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Vascular YR3 > Chronic Arterial Insufficiency > Flashcards

Chronic Arterial Insufficiency Flashcards

1
Q

Assessment of vascular system

A
  • Golden 5 - consent, chaperone, privacy, exposure, confidentiality
  • Observations - calculate NEWS score
  • Radial pulse - peripheral pulse, rate rhythm, volume, character, delay + capillary refill
  • Carotid pulse - central pulse, not at same time, check peripheral and central at same time
  • CVS exam - listen to heart sounds
  • Lower limbs - inspection (standing) and palpation
  • Inspect - hair changes, swelling, assymetry, skin changes
  • Palpation - examine normal side first
  • Pulses - distal to proximal (dorsalis pedis first)
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2
Q

What happens in CAI?

A
  • Collateral vessels form
  • Allow blood supply to go past blockage
  • Body does not have time to do this in acute cases
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3
Q

What is AI?

A
  • Anything that hinders blood flow in arteries
  • More common in men than women
  • Increased prevalace with age
  • Presents with intermittent claudication usually
  • Atherosclerosis common cause
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4
Q

Composition of arteries vessels

A
  • Tunica adventitia
  • Tunica media
  • Tunica intima (inside) - this is what atherosclerosis affects

Large plaques can affect nutrition to tunica media from tunica intima = apoptosis = damage to wall = aneurysms

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5
Q

Lower limb vasculature

A
  • L4 = level of common iliac
  • Then external and internal iliac
  • As external iliac crosses inguinal ligament = femoral artery
  • Femoral triangle
  • Profunda femoris and superficial femoral artery branch
  • Knee - superficial artery –> Popliteal artery
  • –> anterior and posterior tibial artery (posterior) and peroneal artery (lateral)
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6
Q

Arteriosclerosis

A
  • Hardening of arteries due to thickening of BV wall, medium and large arteries
  • Can be split into atherosclerosis (intima), arteriolosclerosis (small arteries hyaline) Monkeberg medial calcific sclerosis (calcium in media)
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7
Q

What is atherosclerosis and atheromatous plaques

A
  • Hardening of arteries due to intimal atheromatous plaque
  • Has necrotic lipid core (cholesterol) with fibromuscular cap - can rupture
  • Damage endothelium = lipid moves into intima
  • Lipids oxidised and consumed by macrophages = foam cells
  • = inflammation, SM proliferation, deposition of ECM
  • = turbulant blood flow
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8
Q

Consequence of turbulant blood flow in arteries

A
  • Arterial thrombus
  • As can cause endothelial injury and stasis of blood
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9
Q

RF for CAI

A

Same as CVS
* Age
* Smoking
* Hypertension
* Smoking etc etc

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10
Q

Classification of PAD

A
  • Fontaine classification
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11
Q

Fontaine classification

A

1 - Asymptomatic
2 - intermittent claudication (2a is more than 200m, 2b is within 200m)
3 - rest pain
4 - ulceration, gangrene or both

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12
Q

What is intermittent claudication?

A
  • Cramp like pain felt in muscles
  • Commonest site = calf
  • As superficial femoral artery most commonly affected
  • Brought on by walking, relieved by standing still (unlike neuropathy) not present on first step (like OA)
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13
Q

Classifcation of IC

A
  • Boyds Classification
  • I-IV
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14
Q

Claudication distance?

A
  • Relative - Distance a person can walk before the onset of pain
  • Absolute - distance person can walk before they cannot walk anymore
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15
Q

What is rest pain?

A
  • Pain in limb at rest
  • Classically at night time - felt in foot most common
  • Exacerbated by lying down/elevating foot
  • May improve by hanging foot out of bed
  • Due to involvement of vasa nervorum (nerves in tunica adventitia)
  • Pressure of enviroment on foot makes it worse - even touching can hurt with duvet
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16
Q

Management of rest pain

A
  • Analgesia - need to help sleep
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17
Q

What is critial stenosis / critical limb ischaemia?

