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Cardiovascular System > Peripheral Arterial Disease - Presentation, Investigation & Therapy > Flashcards

Peripheral Arterial Disease - Presentation, Investigation & Therapy Flashcards

1
Q

What are the main and less common causes of CLI (critical limb ischaemic) in the lower limbs?

(3)

A

Main: atherosclerosis of arteries

Less common: vasculitis, Buerger’s disease

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2
Q

What are the risk factors associated with CLI?

6

A 
Male
Age
Smoking
Hypercholesterolaemia
Hypertension
Diabetes
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3
Q

The sequence of progression with atherosclerosis is as follows:

Initial lesion - fatty streak - intermediate lesion - atheroma - fibroatheroma - complicated lesion

What happens in the initial lesion stage?

(3)

A
  • macrophage infiltration
  • isolated foamy cells
  • growth mainly by lipid addition
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4
Q

The sequence of progression with atherosclerosis is as follows:

Initial lesion - fatty streak - intermediate lesion - atheroma - fibroatheroma - complicated lesion

What happens in the fatty streak stage?

(1)

A
  • mainly just intracellular lipid accumulation
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5
Q

The sequence of progression with atherosclerosis is as follows:

Initial lesion - fatty streak - intermediate lesion - atheroma - fibroatheroma - complicated lesion

What happens in the intermediate lesion stage?

(2)

A
  • continued intracellular lipid accumulation

- small extracellular lipid pools

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6
Q

The sequence of progression with atherosclerosis is as follows:

Initial lesion - fatty streak - intermediate lesion - atheroma - fibroatheroma - complicated lesion

What happens in the atheroma stage?

(2)

A
  • continued intracellular lipid accumulation

- lipid core begins to develop from extracellular lipids

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7
Q

The sequence of progression with atherosclerosis is as follows:

Initial lesion - fatty streak - intermediate lesion - atheroma - fibroatheroma - complicated lesion

What happens in the fibroatheroma stage?

(3)

A
  • there is now a single or multiple lipid core
  • smooth muscle and collagen increases (main growth mechanism)
  • fibrous/calcific cap formed around lipid core
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8
Q

The sequence of progression with atherosclerosis is as follows:

Initial lesion - fatty streak - intermediate lesion - atheroma - fibroatheroma - complicated lesion

What happens in the complicated lesion stage?

(3)

A
  • surface defect
  • haematoma/haemorrhage
  • thrombosis
  • rupture/embolism
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9
Q

What is stage I of the Fontaine Classification for chronic ischaemia?

A

Asymptomatic, incomplete blood vessel obstruction.

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10
Q

What is stage II of the Fontaine Classification for chronic ischaemia?

A

Mild claudication pain in limb.

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11
Q

What are the subclassifications of stage II?

A

IIA: claudication >200m walking

IIB: claudication <200m walking

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12
Q

What is stage III of the Fontaine Classification for chronic ischaemia?

A

Rest pain, mostly in the feet.

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13
Q

What is stage IV of the Fontaine Classification for chronic ischaemia?

A

Necrosis and/or gangrene of the limb.

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14
Q

Which stage(s) are considered to be CLI?

A

III & IV

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15
Q

What information should be gathered surrounding leg pain during a history?

A

Claudication:

  • exercise tolerance
  • effect of incline
  • change over time
  • relieved by rest
  • location/bilateral
  • character

Rest pain:

  • character
  • relief factors
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16
Q

What things should be considered/asked about during a past medical history for leg ischaemia?

(4)

A
  • hypertension
  • DM
  • hypercholesterolaemia
  • surgeries
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17
Q

What things should be considered/asked about during the social history for leg ischaemia?

(2)

A
  • occupation

- smoking

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18
Q

What is an important step to take before carrying out a leg examination of suspected ischaemia?

A

expose both legs

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19
Q

What should you inspect for during a leg examination?

3

A

ulceration
pallor
hair loss

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20
Q

What should you palpate/feel for during a leg examination? (4)

Where should you start on the leg?

(3)

A

Start at the toes, comparing both sides

Temperature
Capillary refill time
Peripheral sensation
Pulses – start at the aorta

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21
Q

What should you auscultate for during a leg examination?

2

A

Using a hand held doppler, check the dorsalis pedis and posterior tibial pulses

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22
Q

Doppler auscultation over the dorsalis pedis will show what in healthy, more unhealthy and very unhealthy arteries?

A

healthy- triphasic nature

unhealthy- biphasib

very unhelathy- monophasic

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23
Q

What are the specialist tests carried out for chronic limb ischaemia?

(2)

A

Ankle Brachial Pressure Index

Buerger’s test

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24
Q

How do you calculate ABPI (ankle brachial pressure index)?

What is the normal threshold i.e. what does a low reading indicate?

A

ankle pressure divided by brachial pressure

threshold = 0.5
<0.5 = CLI
the smaller the value, the more severe

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25
Q

What does a ABPI of 1+ indicate?

A

symptom free

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26
Q

What does a ABPI of 0.95-0.5 indicate?

A

intermittent claudication

27
Q

What does a ABPI of 0.5-0.3 indicate?

28
Q

What does a ABPI of <0.2 indicate?

A

gangrene/ulceration

29
Q

Describe Buerger’s test.

4

A
  • elevate legs
  • pallor < 20 degrees = severe ischaemia (CLI)
  • legs over edge of bed
  • slow colour regain/dark red colour = CLI
30
Q

What imaging techniques would be used to investigate potential CLI?

