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Peripheral Vascular Conditions Flashcards

1
Q

Pathogenesis of Atherosclerosis

A

Normal Artery –> Fatty streak –> Fibrofatty Plaque –> advanced/vulnerable plaque–> aneurysm + rupture/occlusion by thrombus/critical stenosis

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2
Q

Normal artery –> Fibrofatty plaque RFs

A 
At lesion prone areas
Endothelial dysfunction
Monocyte adhesion/emigration
SMC migration to intima
SMC proliferation
ECM elaboration
Lipid accumulation
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3
Q

Fibrofatty Plaque –> Advanced/vulnerable plaque

A 
Cell death/degeneration
Inflammation
Plaque growth
Remodelling of plaque and wall ECM
Organization of thrombus
Calcification
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4
Q

Advanced/vulnerable plaque –> aneurysm and rupture

A

Mural thrombosis
Embolization
Wall weakening

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5
Q

Advanced/vulnerable plaque –> occlusion by thrombus

A 
Plaque rupture 
Plaque erosion
Plaque haemorrhage
Mural thrombosis
Embolization
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6
Q

Advanced/vulnerable plaque –> critical stenosis

A

Progressive plaque growth

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7
Q

Plaques are made up of

A

Cells (SMC, macrophages and other WBC)
ECM (collagen, elastin, and PGs)
Lipids

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8
Q

Intermittent claudication

A

Pain in limb- most often noticed in calf, but may also be felt in buttocks or thighs
Brought on by exertion
Relieved at rest
Recurs on similar effort

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9
Q

Spinal ischaemia

A

Spinal cord stenosis has similar pain to intermittent claudication
Difference is that just standing doesn’t make it better, they have to sit down

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10
Q

Critical Limb ischaemia

A 
Rest pain (constant pain + opiate analgesia) +/- tissue loss
<50mmHg at ankle
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11
Q

PAD epidemiology- in population 55-74 yrs

A

25% asymptomatic PAD

5%- claudication (23% of claudicants will develop CLI over 10 years)

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12
Q

PAD epidemiology

A

Correlation of ABPI with increased risk of death
PAD has a greater mortality rate than cerebrovascular/coronary artery disease
3% death per year

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13
Q

Critical limb ischaemia facts

A

90% require reconstruction/angioplasty
25% amputation rate
50% die within 5 yrs (MI, CVA)

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14
Q

Critical limb ischaemia clinical indicators/examination findings

A

Sensation
Movement
Pain

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15
Q

Critical limb ischaemia diagnosis

A

History
Examination
Investigations

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16
Q

Critical limb ischaemia investigations

A

ABPI (confounders)
Duplex
MRA/CTA
Diagnostic angiogram

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17
Q

Critical limb ischaemia RFs

A 
Smoking
Diabetes
Hypertension
Hypercholesterolaemia
Hyperhomocysteinaemia
C reactive protein
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18
Q

Claudication timeline- in 100 claudicants-

A

50 improve
30 remain same
20 deteriorate –> 5 of these have intervention–> 1/2 amputated

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19
Q

Claudication treatment- conservative

A 
Lifestyle modification (exercise)
Stop smoking
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20
Q

