Management of Vascular Disorders Flashcards
What is the pathophysiology causing peripheral vascular diseases/problems?
Atherosclerosis
What is the definition of atherosclerosis?
Hardening of the arteries
What other systemic diseases often overlap in patients with peripheral arterial disease?
Coronary disease
Cerebrovascular disease
Diabetes
Kidney disease
What is claudication?
Pain in the leg on walking due to blocked or narrowed arteries
What is the physiology of claudication?
When the arteries are narrowed, less oxygen is delivered to muscles, which then undergo anaerobic metabolism leading to an abnormally rapid build-up of lactic acid in the muscles causing local pain in that muscle group (particularly the calf muscles)
What are some key questions to ask that can help make the clinical diagnosis of claudication?
Does the pain ever occur standing still or sitting? (No because not using muscles)
Is it worse if you walk uphill or hurry? (Yes because more lactic acid is produced)
What happens to it if you stop and stand still? (It goes away within a few minutes as lactic acid gets washed away and oxygen debt is repleted)
Where do you feel the pain or discomfort? (Typically calf muscles, atypically thigh or buttock muscles, definitely not in foot or toes)
How to diagnose claudication?
Typical history
Examination for absent pulses
Exclusion of other conditions (eg arthritis in hip or knee)
Measure blood pressure in the legs using hand-held doppler (Ankle-brachial pressure index <0.9 is diagnostic for presence of PAD)
Vascular imaging with CT or MR (magnetic resonance) angiography or Duplex Doppler scanning
What to ask when assessing vascular history?
Myocardial infarction/angina/heart failure
Stroke/TIA
Diabetes
Smoking and other risk factors
Social circumstance/quality of life
Medications
What is the 5-year fate of untreated claudication (MI, other causes, amputation)?
20% die of MI
10% die of other causes
3% amputation
What are the medical therapy options available to manage patients with peripheral arterial disease?
Blood pressure control
Lipids control
Antiplatelet (Clopidogrel/aspirin)
Angiotensin-converting enzyme inhibitor (ACEI)
Diabetes control
What lifestyle changes can be made to help reduce the symptoms of the peripheral arterial disease?
Stop smoking
Exercise - walking
Weight reduction
Improved diet
What is critical ischaemia?
Ischemia that is severe enough to threaten the loss of the limb or part of the limb (amputation)
What are the clinical features of critical ischaemia?
Rest pain (not just when walking)
+/- gangrene or ulcers
Doppler pressures in foot <50mmHg
What are the symptoms of vascular rest pain due to critical ischaemia (different from pain in claudication)?
Felt in toes/foot
Often severe
Worse at night
Hang foot out of bed or sleeps in a chair (gravity)
What is most likely to happen to patients with critical ischaemia if nothing is done?
Amputation
What is the priority for patients with critical ischaemia?
Revascularisation to unblock or bypass diseased vessels
What can be done to investigate the sites of blockage?
Duplex scan (non-invasive)
Angiogram
Computed tomography angiography (CTA) or magnetic resonance angiography (MRA)
What are the two urgent revascularisation procedures that patients with critical ischaemia can undergo?
Balloon angioplasty
Bypass surgery (FemPopliteal/Aortofemoral/Axillo-femoral)
What does acute mean in acute ischaemia of the leg?
Sudden onset
What are the major causes of acute ischaemia of the leg?
Thrombosis
Embolism
What are some rare causes of acute ischaemia of the leg?
Trauma
Extrinsic compression
Severe venous obstruction
Low flow states/vasospasm
Vasoconstrictor drugs