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Cardio > Peripheral arterial disease > Flashcards

Peripheral arterial disease Flashcards

1
Q

What are the 3 main peripheral arterial diseases?

A

Chronic ischaemia

Acute ischaemia

Diabetic foot disease

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2
Q

The aorta splits into the ____

A

Common iliac arteries

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3
Q

The common iliac arteries split into the _____

A

Internal & external iliac arteries

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4
Q

The external iliac artery becomes the ______

A

Common femoral artery

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5
Q

What artery branches off the common femoral artery?

A

Profunda femoris

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6
Q

The common femoral artery eventually becomes the _______

A

Superficial femoral artery

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7
Q

At the level of the knee, the superficial femoral artery has become the ______

A

Popliteal artery

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8
Q

What three main arteries continue from the popliteal artery?

A

Posterior tibial artery - to the ankle

Peroneal artery

Anterior tibial artery:
- Becomes the Dorsalis pedis - to the foot

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9
Q

What are the 5 palpable arterial pulses on the abdomen/lower limbs?

A

Aorta

Common femoral

Popliteal

Posterior tibial

Dorsalis pedis

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10
Q

Describe how to palpate the aortic pulse

A

Above the umbilicus. Use two hands to feel for pulsation vs. aortic expansion

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11
Q

Describe how to palpate the common femoral pulse

A

Mid-inguinal point, half way between the Anterior Superior Iliac Spine and the pubic symphysis

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12
Q

Describe how to palpate the popliteal pulse

A

Use both hands to feel deep in the popliteal fossa – leg relaxed into your hands

Popliteal fossa = back of knee

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13
Q

Describe how to palpate the Posterior tibial pulse

A

half way between the medial malleolus and the Achilles tendon

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14
Q

Describe how to palpate the Dorsalis pedis pulse

A

Lateral to the extensor hallucis longus tendon

tendon to your big toe

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15
Q

What causes Chronic limb ischaemia?

A

Atherosclerotic disease of the arteries supplying the lower limb

Less commonly:

  • Vasculitis
  • Buerger’s disease

Blockage of blood flow to parts of lower limb

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16
Q

List the risk factors for chronic limb ischaemia

A

Male
Elderly
Smoker

Hypercholesterolaemia
Diabetes
Hypertension

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17
Q

Describe the progression/development of an atheromatous plaque

A

Initial lesion

Fatty streak

Intermediate lesion

Atheroma

Fibroatheroma

Complicated atheroma

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18
Q

How are the symptoms of CLI classified?

A

Fontaine Classification

Stage 1 - 4

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19
Q

Describe the features of stage I CLI

A

Asymptomatic

Blood vessel is not obstructed

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20
Q

Describe the features of stage II CLI

A

Mild claudication pain in limb

Stage IIA = After walking over 200 metres

Stage IIB = Less than 200m before pain

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21
Q

What are the main features of Stage III CLI?

A

Rest pain, mostly in feet

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22
Q

What are the main features of Stage IV CLI?

A

Necrosis and/or gangrene

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23
Q

In a clinical examination:

What signs on inspection would indicate chronic limb ischaemia?

A

Expose both legs:

Ulceration
Pallor
Hair loss

^signs of Chronic ischaemia

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24
Q

In a clinical examination:

What things should you palpate/feel when looking for chronic limb ischaemia?

A

Temperature

Capillary refill time

Peripheral sensation

Pulses – start at the aorta

25
Q

In a clinical examination:

Describe the auscultation process for CLI investigation

A

Using hand held doppler:

Auscultate the Dorsalis pedis & posterior tibial pulses

26
Q

What special examinations could be carried out to investigate CLI?

A

Ankle brachial pressure index

Buerger’s disease test

27
Q

What does the ankle brachial pressure index tell you?

A

Ratio of AP:BP

Score of 1 or more is all good

The closer the score to 0, the worse:
- Gangrene gives a score < 0.2

28
Q

How and why do we carry out the Buerger’s disease test?

A

Buerger’s disease is a less common cause of CLI

Elevate the legs:

  • Pallor
  • If Buerger’s ankle shows at < 20 degrees elevation then patient has severe CLI

Hang feet over edge of bed:
- Dark red colour (which appears slowly)

29
Q

Imaging is a key investigative technique for CLI

What types of imaging can be used?

A

Duplex

CTA / MRA

Digital subtraction angiography

30
Q

Why is Duplex imaging used to investigate CLI?

A
  • Dynamic
  • No radiation or contrast

However:

  • Not good for imaging abdomen
  • Operator dependant
  • Time consuming
31
Q

Why is CTA / MRA used to investigate CLI?

A

CT angio / Magnetic resonance imaging

  • Detailed image
  • Diagnostic (NICE)

However:

  • Contrasts & radiation
  • Can overestimate calcification
  • Contrast is difficult to use in low flow states
32
Q

What medications are prescribed to those with CLI?

A

Anti-platelet - Clopidogrel or Aspirin

Statin

33
Q

Why are Statins prescribed to people with CLI?

A

Inhibits platelet activation and thrombosis, endothelial and inflammation activation, plaque rupture

34
Q

What are the main risk factors that are controlled in order to manage CLI?

