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Year 3 - CR > Limb Ischaemia and Peripheral Vascular Disease > Flashcards

Limb Ischaemia and Peripheral Vascular Disease Flashcards

1
Q

What is peripheral vascular disease

A
  • This is a commonly caused by atherosclerosis and usually affects the aorto-illac or infra-inguinal arteries
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2
Q

What are the two types of limb ischaemia

A
  • Chronic lower limb ischaemia

- Acute lower limb ischaemia

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3
Q

What are the risk factors for chronic lower limb ischaemia

A
  • smoking
  • diabetes
  • hypercholesterolaemia
  • hypertension
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4
Q

What classification is used to describe peripheral arterial disease

A

Fontamine classification

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5
Q

What are the symptoms according to the Fontaine classification for peripheral arterial disease

A
  • Stage 1 - asymptomatic
  • Stage 2 - intermittent claudication
  • Stage 3 - rest pain/nocturnal pain
  • Stage 4 - necrosis/gangrene
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6
Q

What is intermittent claudication

A
  • this is when patients complain of exertion discomfort most commonly in the calf which is relieved by rest
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7
Q

Where do patients with aorta-iliac disease feel pain

A
  • in the buttock
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8
Q

What is rest pain

A
  • patients with rest pain experience severe, unremitting pain in the foot which stops a patient from sleeping
  • partially relieved by dangling the foot over the edge of the bed or standing on a cold floor
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9
Q

What are the signs of chronic limb ischaemia

A
  • cold
  • dry skin
  • lack of hair
  • pulses diminish or absent
  • ulceration may occur
  • dark discolouration of the toes
  • gangrene
  • abdomen should be examined for a possible anuesym
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10
Q

What are the differential diagnosis for chronic limb ischaemia

A
  • spinal canal claudication
  • osteoarthritis hip/knee
  • peripheral neuropathy (associated with numbness and tingling)
  • popliteal artery entrapment (young patients who may have normal pulses)
  • venous claudication (bursting pain on walking with a previous history of DVT)
  • Fibromuscular dysplasia
  • Buerger’s disease (young males, heavy smokers)
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11
Q

What investigations do you carry out for someone with limb ischaemia

A
  • severity of the disease is indicated by the ankle/brachial pressure index
  • Digital subtraction angiography
  • duplex ultrasound using B mode ultrasound and colour doppler
  • three dimensional contrast enhanced MR angiography
  • CT angiography
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12
Q

What is an ankle/brachial pressure index

A
  • measurement of the cuff pressure at which blood flow is detectable by the brachial artery (ankle/brachial pressure)
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13
Q

What level is the ankle/brachial pressure index at with intermittent claudication

A
  • it is associated with an ABPI of 0.5-0.9

- values of greater than 0.5 are associated with critical limb ischaemia

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14
Q

What lifestyle management should be recommended with patients with chronic limb ischaemia

A
  • stop smoking
  • diabetes - improve car e
  • hypercholesterolaemia should be treated with statins
  • Prescribe antiplatente agents - clopidogrel = 1st line
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15
Q

What is the pharmacological therapy used to treat chronic limb ischaemia

A
  • Cilostazol

- naftidrofuryl

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16
Q

What does Cilostazol do

A
  • this is a phosphodiesterase III inhibitor that increases level of cAMP, this produces vasodilation and reversibly inhibits platelet aggregation
17
Q

What does naftidrofuryl do

A
  • is a vasodilator agent that inhibits vascular and platelet 5-hydroxytryptamine receptors and can reduce lactic acid levels
18
Q

What is the surgical treatment for chronic limb ischaemia

A
  • percutaneous transluminal angioplasty
  • bypass procedures
  • Amputation
19
Q

What are the symptoms of acute lower limb ischaemia

A
  • pain
  • pallor
  • paraesthesia
  • paralysis
  • perishingly cold
20
Q

What are the signs of acute lower limb ischaemia

A
  • limb is cold
  • mottling and marbling of the skin
  • sensation and movement of the leg are reduced in severe ischaemia
  • compartment syndrome can develop
21
Q

What are the common causes of acute lower limb ischaemia

A
  • embolic disease - due to cardiac thrombus and cardiac arrhythmias
  • thrombotic disease - usually due to chronic atherosclerotic stenosis in a patient who has previously reported symptoms of claudication
  • Trauma - causing compartment syndrome
22
Q

What is the medical management of acute lower limb ischaemia

A

It is dependent on the degree of ischaemia

- patients showing improvement may be treatable with heparin and appropriate treatment of the underlying cause

23
Q

What is the surgical and radiological management of acute lower limb ischaemia

A
  • patients with mild to moderate ischaemic symptoms who have an occluded graft may need graft thrombolysis
  • Intra arterial thrombolysis may reveal an underlying stenosis within a graft or native vessel that can be treated with angioplasty
  • patients with embolus will have it removed
  • bypass graft
24
Q

What happens when an ischaemic limb is revascuarlized

A
  • can cause a repercussion injury, with the release of toxic metabolites into circulation
  • this can lead to compartment syndrome which will require a fasciotomy
25
Q

What investigations should be carried out on emergency acute limb ischaemia

A
  • Routine bloods including a serum lactate
  • A thrombophilia screen
  • ECG
  • Doppler ultrasound
  • CT angiography
26
Q

What are the cardinal features of critical ischaemia

A
  • ulceration and gangrene

- foot pain at rest - relieve at night by handing legs off bed

27
Q

What are the signs of limb ischaemia

A
  • absent femoral, popliteal or foot pulses
  • cold white legs
  • atrophic skin
  • punched out ulcers (often painful)
  • postural dependent colour change

Severe ischaemia

  • capillary refill greater than 15 seconds
  • Buerger’s Angle ( angle that leg goes pale when raised of the couch) less than 20 degrees
28
Q

How do you manage claudication

A
  • Supervised exercise programme (2h/week of 3 months) - reduce symptoms by improving collateral blood flow; exercise to the point of maximal pain
  • Vasoactive drugs - e.g. Naftidrofuryl oxalate - modest benefit
29
Q

Describe how percutaneous transluminal angioplasty work

A
  • Used for disease limited to a single arterial segment
  • Balloon is inflated in narrowed segment
  • Stents can be used to maintain arterial patency
30
Q

How does surgical reconstruction work

A
  • if atheromatous disease is extensive but distal run-offs is good
  • autologous vein grafts superior to prosthetic grafts when knee joint is crossed
31
Q

What are the causes of acute limb ischameia

A
  • Thrombosis in situ = 40%
  • Emboli = 38%
  • graft/angioplasty occlusion - 15%
  • Trauma
32
Q

What are the clinical features of acute limb ischaemia

A
  • pale
  • pulseless
  • pain
  • paralysis
  • paresthesia
  • polar
33
Q

What is the management of acute limb ischaemia

A
  • Surgical emergency requiring revascularisation within 4-6 hours to save limb
  • if diagnosis is in doubt do urgent arteriography

Options

  • open surgery or angioplasty
  • If embolic: surgical embolectomy, local thrombolysis
  • Anticoagulate with heparin after procedure

Year 3 - CR (44 decks)

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