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JMS - Vascular > Peripheral Arterial Disease > Flashcards

Peripheral Arterial Disease Flashcards

1
Q

Chief feature of PAD

A

Intermittent Claudication

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2
Q

65% have coexisting disease of what?

A

Cerebral or coronary artery disease

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3
Q

2 types of PAD?

A

Acute Limb Ischaemia

Chronic Limb ischaemia

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4
Q

Difference betweeen Acute Limb Ischaemia and chronic limb ischaemia in terms of pathophysiology?

A

Acute = Usually due to an embolus (emboli broken off causing sudden onset blockage in a smaller artery)

Chronic = Usually due to a thrombus (static blockage that gets bigger till it causes an occlusion over time)

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5
Q

Acute/Chronic limb ischaemia

Which one is a surgical emergency?

What needs to be done?

Within how long?

A

Acute Limb Ischaemia

Surgical revascularisation

4-6 hours

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6
Q

RF for chronic limb ischaemia

A 
HTN 
Smoking 
T2DM 
High cholesterol 
Obesity
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7
Q

RF for acute limb ischaemia

A

AF

Aneurysm (dilated blood vessel - turbulent flow - clots form leading to emboli).

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8
Q

Chronic Limb ischaemia - how does it overcome obstruction?

A

Developing collaterals over time

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9
Q

Two types of chronic limb ischaemia

A

Critical and non-critical

Critical - rest pain and having to sleep in chair + collaterals can’t cope.

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10
Q

Tx of Acute Limb ischaemia

A

urgent open surgery or angioplasty

within 6 hours:
- embolectomy (if done after 6hrs - risk of compartment syndrome)

longer than 9 hours:
- fasiotomy (fascia - relieve pressure)

OR

local thrombolysis (tissue plasminogen activator t-Pa)

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11
Q

Tx of Chronic Limb Ischaemia

what are the conservative and medical measures?

if these have failed?

A

conservative:

encourage exercise (3x30mins) to improve collateral flow - exercise till point of maximal pain, quit smoking, treat HTN and cholesterol

medical:

  • statin + antiplatelet (clopidogrel - 1st line) - reduce risk of critical ischaemia
  • naftidrofuryl oxalate - for those not intending to undergo revascularisation + if exercise fails to improve symptoms

surgical:
* angioplasty (can’t angioplasty an occlusion (block) but you can for stenosis (narrowing)). used only if affecting one arterial segment of a single artery - stent used via ballon inflation

  • surgical reconstructon - if extensive but run-off is good (collaterals fill distal vessels) - do bypass graft
  • amputation - patient’s decision - if ongoing pain - preserve knee
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12
Q

Six P’s for Acute Limb Ischaemia

A 
Painless
Pulseless 
Perishingly cold 
Parasthesia 
Paralysis 
Pallor
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13
Q

Features of Critical Ischaemia

A

Rest pain
Burning pain at night relieved by hanging legs over side of bed or sleeping in chair
Ulceration
Gangrene

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14
Q

Calf claudication a sign of?

A

femoral disease

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15
Q

Buttock claudication a sign of?

A

iliac disease

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16
Q

Classification for PAD?

A

Fontaine’s classification

  1. Asymptomatic
  2. Intermittent claudication
  3. Foot pain at rest
  4. Ulceration/gangrene (critical ischaemia)
17
Q

What is a +ve Buerger’s angle when raising leg off couch

A

<20 degrees - see leg go pale

18
Q

signs of PAD

A

Absent distal pulses
cold, white legs
postural dependent colour change
ulcers

19
Q

Ix for PAD

1) do a thrombophilia screen in which patients?
2) CRP/ESR to exclude what?
3) ABPI?

A

1) <50yrs
2) DM or arteritis
3) Ankle Brachial Pressure Index
- Normal (1-1.2
- PAD (0.4-0.9)
- Critical Limb ischaemia (<0.4)
- DM (>1.2) - incompressible calcified vessels from atherosclerosis

20
Q

1st line imaging for PAD?

A

Colour Duplex US

21
Q

if considering intervention for PAD:

what imaging would you then choose?

A

MRI/CT Angiography

22
Q

if in doubt with diagnosis of acute limb ischaemia what would you do before surgical intervention

A

urgent arteriography

23
Q

in acute limb ischaemia management - what do you do once you’ve done either a embolectomy or fasciotomy

A

anticoagulate with heparin

24
Q

What can be used to treat the complication of phantom limb pain in amputation

A

Gabapentin

25
Q

A 69-year-old man attends his GP with symptoms of intermittent claudication. He has a past medical history of gastro-oesophageal reflux for which he takes lansoprazole. On examination he has absent dorsalis pedis pulses in both feet, his blood pressure is 134/85 mmHg and his heart rate is 82 bpm. An ankle-brachial pressure index is performed which confirms a diagnosis of peripheral arterial disease.

Which of the antiplatelet agents are most appropriate as first line treatment for this gentleman?

A

Clopidogrel

26
Q

A 62-year-old man with intermittent claudication is reviewed. He is currently taking clopidogrel and simvastatin. Despite regular exercise he is still symptomatic. Clinical examination shows no signs of critical limb ischaemia. Which one of the following interventions should be considered next?

Angioplasty 
Amlodipine 
Amputation 
Isosorbide Mononitrate 
Compression stockings
A

Angioplasty

27
Q

A 65-year-old man presents to his GP with bilateral ‘burning sensation’ at the back of his legs after walking approximately 100 yards. This sensation is relieved by rest.

His ankle brachial pressure index (ABPI) is 0.8.

What is the first-line imaging to investigate this patient further?

A

Duplex US

28
Q

A 66-year-old man reports that he is struggling to walk his dog as he finds that his calves are intensely painful after about 10 mins. A lower limb examination is normal aside from absent posterior tibial and dorsalis pedis pulses. His past medical history includes a myocardial infarction 3 years ago and he also smokes 30/day.

Given the likely diagnosis, which medication should he be prescribed daily for secondary prevention of cardiovascular disease?

A

Clopidogrel 75mg

29
Q

A 28-year-old man undergoes a ileocaecal resection and end ileostomy for Crohn’s disease. One year later he presents with a deep painful ulcer at his stoma site

A

Pyoderma gangrenosum is associated with inflammatory bowel disease. It is commonly found on lower limbs and described as being painful, the size of an insect bite and growing.

30
Q

A 24-year-old lady from Western India presents with symptoms of lethargy and dizziness, worse on turning her head. On examination her systolic blood pressure is 176/128. Her pulses are impalpable at all peripheral sites. Auscultation of her chest reveals a systolic heart murmur

A

Takayasu’s arteritis most commonly affects young Asian females. Pulseless peripheries are a classical finding

31
Q

A 55-year old-man comes to see you saying that his father recently died of an abdominal aortic aneurysm.

He asks whether he will be screened for this condition and at what age?

A

Single Abdo US at age 65

32
Q

A 73-year-old lifelong heavy smoker presents to the vascular clinic with symptoms of foot ulceration and rest pain. On examination her foot has areas of gangrene and pulses are impalpable.

What is their ABPI?

A

0.3

33
Q

A 63-year-old man presents with a claudication distance of 15 yards. He is a lifelong heavy smoker. On examination his foot is hyperaemic and there is a small ulcer at the tip of his great toe.

What is their ABPI?

A

0.5

34
Q

A 77-year-old morbidly obese man with type 2 diabetes presents with leg pain at rest. His symptoms are worst at night and sometimes improve during the day. He has no areas of ulceration

What is their ABPI?

A

> 1.2

JMS - Vascular (9 decks)

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