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TCD Vascular > Limb Problems > Flashcards

Limb Problems Flashcards

1
Q

What are two complications of renal atherosclerosis?

A

-Hypertensive nephropathy (longstanding hypertension chronically deprives kidneys of blood flow, leading to decline in kidney function)
-Hypertension resistant to medical management (renal artery stenosis causes hypertension as kidney’s response to insufficient blood flow is to regulate systemic BP higher)

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2
Q

What are four complications of cerebrovascular atherosclerosis?

A

-TIAs
-Strokes
-Amaurosis fugax (a transient unilateral loss of vision due to emboli passing into ophthalmic artery)
-Drop attacks (sudden episodes of dizziness or syncope)

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3
Q

What are four complications of lower limb artery atherosclerosis (peripheral arterial disease)?

A

-Intermittent claudication (calf pain on walking caused by stenosis or occlusion to artery supplying the calf or thigh)
-Gangrene (necrosis of skin or whole digit of foot due to poor arterial supply)
-Arterial foot ulcer (break in skin due to arterial supply poor enough that skin integrity is not maintained)
-Ischaemic rest pain (pain in limb at rest due to insufficient arterial supply to perfume the limb even without exertion)

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4
Q

How does gangrene appear?

A

Black, dry and sometimes shrivelled.

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5
Q

What does the term ‘tissue loss’ refer to?

A

The clinical entities of gangrene and ulcers.

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6
Q

When is ischaemic rest pain classically worse?

A

At night, due to removal of effect of gravity when the lower limb is raised in bed.

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7
Q

What are three complications of mesenteric artery atherosclerosis?

A

-Post-prandial abdominal pain (severe pain after eating due to occlusion of arteries supplying the bowel)
-Weight loss (patient sometimes avoids food for fear of precipitating pain)
-Acute abdominal pain (sudden occlusion to blood supply of bowel can cause bowel ischaemia and pain)

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8
Q

How is acute abdominal pain due to bowel ischaemia characterised?

A

Central, constant abdominal pain sometimes associated with nausea or vomiting, and/or loose stools.

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9
Q

What are the three main types of ulceration in the leg and foot?

A

-Venous
-Arterial
-Neuropathic

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10
Q

What is meant by the ‘gaiter’ of the leg?

A

The area around the malleoli and lower calf

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11
Q

What are three signs of chronic venous insufficiency?

A

-Venous ulcers
-Varicose veins
-Thickened skin

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12
Q

Describe the varying depths of different types of ulcers.

A

Venous - shallow
Arterial - deep
Neuropathic - deep

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13
Q

What colours are the different types of ulcers?

A

Venous - pink
Arterial - pale/yellow/black
Neuropathic - pink

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14
Q

Which type of ulcer is classically largest?

A

Venous ulcers

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15
Q

Which region of the lower limb are each type of ulcer classically found?

A

Venous - gaiter area
Arterial - forefoot/toes
Neuropathic - plantar foot

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16
Q

Which type of ulcer does an examination finding of ‘sunset foot’ indicate?

A

Arterial

17
Q

Which type of ulcer does an examination finding of abnormal foot shape indicate?

A

Neuropathic (abnormal foot shape due to diabetic neuropathy)

18
Q

What other visible features can be seen on examination of a lower limb with venous ulceration? (2)

A

Varicose veins
Skin changes of chronic venous insufficiency

19
Q

In which type of ulcer may pedal pulses be absent?

A

Arterial ulcers

20
Q

What are the classical risk factors for venous ulcers? (3)

A

-Previous DVT
-Previous limb fracture
-Previous varicose vein surgery

21
Q

When does Chronic Limb Threatening Ischaemia (CLTI) occur?

A

When arterial limb supply to lower limb is insufficient even when muscles are resting, causing skin breaks (i.e ulceration) and ischaemic rest pain.

22
Q

What are the two venous systems that drain the lower limb?

A

Superficial - drains skin and subcutaneous tissues
Deep - drains muscles

23
Q

What are ‘perforators’?

A

Connections between the superficial and deep venous systems

24
Q

What does the term ‘chronic venous insufficiency’ describe?

A

The condition that results from inadequate venous drainage from the lower limb.