Claudication treatment- medical

A

Risk factor optimisation

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21
Q

Claudication treatment- surgical

A

Endovascular- angioplasty
Open- surgical bypass
Adjuncts

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22
Q

Diabetes control- claudication

A

Reduce HbA1c by 1% –> 21% reduction in complications

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23
Q

Cholesterol control- claudication

A

Simvastatin 40mg –> 24% reduction in revascularisation

HDL protective, LDL causes atherosclerosis

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24
Q

Blood pressure control- claudication

A

HOPE study 26% reduction in events

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25
Anti-platelets- claudication
Aspirin 75mg --> 23% reduction in events
26
Anti-oxidants and vitamins- claudication
Omega 3 fish oils
27
Cilostazol (pletal) - claudication
Phosphodiesterase inhibitor
28
Claudication- angioplasty
Catheter inserted into femoral artery Balloon/stent positioned Balloon/stent expanded
29
Angioplasty risk
``` Failure to dilate (10-20%) Re-stenosis Surgical salvage (<2%) Amputation (<0.3%) Death (<0.2%) Contrast anaphylaxis Renal dysfunction <24hrs (10%) ```
30
Angioplasty benefit
Minimally invasive Short stay Quick recovery
31
Bypass surgery
Preserved for patients with CL (+/- life altering claudication) Autologous- vein Synthetic- PTFE/Dacron
32
Dacron
basic tube used in bypass
33
PTFE
tube used in bypass- synthetic
34
Fem- above knee popliteal bypass: 2 yr primary patency
long saphenous vein- 81% Human umbilical vein- 70% PTFE- 69%
35
Fem- above knee popliteal bypass: 5yr primary patency
Long saphenous vein- 73% Human umbilical vein- 53% PTFE- 39%
36
Vein patches- risks
``` Graft failure (variables) MI Infections Limb loss Death ```
37
Vein patches- benefit
Save limb Retain independence Wound healing
38
Non surgical treatments in CLI- Prostanoids
Iloporost | Better than placebo for rest pain and ulcer healing
39
Non surgical treatments in CLI- lumbar sympathectomy
Abolishes arteriolar and capillary construction | Alters pain transmission
40
Non surgical treatments in CLI- Spinal cord stimulation
Epidural stimulation for intractable ischaemic pain
41
Non surgical treatments in CLI- gene therapy
Angiogenic growth factors (VEGF, PDGF)
42
Non surgical treatments in CLI- Stem cell therapy
Endothelial progenitor cells
43
Aneurysm definition
Localised dilatation of an artery greater than twice normal diameter
44
Popliteal aneurysm
10% of those with a AAA have a popliteal aneurysm 50% of those with a popliteal aneurysm have an AAA 50% of popliteal aneurysms are bilateral
45
Abdominal aortic aneurysm epidemiology
``` Aortic diameter >3cm Growth +-10%/yr 9% prevalence in men over 65 12% incidence in hypertensive men Mortality at rupture 90% ```
46
AAA pathology summary
Intimal atherosclerosis Mural thrombus Destruction of elastic lamellae Inflammatory response is due to imbalance (matrix degrading proteinases don't equal inhibitors (MMP/plasminogen activators)) Autoimmune response, increased cytokines, chemoattractants and peptide growth factors
47
Altered gene products in AAA formation (in aortic tissue/blood formation)
``` Increased proteolysis (MMP-1, MMP-9) Increased inflammation- (cytokines, Chlamydia Ag/Ab, Adhesion molecules) ```
48
AAA Risk factors
``` 1-5% positive family history Ethnicity- N Europeans > Asians/Africans Smoking- relative risk=2 (and increased expansions) Hypercholesterolaemia Hypertension NOT DIABETES ```
49
Types of aneurysm
Saccular aneurysm Fusiform aneurysm Ruptured aneurysm
50
AAA- indication for surgery
AAA>5.5cm diameter Rapid AAA enlargement (<1cm/yr) Symptomatic AAA
51
AAA surgery risk
``` Mortality (5-10%) Myocardial infarction Multi-organ failure Paraplegia Haemorrhage Infections (wound/graft) Fistulae Hernia ```
52
Endovascular AAA repair (EVAR) Pros
2% mortality Decreased insult 2 day hospital stay Can be percutaneous
53
EVAR cons
Cost surveillance re-interventions durability?
54
Rupture risk in 1 year- aortic diameter <5.5cm
1-2%
55
Rupture risk in 1 year- aortic diameter 5.5-6.5cm
8%
56
Rupture risk in 1 year- aortic diameter 6.5-7cm
15-20%
57
Rupture risk in 1 year- aortic diameter >7cm
30%
58
Rupture risk in 1 year- aortic diameter 10cm
100%
59
Most frequent misdiagnoses in patients with AAAs
``` Miscellaneous 13% Renal colic 23% Diverticulitis 12% GI bleed 13% Acute MI 9% Back pain 9% Motor vehicle accident 7% Sepsis 7% Other GI disorders 7% ```
60
AAA screening
Men Over 65 Single trans- abdominal ultrasound
61
Varicose veins epidemiology
``` 1/3 population 18-65 Probably genetic link (familial) 90,000 varicose vein procedures/year UK Effect quality of life Surgery improves quality of life ```
62
Varicose vein description
Dilated Tortuous Incompetent Refluxing
63
Varicose vein clinical assessment
history- previous DVT, previous long bone Examination- bleeding, skin problems Investigation- patent deep veins, confirm root cause
64
VV treatment- conservative
Leg elevation | Class 1 compression hosiery
65
VV treatment- medical
topical relief
66
VV treatment- surgical
Open ligation + stripping Foam sclerotherapy Endovenous solutions
67
Complications of VVs
``` Swelling Discomfort Itching Varicose eczema Haemosiderin deposition Lipodermatosclerosis Bleeding Ulceration ```
68
VV endovenous treatment
Disposable catheter inserted into vein Vein warmed and collapses Catheter withdrawn, closing vein
69
VV complications of treatment- early
``` Bleeding Bruising Discomfort Infection DVT/PE ```
70
VV complications of treatment- late
Recurrence | Parasthesia
71
Endovenous technology benefits- improvement over vein stripping
One hour treatment time Immediate ambulation Can be performed in physician's office Much less expensive
72
Aortic Dissection
History- cardiac type Examination- pulses Diagnosis- CTA
73
Aortic Dissection RFs
Hypertension Genetic Connective tissue

Met 3a (7 decks)

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