the heart failure.
Why would you do an echocardiogram ?
cause of the failure
Why would you do an ECG ?
if it is normal then it is not going to be a LVSD
What is the scale of severity for an LVEF ?
A normal range is 55%-70%, mild if 44-55%, moderate is 30-40% and severe is < 30 %.
How is a chronic heart failure diagnosis made?
evidence of cardiac dysfunction and signs and symptoms
How is chronic heart failure treated ?
Get BNP
refer to specialist
Urgent referral if BNP > 2000 routen referral is BNP <2000
Get a heart failure nurse for the patient
Then ABEL
Describe what ABEL is
ACEI i.e. Ramipril. A ARB can be used instead if a patient is ACEI non-tolerant.
Beta blockers i.e. Bisoprolol which should only be given to stable patients without any acute presentation.
Aldosterone antagonist i.e. Spironolactone are not automatically started but if there is a reduced LVEF and poorly controlled symptoms them it is.
Loop diuretics i.e. Furosemide. A loop diuretic works by inhibiting the Na K and Cl transporters in the loop of Henle and therefore reduce re-absorption. If patients become resistant to furosemide then you can add in thiazide which is a very powerful combination. Loop diuretics should therefore be kept at the minimise does required to improve symptoms.
What are the ADRs of diuretics ?
dehydration, hypotension,
What is congestion ?
excess of blood in vessel, tissue or organs
What is primary congestion ?
it is the only pathology going on
What is secondary congestion ?
It is caused by another condition
What is acute local congestion caused by ?
a backlog of blood through the circulatory system
What can congestion result in ?
Stasis and DVT
Kidney and heart failure
Haemorrhage
Ischemia and infarction
Signs and symptoms of congestion
crepitations, tachycardia, cor pulomale, increased JVP, peripheral oedema
nutmeg liver which is red/brown and pale with spotty appearance because there is a build of fluid there as well as in the venous system.
What is blood flow controlled by in healthy tissue ?
hydrostatic pressure, oncotic pressure and the characterises and area of the endothelium.
What is oedema ?
the accumulation of abnormal amount of fluids in the extravascular compartments
Where does oedema occur ?
intercellular tissue compartments or in body cavities
Or intracellular spaces
What are the two types of oedema ?
Transudate
Exudate
What is a Transudate oedema ?
A transudate oedema is caused by a change to the haemodynamic forces which act across a capillary wall this is the case in cardiac failure and fluid overload. Transudate oedema does not contain much protein or album or cells but lots of water and electrolytes.
What is a Exudate oedema ?
A exudate oedema is where there is inflammatory response to increases vascular permeability. This can be caused by tumours, allergens etc. It has a high protein and album content as well as a high water and electrolytes content.
What type of oedema is peripheral oedema ?
transudate oedema
What is pitting oedema ?
A type of peripheral oedema
What is a congenital heart disease?
condition which a baby is born with
Are congenital condition genetic ?
Not always but yes often they are caused by an abnormal gene
What is a some things which can go wrong with genetics and result in an genetic mutation ?
CNVs are copy number variations which affect a whole or part of a chromosome
SNVs are single nucleotide variations which affect just one gene
If it is not genetic what else can it be ?
Caused by a teratogen
Multifactorial (Combination of risk factors)
Describe how down syndrome can result in cardiac disease
-In 15% of down syndrome patients there is a atrio-ventricular septal defects. Is where there is a defect of the interatrial or intraventricular septum.
what pathway is a group of conditions related to ?
MAPK pathway
What are the names of congeal conditions related to the MAPK pathway ?
Noonan’s,
leopard
Costello
What should you do to investigate if you suspect these?
run tests for them all
Describe a communality between these conditions
In these conditions there is Nuchal translucency which causes patient to have have neck webbing and puffy hands
Describe Noonan’s syndrome
Noonan’s syndrome patients will present with pulmonary stenosis, short suture, a characteristic face, the PTPN11 mutation, and the neck webbing
Describe Leopard syndrome
same symptoms as Noonan’s
+
deafness.
Describe Costello’s syndrome
same symptoms as Noonan’s
+
higher cancer risk and cardiomyopathy.
What conditions are cased by a 22q11 mutation ?
DiGeorge and Shpintzen syndromes
describe DiGeorge
DiGeorge presents with thymic hypoplasia, hypoparathyroidism, outflow tract cardiac malformation and is usually a sporadic condition.
describe Shpintzen
Shpintzen syndrome presents with cleft palate/palatial insufficiency, outflow tract cardiac malformation, a characteristic face and it is an autosomal dominant conditions. Other symptoms of these conditions include long fingers and speech delay.
