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Year 3 Breast and Vascular Surgery > Limb ischaemia > Flashcards

Limb ischaemia Flashcards

1
Q

Cause of limb ischaemia

A

Atherosclerosis

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2
Q

Atherosclerosis

A
  1. Endothelial injury
  2. Chronic inflammation
    - Lipid-laden foam cells produce GFs, cytokines and ROS
    - lymphocyte and SMC recruitment
  3. SM proliferation: conversion of fatty streak to atherosclerotic plaque with fibrous cap
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3
Q

Risk factors

A 
Modifiable:
• Smoking
• HTN
• Poor DM control
• Hyperlipidaemia
• Sedentary lifestyle
Non-modifiable
• FH and PMH
• Male
• ↑ age
• Genetic
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4
Q

Intermittent Claudication

A
  • Cramping pain after walking a fixed distance
  • Pain rapidly relieved by rest
  • Calf pain = superficial femoral disease (commonest)
  • Buttock pain = iliac disease
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5
Q

Critical Limb Ischaemia

A

Ankle pressure < 50mmHg and either:

  • Pain at rest requiring analgesia for 2+ wks
  • Especially at night
  • Usually felt in the foot
  • Pt. hangs foot out of bed
  • Ulceration or gangrene
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6
Q

Leriche’s Syndrome

A

Atherosclerotic occlusion of abdominal aorta and iliacs

Triad:

  • Buttock claudication and wasting
  • Erectile dysfunction
  • Absent femoral pulses
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7
Q

Buerger’s Disease

A

Thromboangiitis Obliterans
• Young, male, heavy smoker
• Acute inflammation and thrombosis of arteries and
veins in the hands and feet → ulceration and
gangrene - black fingers

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8
Q

Signs if limb ischaemia

A
  • Loss of pulses and increased cap refill time
  • Ulcers: painful, punched-out, on pressure points
  • Onycholysis
  • Skin: cold, pallor, atrophy, absent hair
  • Venous guttering
  • Muscle atrophy
  • ↓ Buerger’s Angle
  • +ve Buerger’s Sign
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9
Q

Buerger’s Angle

A
  • ≥90: normal
  • 20-30: ischaemia
  • <20: severe ischaemia
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10
Q

Classification system for limb ischemia

A

Fontaine

Rutherford

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11
Q

Investigations for chronic limb ischaemia

A 
Doppler Waveforms
ABPI
Walk test - maximum claudication distance
Bloods 
Imaging

BP
CBG + HbA1c
Lipid profile
ECG

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12
Q

Abnormal doppler

A
  • Mild stenosis: biphasic

* Severe stenosis: monophasic

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13
Q

Conservative Mx

A 
Conservative:
• ↑ exercise 
• Stop smoking
• Wt. loss
• Foot care
• HTN, lipids, DM control - CVS risk reduction first line
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14
Q

Prognosis of chronic limb ischaemia

A

1/3 improve
1/3 stay the same
1/3 deteriorate

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15
Q

Medical Mx for chronic limb ischaemia

A
  • Lifestyle advice
  • Stain
  • Antiplatelets: aspirin/ clopidogrel
  • Optimise DM
  • Analgesia: may need opiates
  • Supervised exercise programme

Surgery:
• Percutaneous Transluminal Angioplasty ± stenting
• Bypass graft
• Amputation if can’t revascularise

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16
Q

Indications for surgical reconstruction

A
  • V. short claudication distance (e.g. <100m)
  • Symptoms greatly affecting pts. QoL
  • Pain at rest
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17
Q

Acute limb ischaemia time frame

A

Acute limb ischaemia <14d

• Acute on chronic: worsening symptoms and signs <14d

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18
Q

Chronic limb ischaemia time frame

A

Ischaemia for >14d

19
Q

Severity

A

Incomplete: limb not threatened

Complete: limb threatened
- Loss of limb unless intervention w/i 6hrs

Irreversible: requires amputation

20
Q

Causes of acute ischaemia

A

• Thrombosis (often incomplete)
- Previously stenosed vessel with plaque rupture

• Embolism (Often complete ischaemia)

  • Valve disease
  • Iatrogenic
  • Cholesterol in long bone fracture
  • Paradoxical (venous via PFO)
  • Graft / stent occlusion
  • Trauma
  • Aortic dissection
21
Q