A
  • Critical stenosis is occlusion of greater than 70%
  • Imminent threat to limb
  • Can cause tissue loss
18
Q

Tissue loss in PAD

A
  • Ulceration or gangrene
  • Gangrene can be wet or dry
  • Divide foot into forefoot, midfoot and hindfoot
  • Zone of demarcation - clear between devitalised and healthy tissue?
  • Sometimes associated erythema
19
Q

Wet vs dry gangrene

A
  • Wet has additional infection on top of necrosis
20
Q

Types of gangrene

A
  1. Dry
  2. Wet
  3. Gas - clostridium perfringens
21
Q

Investigations for gangrene

A
  • X-ray to check for osteomyelitis
22
Q

Management PAD 4 meds and lifestyle

A
  • DATES - Diet, alcohol, tabacco, exercise, stress
  • Antiplatelets (Clopidogrel, if not aspirin)
  • Statins (high intensity)
  • PPI? - Lansoprazole if high risk
  • Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator)
23
Q

Antiplatelets for PAD

A
  • Aspirin - COX (cyclooxygenase) inhibitor, prevents formation of thromboxane from arachidonic acid
  • Clopidogrel - binds to ADP and inhibits
24
Q

MOA of statins

A
  • Inhibit HMG Co-A reductase
  • = decreased liver cholesterol increased LDL receptor expression
25
Q

What NOT to give someone with PAD in hospital and why?

A
  • TED stockings - thromboembolic deterrent stockings
  • Further impede blood flow in arteries that are already compromised
  • Use LMWH if need instead
26
Q

Investigation for PAD - of choice

A
  • Often clinical, can use ABPI too
  • USS doppler
  • CT angiogram if needed before surgery sometimes or if higher up as bowel gas can get in way of USS - contrast needed
27
Q

Things to check before CT with contrast

A
  • Allergies
  • Kidney function
  • Pregnancy
28
Q

Surgical options for PAD

A
  • Angioplasty
  • Bypass
  • Amputation if not suitable for revascularisation
29
Q

Whats angioplasty?

A
  • Minimally invasive
  • Through groin vessel usually
  • Go in with catheter
  • Inflate balloon and can leave stent in place if needed
  • Sometimes have antiplatelet drugs on stent?
30
Q

What is bypass?

A
  • Use graft to bypass blockage in artery
  • Bypass sometimes needed if vessel is too narrow for angioplasty
  • Can use long saphenous vein for this or omniflow (biosynthetic graft)
31
Q

How can veins be used for arterial replacement in bypass?

A
  • Remove valve function - reverse
  • Need at least 3mm calibre to be suitable
  • Assess intraoperatively to check for leaks
  • Superficial vein used - long saphenous vein, allows deep system to take over if it needs t
32
Q

Which vessels most least likely to be involved in PAD?

A
  • Upper limb arteries eg Brachial artery is uncommon
33
Q

What symptoms are associated with PAD?

A
  • Intermittent claudication
  • Rest pain
  • Dry or wet gangrene
  • Sexual dysfunction
  • Cold peripheries
34
Q

BMT for PAD

A
  • Antiplatelets (NOT anticoags)
  • Statins
  • PPIs
    • DATEs
35
Q

Test for PAD severe ischaemia

A
  • Buergers test
  • Patient lie supine and raise legs until they go pale
  • Lower them until colour returns
  • Angle at which limbs go pale = Buergers angle
  • Less 20 degrees = severe ischaemia
36
Q

What is Leriche syndrome?

A
  • Type of PAD affecting aortic bifurcation

Presents with:
* Buttock pai or thigh pain
* Erectile dysfunction

37
Q

How can critical limb threatening ischaemia be defined?

A
  • Ischaemic rest pain greater than 2 weeks
  • Presence of ischaemic legions/gangrene
  • ABPI less than 0.5

Can see gangrene, hair loss and thickened nails on exam

38
Q

Differentials for claudication presentation

A
  • Spinal stenosis - symptoms relieved by sitting rather than standing still
  • Acute limb ischaemia - present within hours, less than 14 days duration of symptoms
39
Q

ABPI and severity of PAD

A
40
Q
A

Vascular YR3 (16 decks)

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