When should you tests for a 22q11 mutation ?
If more than two of these symptoms
What can cause the 22q11 mutation ?
These conditions are so common because of the low copy number repeats. A number of sections on the gene look similar and have a low copy number and therefore confusion can happen between these sections resulting in deletion or translocation.
What is Williams syndrome?
A similar kind of confusion causes Williams syndrome where there is aortic stenosis, hypercalcemia, 5th finger clinodactyly, a characteristic face, a cocktail party manner (They talk without saying anything). It is caused by a deletion on chromosome 7.
What is Marfan’s syndrome?
Marfan’s is an autosomal dominant, multisystem connective tissue disease caused by a mutation on the 15q21 gene. It causes tall stature and pes pleunus (flat feet). In order to diagnose there must be 2 of 5 categories [ See image]. Management includes observations and beta blockers, angiotensin II receptor blockers etc.
What is Romano-Ward syndrome ?
Romano-Ward syndrome. Here there is a long QT which causes seizures and sudden death. It can be induced by emotion, exercise or drugs. It can be seen on an ECG.
What is Brugade syndrome ?
This casues ventricular fibrillation and a prolongs PR interval, enlarged LV and therefore poor function. It is common in young men. Management includes avoiding a fever, excess alcohol and a ICD (implanted cardiac defibrillation) can be considered.
What is Hypertrophic cardiomyopathy sarcomere disease ?
Involves the thickening of the muscle can is causes obstructure to blood flow and arrhythmias. Titin TTN is the most common cause.
Examples of teratogens
alcohol rubella
Examples of teratogens caused conditions
Foetal alcohol syndrome causes babies to be born early, small, ADHD, and have wide eyes. This occurs if the mother has had more than 3-5 units of alcohol each week.
What is cardiomyopathy ?
a disease of the heart muscle tissue
What is the general prognosis of cardiomyopathy ?
These have a poor prognosis and generally lead to heart failure
What are three main factors which affect the performance of the heart?
preload, afterload and contractility
What is primary cardiomyopathy ?
cardiomyopathy which is confined to the heart and is normally caused by genetic
What is secondary cardiomyopathy ?
where it is caused by another condition
What are some main conditions which can cause secondary cardiomyopathy ?
ischemia and valvular disease
Can cardiomyopathy be reversible ?
yes when the causing condition is reversible, i.e. alcohol, tropical disease, post partum
How is cardiomyopathy diagnosed ?
Using an echocardiogram
Signs and symptoms of cardiomyopathy
Similarly to chronic heart disease
What are the names of the different types of cardiomyopathy ?
Dilated
Hypertrophic
Restrictive / infiltrative
Describe dilated cardiomyopathy
where there is dilated of the cardiac muscle in one or both ventriculus which makes the muscles weak. This reduced contractility and function which causes a reduced ejection fraction. This is the most common type. There will also be a S3 gallop.
describe Hypertrophic cardiomyopathy
there is hypertrophy of the ventriculus including the intraventricular septum without chamber dilation. This results in reduced ability of the heart to fill. It is the most common cause of primary cardiomyopathy. It is most commonly caused by an autosomal mutation. The reduced ability to fill results in a reduces cardiac output. NOTE that the ejection fraction is usually still normal i.e. the blood that is in the heart is getting pumped out.
describe Restrictive or infiltrative cardiomyopathy
the heart muscles become stiff and not elastic. In the ventricles this means that the sarcomere cannot lengthen effectively and so there is reduced ability to fill and therefore reduced cardiac output. This also causes dilated atria due to a build up of back pressure.
How is cardiomyopathy treated ?
same as for chronic heart failure
What is myocarditis ?
inflammation of the cardiac muscle
What is myocarditis caused by ?
trauma, infection or ischemic heart disease and most commonly a virus but can also be bacterial
What does inflammation of the heart muscle cause ?
decreased cardiac output and therefore can cause varying degrees of heart failure. It can also result in an arrhythmia. It eventually takes the appearance of dilated cardiomyopathy
Signs and symptoms of myocarditis
Chest pain and before that they may have a viral symptoms i.e. fever, malaise, cough etc. Before the cough they may also be asymptomatic. Then later on symptoms of heart failure.
How should you investigate myocarditis ?