25
Q

What changes in appearance of a limb may be related to chronic venous insufficiency? (6)

A

-Brown skin (due to haemosiderin deposition within the skin)
-Erythema
-Ulceration (skin weakened by pooling of fluid within it due to poor venous drainage)
-Oedema
-Rash (venous or varicose eczema)
-Thickened skin (lipodermatosclerosis - reaction to chronic oedema and inflammation)

26
Q

What symptoms may arise from chronic venous insufficiency? (6)

A

-Night cramps
-Restless legs
-Pain in lower limb (can be specific to varicose veins themselves if present)
-Itching
-Aching (worsening throughout the day due to spending longer upright)
-Heaviness (may also be described as a ‘dragging’ feeling)

27
Q

What is venous claudication?

A

Pain in the calf/foot after walking a good distance, associated with swelling.

28
Q

Why is the muscle most likely to suffer from intermittent claudication the calf? (2)

A

-Peripheral arterial disease is common in the femoral-popliteal vessels responsible for delivering blood to that part of the leg.
-The calf muscle also works very hard during exercise, and therefore suffers most from poor arterial supply.

29
Q

Where may intermittent claudication pain be felt in patients with disease of the iliac arteries?

A

In the gluteal muscles, causing buttock pain

30
Q

What is ‘sunset foot’?

A

Vasodilation of the superficial blood vessels in patients with chronic limb threatening ischaemia, causing erythema of the forefoot/toes that resolves on raising the foot.

31
Q

What is Ankle-Brachial Pressure Index (ABPI)?

A

The ratio of systolic blood pressure at the ankle to that in the arm, indicating vessel competency.

32
Q

How is Anke-Brachial Pressure Index (ABPI) performed? (4)

A

-Hand held Doppler used to auscultate the arterial waveform in the brachial artery.
-BP cuff inflated until signal disappears; pressure at which this happens is recorded (this is systolic pressure).
-Same manoeuvre performed in leg, with Doppler auscultating posterior tibial and/or dorsalis pedis artery; pressure at which signal disappears is again recorded.
-Two pressures are compared as a ratio.

33
Q

How are Ankle-Brachial Pressure Index (ABPI) results interpreted? (3)

A

—>A ratio of 1 indicates a normal result - blood flow in the leg is the same as that to the arm.
—>Ratio < 0.8 - patient may suffer with intermittent claudication, or have no symptoms.
—>Ratio < 0.4 - blood flow may be so restricted that patient has pain at rest and/or at night, and tissue loss in foot = suggestive of chronic limb threatening ischaemia

34
Q

Why can Ankle-Brachial Pressure Index (ABPI) readings be more difficult to obtain accurately in diabetic patients?

A

The walls of the arteries in these patients are more likely to be calcified, making them less able to be compressed using a blood pressure cuff.

35
Q

How is peripheral arterial disease managed (NICE guidelines)? (2)

A

-Offer patient information, advice, support and treatment regarding secondary prevention of cardiovascular disease (lifestyle changes, statins and anti-platelet medications)
-Prevention, diagnosis and management of diabetes and hypertension

36
Q

What are the management options for intermittent claudication? (4)

A

-Supervised exercise programme
-Angioplasty and stenting (when above doesn’t work and imaging confirms suitability)
-Bypass surgery and graft types (in severe, lifestyle-limiting cases when above unsuccessful/unsuitable)
-Naftidrofuryl oxalate (only when patient refuses surgery)

37
Q

What is Naftidrofuryl oxalate?

A

A peripheral vasodilator used to treat peripheral and cerebral vascular disease.

38
Q

What is involved in an angioplasty of the superficial femoral artery? (3)

A

-Needle used to puncture common femoral artery at level of the groin.
-Contrast injected into artery to visualise the stenosis or occlusion.
-Wire passed through the diseased artery and a balloon is passed over the wire; this is inflated in the diseased segment to widen the channel of flow.

39
Q

What are the red flag symptoms requiring urgent referral to hospital for unilateral limb pain? (4)

A

-Rest pain/night pain in forefoot or toes
-Tissue loss (gangrene or ulceration)
-Sensorimotor deficit
-Acute swelling

TCD Vascular (2 decks)

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