A

Smoking cessation

If hypertensive - aim to reduce BP < 140/85

If diabetic - tight glycaemic control to prevent microvascular disease

35
Q

Aside from medication and measures to control risk factors, what else is used to manage CLI?

A

Exercise

36
Q

If medication etc does not work, and a patient’s CLI is continuing to worsen

What is the next ‘step’ in their medical treatment?

A

Revascularisation surgery or amputation

37
Q

What are the types of ravscularisation surgeries?

A

Open surgery:
- Bypass and/or endartorectomy

Endovascular:

  • Balloon angioplasty
  • Stent placement
  • Atherectomy
38
Q

What is an angioplasty?

A

Using a weird ballon stick catheter thing you insert into vasculature and go to site of atheroma

Balloon has stent around it

Balloon expands & compresses the atheroma

Stent remains and compresses the plaque

Some stents have drugs imbedded in them to do spicy things

39
Q

In order for surgical bypass to be possible, what is required?

A

Inflow

Suitable conduit

Outflow

40
Q

What can be used as a conduit?

A

Can either be autologus - ie a vein from the arm or leg

or can be synthetic - PTFE/Dacron (no idea)

41
Q

What are the risks of surgical bypass?

A

General - all the usual ones like infection, DVT etc

Technical - Damage to nearby vein, artery, nerve, distal emboli, graft failure (stenosis, occlusion)

Often requires re-intervention 18-40%

42
Q

The BASIL trial compared the benefits and faults of Angioplasty & surgery for CLI

What was the basic conclusion?

A

If short term results are what matters - Angioplasty is preferred

However, if the patient has a reasonable life expectancy and is suitable for surgery - then surgery is better

  • Surgery has high short term morbidity but is more durable in the long term than angioplasty which is more of a ‘short term fix’
43
Q

What is Acute limb ischaemia?

A

Blockage of blood flow to area of leg causes by either a thrombus or an embolus from a proximal artery

Emergency situation

30% embolic, 60% thrombosis in situ

44
Q

Describe the causes/pathophysiology of ALI

A

Arterial embolus: 30%

  • MI
  • AF
  • Proximal atherosclerosis

Thrombosis: 60%
- usually of previously diseased artery

Trauma
Dissection
Acute aneurysm thrombosis

45
Q

What are the 6 P’s of ALI

A 
Pain 
Pallor 
Pulse deficit 
Paraesthesia - pins and needles 
Paresis/paralysis 
Poikilothermia (cold)

Compare legs

46
Q

ALI can cause compartment syndrome

What is this, and why is it bad?

What blood marker is present?

A

Ischaemia of muscle compartment which is irreversible after 6-8 hours

Characterised by:

  • Tense but tender calve muscle
  • Inflammation, oedema & venous obstruction
  • Rise in creatine kinase

Risk of renal failure - myoglobulinaemia

47
Q

If an episode of ALI causes too much damage for a limb to be salvageable, what are the potential courses of action for the patients care?

A

If amputation is beneficial and the patient is willing, then amputate ischaemic limb

If disease is too bad for amputation to save patient, or patient does not want to be amputated then palliate

48
Q

A patient has Acute limb ischaemia, but the ischaemic limb is salvageable, what is the course of action?

A

If suspicion of ONLY embolus:
- embolectomy

If suspicion of thrombosis in situ (not embolised):
- Either endovascular or open surgery

49
Q

What endovascular procedures can be used to ALI?

A

Mechanical thrombectomy / thrombolysis

Only if patient has thrombosis in situ

50
Q

What open surgical procedures are carried out to treat acute limb ischaemia?

A

Open embolectomy +/- bypass

Only for patients with thombosis in situ

51
Q

What happens in an embolectomy?

A

Incision into artery and wire thing with small balloon at end passed in

Wire pushed through embolus and balloon inflated on other side

Wire used to pull/guide embolus out through the incision

52
Q

What is the peri-operative mortality rate for Acute limb ischaemia?

A

22%

53
Q

How common is it for someone with diabetes to get a diabetic foot ulcer?

A

25% of diabetic patients will get a foot ulcer in their lifetime

54
Q

What are the risks to patients of getting a Diabetic foot ulcer?

A

50% of foot ulcers get infected & 20% require amputation

55
Q

What are the potential causes of Diabetic foot disease?

A 
Microvascular peripheral artery disease
Peripheral neuropathy
Mechanical imbalance
Foot deformity
Minor trauma 
Susceptibility to infection
56
Q

If a diabetic person injures their foot & it becomes infected, how are they treated?

What complications are investigated?

A

Systemic antibiotics

Investigations for:

  • Osteomyelitis
  • Gas gangrene
  • Necrotising fasciitis
57
Q

What is the treatment route for someone who has serious, complicated Diabetic foot disease?

A

Revascularisation:

  • Attempt distal crural angioplasty / stent
  • Distal bypass

If this^ doesn’t work:
- Amputate

58
Q

What adjunctive/less immediate management can be used for Diabetic foot disease?

A

Diligent wound dressing to avoid further infection

Debridement - larval therapy

Negative pressure wound closure

Skin grafts

Cardio (41 decks)

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