Troponin will be elevated in myocarditis as inflammation damages the sarcomeres. Viral and bacterial serology (blood tests) to help determine the cause.
An echocardiogram to assess degree to heart failure and look for complications and causes.
ECG to check for conduction abnormalities. (it is usually abnormal)
How should you diagnose myocarditis ?
MRI of the heart or an endomyocardial biopsy
How is myocarditis treated ?
Drugs or a pace maker. Supportive treatments. For myocarditis anti-inflammatory drugs are not effective. Treatment for heart failure. Immunotherapy can also sometimes be used.
What is pericarditis?
the inflammation of the pericardium
Does it always exist alongside myocardial involvement ?
no
What causes pericarditis ?
viruses but they can be caused by bacterial or be a result of MI
Symptoms of pericarditis
fever, chest pain with pleuritic features and postural features, sitting forward usually improves it lying back makes it worse, raised temperature, feeling very unwell.
Investigations of pericarditis
Investigations include ECG and echo, troponin may be raised if myocardial involvement too. Often gets better on its own but good to treat symptoms. Bacterial must be drained even if small. For pericarditis anit-inflammatory drugs are required.
What is rheumatic fever ?
Rheumatic fever is an autoimmune disease which develops a few weeks after a Group A beta haemolytic streptococcal infection
What are the risk factors for rheumatic fever ?
streptococcal infection
genetic predisposition
What age group is most affected by rheumatic fever ?
5-15 yo
How does rheumatic fever present ?
It presents with a history of a throat infection (sore throat) a couple of week ago, fever, joint pain of the mainly large joints (Painful polyarthritis) and skin rash.
What can rheumatic fever cause ?
It can also result in pancarditis (inflammation all three layer of the heart wall) in the acute phase and carditis (pericarditis, myocarditis and valvulitis). It can also cause a heart murmur.
What are the investigations for rheumatic heart disease?
Investigations include an ECG, CXR, Echocardiogram
What is the treatment for rheumatic fever ?
symptomatic relief i.e. paracetamol. Prophylaxis is also started. Antibiotics are recommended in confirmed diagnosis, aspirin and bed rest.
What is one main complication of rheumatic fever ?
rheumatic heart disease
How does rheumatic fever become rheumatic heart disease ?
This transition happens especially if there is pancarditis or repeated strep infections
What is rheumatic heart disease ?
This is where the valves of the heart are permanently damaged. The damaged valves are malformed, there is cusp/leaflet thickenings, commissural fusion, shortening and thickening and fusion of chordae tendinea.
What are the consequences of damaged valves in rheumatic heart disease ?
It results in stenosis and or regurgitation of valves (especially the mitral and aortic on the left side of the heart. Tricuspid valve involvement is infrequency and pulmonary valve involvement is rare).
What valvular condition is not caused by rheumatic heart disease ?
aortic stenosis
How is rheumatic heart disease investigated ?
echocardiogram
How is rheumatic heart disease treated
Treatment can also be surgery for patients with heart failure, valvular dysfunction, cardiac complications, uncontrolled infection (Where there is a persistent fever and positive blood cultures) and in order to prevent embolism (if the vegetation is persistently lager >10mm or there is more than one embolic episodes).
What is infective endocarditis ?
inflammation of the endocardium of the heart. The endocardium is the inner layer of the heart and it usually involves the valves
What is infective endocarditis characterised by ?
vegetations (little bundles of cells and microbes which should be there. Often they include platelets, fibrin and microorganisms)
How will IE present ?
embolic stokes, MI, PE and infarction of other places in the body i.e. the kidneys.
What are risk factors for IE ?
prosthetic valves, having a cardiac device, IV drug users, having congenital heart disease, having rheumatic valve disease, having mitral valve prolapse, being immunosuppressed and having a long stay in ITU or hospital.
What are signs and symptoms of IE ?
heart murmurs (found in 85% of cases), a fever, chills, rigors, poor appetite, weight loss, Osler nodes (red-purple, slightly raised, tender lumps, often with a pale centre, pain often precedes development of the visible lesion by up to 24 hours they are typically found in the fingers and toes), Janeway lesions (Rare, non tender, small erythematous or haemorrhagic mucular, popular or nodular lesions on the palms or soles only a few mm in diameter), Splinter haemorrhages (Thin, red and reddish/brown lines of blood under the nails), Roth spots (White centred retinal haemorrhage).
How is IE investigated ?
Echo
How is IE diagnosed ?
Blood cultures 3 each 30 mins apart
How is IE treated ?