(3)

A
  • duplex ultrasound
  • MRA/CTA
  • digital subtraction angiography
31
Q

Patients with peripheral arterial disease (PAD) are considered at the same high risk level and should be managed in the same way as what group of patients?

A

patients with coronary artery disease (CAD)

32
Q

What is the best medical/pharmacological therapy for CLI?

A
  • antiplatelets

- statin

33
Q

What do statins do?

3

A
  • Inhibits platelet activation/thrombosis
  • inhibits endothelial and inflammation activation
  • prevents plaque rupture/embolisation
34
Q

What are other conservative ways to manage CLI?

4

A
  • BP control <140/85
  • smoking cessation
  • diabetic control
  • exercise
35
Q

What is the BP target for CLI?

36
Q

What is the best treatment for moderate CLI?

A
  • medical therapy

- conservative therapy

37
Q

What is the best treatment for severe CLI?

38
Q

What are the open surgery procedures performed in CLI?

2

A
  • by-pass

- endarterectomy

39
Q

What is an endarterectomy?

A

open up artery, clean the plaque, and lightly stitch it back to avoid further narrowing

40
Q

What are the endovascular surgical procedures performed in CLI?

A

Balloon angioplasty
Stent placement
Atherectomy

41
Q

What is an atherectomy?

A
  • minimally invasive endovascular surgery technique for removing atherosclerosis from blood vessels within the body.
42
Q

What is an angioplasty?

A
  • minimally invasive endovascular procedure used to widen narrowed or obstructed arteries or veins, typically to treat arterial atherosclerosis.
43
Q

What is needed for a surgical bypass graft for CLI?

3

A
  • inflow
  • conduit
  • outflow
44
Q

What are the different types of conduits used during by-pass surgery?

(2)

A
  • autologous: (vein from legs, arm)

- synthetic:(PTFE/Dacron)

45
Q

What are the risks associated
with surgical bypass for CLI?

(6)

A
  • bleeding
  • infection
  • DVT/MI/CVA/PE/LRTI
  • damage to nearby v/a/n
  • distant emboli
  • graft failure
46
Q

What is the aetiology of acute limb ischaemia?

5

A
  • thrombus
  • embolus
  • dissection (e.g. carotid dissection)
  • trauma (e.g. car accident)
  • Acute aneurysm thrombosis (e.g. popliteal)
47
Q

What can lead to an arterial embolus? (3)

What is this not the same as?

A

MI/AF/proximal atherosclerosis

DVT/PE

48
Q

What are the clinical presentations of acute limb ischaemia?

6

A
  • pain
  • pallor
  • pulse deficit
  • paraesthesia (abnormal sensation)
  • paralysis
  • poikilothermia

N.b. always compare with contralateral limb

49
Q

What information should be gathered in the history for acute limb ischaemia?

(5)

A
  • cardiac history
  • HPC: onset/duration
  • PMH: chronic limb ischaemia?
  • SH: risk factors
  • functional status
50
Q

What is compartment syndrome?

A

build up of pressure in muscle compartments

51
Q

Describe the pathophysiology of compartment syndrome?

4

A
  1. pressure build = venous obstruction
  2. inflammation/oedema
  3. reduced arterial flow/muscle ischaemia
  4. ultimately this leads to renal failure (myogloulinaemia)
52
Q

What are the signs of compartment syndrome?

2

A
  • increase in creatine kinase

- tense/tender calf

53
Q

What is the treatment process for acute compartment syndrome?

A

fasciotomy

  • fascia is cut to relieve tension or pressure
    to reduce loss of circulation to an area of tissue or muscle
  • limb-saving procedure
54
Q

What is the treatment process for embolus formed in acute compartment syndrome?

A

embolectomy

55
Q

What is the treatment process for thrombosis formed in acute compartment syndrome?

(2)

A

endovascular mechanical thrombectomy

open embolectomy +/- bypass

56
Q

What is the management of acute limb ischaemia if the limb is not salvageable?

(2)

A

palliation

amputation

57
Q

What is the pathophysiology of diabetic foot disease?

6

A
  • Microvascular PAD
  • Peripheral neuropathy
  • Mechanical imbalance
  • Foot deformity
  • Minor trauma
  • more susceptible to infection
58
Q

How can diabetic foot disease be prevented?

4

A
  • foot care
  • foot protection
  • prompt cand regular wound care of skin breaches
  • effective glycaemic control
59
Q

What would be the management plan for a diabetic foot disease?

A
  • prevention
  • effective wound care
  • systemic antibiotics
  • investigate for further disease
60
Q

What further problems could a diabetic foot ulcer progress to?

(3)

A

osteomyelitis
gas gangrene,
necrotizing fasciitis

61
Q

What would be the further management/treatment of a severe/complicated DFU?

A
  • revascularisation

- amputation

62
Q

What are the revascularising techniques for diabetic foot disease?

(2)

A
  • Attempt distal crural angioplasty/stent

- Distal bypass

63
Q

What adjunctive measures can be used to manage/treat diabetic foot disease?

i.e. other than medication/surgery

(4)

A
  • dressings
  • larval therapy (worms)
  • negative pressure wound closure
  • skin grafts
64
Q

What are the sites for lower limb amputation?

6

A
  • hip dislocation
  • above knee
  • below knee
  • symes’
  • trans-metatarsal
  • digital (toes)

Cardiovascular System (37 decks)

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