6 Ps of ischaemic limb

A 
Pain 
Pulseless 
Perishing with cold 
Pallor 
Paralysis 
Paraesthesia
22
Q

Thrombosis

A 
Onset: hrs - days 
Severity: Less severe due to collaterals
Claudication Hx: Present 
Contralateral pulses: Absent 
Diagnosis: Angiography 
Tx: Thrombolysis
23
Q

Embolism

A 
Onset: Sudden
Severity: Profound ischaemia
Embolic source: Often AF
Claudication hx: Absent
Contralateral pulses: present
Diagnosis: Clinical
Tx: Bypass surgery
24
Q

Investigations for acute limb ischaemia

A 
Blood
- FBC, U+E, INR, G+S
- CK
•  ABG - lactate
• ECG
• Imaging
- CXR - PE
- Duplex doppler
- CT angio
- CT arteriogram if surgery
25
Q

Immediate Mx of acute limb ischaemia

A 
Senior help 
• NBM
• Rehydration: IV fluids
• Analgesia: morphine + metoclopramide
• Abx: co-amoxiclav if signs of infection
• Unfractionated heparin IV

• Complete occlusion?

  • Yes: urgent surgery: embolectomy or bypass
  • No: angiogram + observe for deterioration
26
Q

Angiography

A

Not performed if there is complete occlusion

• If incomplete occlusion, pre-op angio will guide any distal bypass.

27
Q

Embolus Mx

A
  1. Embolectomy
  2. Thrombolysis- if embolectomy unsuccessful
  3. Emergency reconstruction or amputation
28
Q

Embolectomy

A
  • Wire fed through embolus
  • Catheter fed over the top
  • Balloon inflated and catheter withdrawn,
    removing the embolism.
  • Adequacy confirmed by on-table angiography
29
Q

Post-embolectomy

A

• Anticoagulate: heparin IV → warfarin

• ID embolic source: ECG, echo, USS aorta, fem and
popliteal artery

30
Q

Complications of embolectomy

A

• Reperfusion injury

  • Local swelling can cause compartment syndrome
  • Acidosis and arrhythmia secondary to ↑K
  • ARDS
  • GI oedema → endotoxic shock

• Chronic pain syndromes

31
Q

Window for acute limb ischaemia surgery

A

6 hours

32
Q

Acute limb ischaemia

A

sudden decrease in limb perfusion that threatens the viability of the limb caused by Complete or partial occlusion of the arterial supply

33
Q

Irreversible limb ischaemia

A

Mottled, non-blanching appearance with hard woody muscles, requires urgent amputation or palliation

34
Q

Long Term Management of acute limb ischaemia

A

Reduction of the cardiovascular mortality risk

  • regular exercise
  • smoking cessation
  • weight loss
  • antiplatelet - low - dose aspirin
35
Q

Complications of acute limb ischaemia

A

Compartment syndrome

  • hyperkalaemia
  • acidosis
  • AKI due to myoglobin release

Reperfusion injury

36
Q

Risk factors for chronic limb ischaemia

A 
Smoking
Diabetes mellitus
Hypertension
Hyperlipidaemia
Increasing age
Family history
Obesity and physical inactivity
37
Q

Stages of chronic limb ischaemia

A

Stage I Asymptomatic
Stage II Intermittent claudication
Stage III Ischaemic rest pain
Stage IV Ulceration or gangrene, or both

38
Q

Chronic limb ischaemia presentation

A

Intermittent claudication

39
Q

Critical Limb Ischaemia clinical features

A

Ischaemic rest pain for greater than 2 weeks, requiring opiate analgesia

Presence of ischaemic lesions or gangrene

ABPI less than 0.5

40
Q

Examination findings of critical Limb Ischaemia

A 
Pale 
Cold 
Weak or absent pulses 
Limb hair loss 
Skin changes - atrophic skin, ulceration, or gangrene
Thickened nails
41
Q

Critical Limb Ischaemia Ix

A 
Vascular exam 
Obs
Bloods - FBC, U+Es, clotting, G+S, lipids, HbA1c
ABG - lactate 
ECG
Doppler USS
Ct angiogram
42
Q

Chronic limb ischaemia complications

A

Sepsis
Acute-on-chronic ischaemia,
Amputation
Reduced mobility and quality of life

43
Q

Classification of acute limb ischaemia

A

Rutherford

Class I - viable

Class II - Marginally threatened

Class III - immediately threatened

Class IV - irreversible

Year 3 Breast and Vascular Surgery (8 decks)

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