Antibiotics
valve replacement
What are the four sections of the aorta called ?
aortic root, the ascending aorta, the aortic arch and the descending aorta
Describe the aortic root
The aortic root has the sinus of Valsalva which has a right, left and non coronary sinus
Where does the sinus of Valsalva join the ascending aorta ?
At the sino tubular junction
Describe the walls of the aorta
The walls of the aorta contain the same three layers as every other blood vessel.
Its tunica intima which is an endothelial layer of cells sitting on a collagen and elastic fibres which sits on an internal elastic membrane.
Its tunica media has smooth muscles cells and secretes elastin in a lamellae.
Its tunica adventitia is a think connective tissue layer which has collagen and elastic fibres. The collagen in the adventitia prevents the elastic arteries from stretching beyond there limits.
Can Atherosclerosis be found in the aorta ?
yes it is very common
What is an Aneurysm ?
is the localised enlargement of an artery caused by a weakening of the vessel wall
What is a true Aneurysm ?
A true aneurysm is caused by weakening and dilation of the wall and affects all three layers
What is a true Aneurysm caused by ?
hypertension and atherosclerosis, smoking and trauma
What is a false aneurysm ?
A false aneurysm is where the dilation of the vessel does not involve all three layers
What is a false Aneurysm caused by ?
trauma, iatrogenic (Caused by medica treatment) or a result of inflammation.
Signs and symptoms of an aneurysm
Aortic aneurysms can be asymptomatic and found accidently.
They may however cause a patient to feel short of breath, have dysphagia and hoariness, back pain, and have a pulsatile mass.
How is a aneurysm found ?
CT angiogram aorta is the main investigation and is used to diagnosis however a MRI aorta can also be used to diagnosis and follow up. CXR, echocardiogram and transoesophageal echocardiogram can also been done if more information is required (TOE is an invasive and very rare). Dilation of the ascending aorta can causes aortic regurgitation.
What is aortic dissection ?
Aortic dissection is where there is a tear in the inner wall of the aorta
Is aortic dissection an example of a true or false aneurysm ?
a false aneurysm
Describe what happens in a artic dissection
Here there is dilation of the tunica media and adventitia. A break in the adventitia allows blood to move into he space between the layers
What causes an aortic dissection ?
hypertension, atherosclerosis, Marfan’s syndrome, bicuspid aortic valve and trauma.
What is an antegrade aortic dissection ?
Blood in this new false lumen can continue to move in the direction of the blood in the aorta
What is an retrograde aortic dissection ?
Blood in this new false lumen can continue to move in two directions one way from the direction of blood flow and one in the direction of blood flow
How can aortic dissection by classified ?
on the De Blakey method
signs and symptoms of aortic dissection
severe sharp chest pain which radiates to the back. It can also cause collapse and stroke. On examination there will be reduced or absent peripheral pulses, hypertension or hypotension, BP mismatch between sides, pulmonary oedema
Investigations for aortic dissection
CT angiogram is the imaging used to diagnose however an ECG and CXR can also be useful.
Treatment for aortic dissection
Half of patents with aortic dissection die before they reach hospital.
A type A aortic dissection is treated with blood pressure control (beta blockers, IVI nitrates, CCBs) emergency surgery is also required. Type B is treated with the same blood pressure medication and percutaneous (endo-vascular) intervention which is a type of surgery.
What is Takayasu’s Arteritis
A Inflammatory and infection disease of the aorta. which is a granulomatous vascular disease affecting more females than males. It affects the aorta and it branches and causes stenosis, thrombosis, aneurysm, and renal artery stenosis It is treated with steroids and immunosuppressants, surgery and percutaneous (endo-vascular) intervention may also be required
What is Syphilis ?
Syphilis is another example. It is an STD caused by the bacteria Treponema pallidum. It is treated with antibiotics to prevent late stages. Tertiary syphilis will develop into one of there types; late neuro-syphills, gummatous syphilis and cardiac syphilis.
What is coarctation of the aorta ?
where there is narrowing of the aorta below the left subclavian artery
What are the three types of coarctations of the aorta ?
There are three types, pre-ductal which is life threatening (B), Ductal (A) and post ductal which is the most common
Signs and symptoms of coarctations ?
cold legs and poor leg pulses.
heart failure and failure to thrive in children and as hypertension and CV complications later in life
Investigations for coarctation
CXR and CMRI
Treatment for coarctation
Treatment is done through percutaneous or surgical correction
What is chronic limb ischemia ?
Chronic limb ischemia occurs as a result of a build up of atherosclerotic plaques in the arteries which supply the lower limb
What else can cause chronic limb ischemia ?
by vasculitis (inflammation of the blood vessels) or Buergers disease
What are the risk factors for chronic limb ischemia ?
male, older age, smoking, hypercholesterolemia, hypertension or diabetes
Classifications of chronic limb ischemia
Stage 1 is asymptomatic and there is incomplete blood vessel obstruction.
Stage 2 is where there is mild claudication pain in the limbs.
Stage 2a is their claudication’s occur when walking more then 200m.
Stage 2b is where claudication’s occur when walking less then 200m.
Stage 3 is when there is pain even at rest.
Stage 4 is where there is necrosis and or gangrene of the limb. Stage 4 is also called critical limb ischemia.
Signs and symptoms of chronic limb ischemia
Loss of exercise tolerance, pain in the legs and or feet, ulceration, pallor and hair loss of the legs
What investigations can be carried out into chronic limb ischemia ?
ABPI (Ankle brachial pressure index) looking at the ankle pressure and brachial pressure. The Buerger’s test, this is where a leg is elevated and checked for pallor, if the angle is <20 degrees then there is sever ischemia. You then hang the feet over the edge of the bed and look to see if the legs regain colour, if they do so slowly and or turn dark red then that is a sign of ischemia. Imaging can also be useful. This includes using a duplex (Which are dynamic, non radiation non contrast images)
What is the treatment for chronic limb ischemia ?
If patients have a high risk of coronary artery disease they should be managed in the same way as someone with coronary artery disease. Combination of antiplatelet and stains. BP should be kept under 140/85 and smoking cessation and diabetes should be controlled. Exercise is also important in recovery. Re-vascularization is open surgery such as a bypass or endarterectomy. Other surgeries include balloon angioplasty, stent placement and atherectomy.
What does acute limb ischemia result in ?
arterial embolus, thrombosis, trauma, dissection and acute aneurysm thrombosis. Acute limb ischemia presents with 6 Ps, Pain, pallor, pulse deficit, paraesthesia, paresis/Paralysis and Poikilothermic. It is always very important to compare each leg.
What is compartment syndrome?
where there is muscular ischemia (which is irreversible after 6-8 hours).
What is involved in compartment syndrome ?
inflammation, oedema, venous obstruction, tense or tender calf, rise in creatinine kinase, risk of renal failure
How is compartment syndrome managed ?
An embolectomy is where a catheter with a balloon is inserted and the clot pulled out at the top.
What is diabetic foot disease ?
microvascular peripheral artery disease where there is peripheral neuropathy and mechanical imbalance
Signs and symptoms of diabetic foot disease
ulcers. It is highly susceptible to infection
Treatment for diabetic foot disease
Good foot care can prevent this. Patients should avoid minor injuries to the feet and should wear appropriate and well fitting footwear. Regular check ups of pressure point and planter surfaces should be checked. Management involved prevention, diligent wound care and infection control so possibly starting them on an antibiotic. Management can also be done using revascularization is very distal disease using distal crural angioplasty/stent and distal bypass. Amputation is also sometimes necessary. There are also adjunctive measures such as dressings, debridement larval therapy, negative pressure wound closure and skin grafts. Amputations can be done at different locations as shown in the image.
Name some venous peripheral diseases
chronic venous insufficiency
Varicose veins
How can Chronic venous disorders be classified
CEAP system [ See diagram]. Anything above C4 (on the scale of C1-C6) can be treated another under 4 wont be eligible for treatment.
Treatment for chronic venous disorders?
surgical or conservative. Deep venous insufficiency is normally treated by compression (conservative) if there is no arterial compromise. This will look like compression banding and elevation. This allow healing however they will continue to get flair ups if they don’t keep wearing there bandaging.
Examples of venous surgeries …
Radiofrequency ablation / endovenous treatment works by intensely heating the inside of the vein. It is quite painful and so patients are given anaesthetic and fluids. There is a risk of thermal injury to the tissues. Immediately after treatment the patient is given compression bandages, to help keep the venous walls stuck together. The compression is essential to the treatment working.
Foam can also be used if a patient cannot undergo endovenous treatment then form can be used. This is sometimes also used in smaller areas. Foam is injected into he vein, this causes the vein walls to be irritated and collapse.
There is also surgical treatment for varicose veins where veins are surgically removed and they can be quite painful. This is becoming less and less common.
