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Cardiovascular > Peripheral Vascular Disease 1 + 2 > Flashcards

Peripheral Vascular Disease 1 + 2 Flashcards

1
Q

Examples of acute limb threats? (3)

A
  • Acute limb ischaemia
  • Acute on chronic limb ischaemia
  • Diabetic foot sepsis
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2
Q

What is an aneurysm? Normal aortic diameter? When is aorta called aneurysmal?

A
  • Dilatation of vessel by more than 50% of its normal diameter
  • 1.2 – 2.0 cm
  • > 3cm called aneurysmal
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3
Q

True aneursysm? False aneurysm? Causes of false aneurysm? (2)
What kind of aneurysm is abdominal aortic aneurysm (AAA)?

A
  • Vessel wall is intact (i.e. bulge involves all 3 layers)
  • breach in vessel wall (surrounding structures act as vessel wall)
  • Fractures, surgical interventions
  • True aneurysm
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4
Q

Shapes of aneurysm? (3)
What shape are the majority of aortic aneurysms?
What shape has higher risk of rupturing?

A
  • Saccular
  • Fusiform
  • Mycotic - arises secondary to infection, involving all 3 layers of the artery
  • Fusiform - majority of aortic aneurysms
  • Saccular higher risk of rupturing than fusiform
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5
Q

What is the pathology of abdominal aortic aneurysm (AAA)? (4 + 1 other pathology)

A

Medial degeneration

  • Regulation of elastin/collagen in aortic wall
  • Aneurysmal dilation
  • Increase in aortic wall stress
  • Progressive dilation

Atherosclerosis

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6
Q

What are risk factors for AAA? (5)

A
  • Age - increases with age
  • Gender (male:female = 6:1)
  • Smoking
  • Hypertension
  • Can run in families
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7
Q

Prevalence of abdominal aortic aneurysm? (3)

A
  • 8% of men >65 yrs
  • 25% with AAA have popliteal aneurysms
  • Ruptured AAA 7th most common cause of male death in UK
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8
Q

Presentation of AAA? (2)

A

Asymptomatic (75%) or symptomatic (25%)

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9
Q

How is asymptomatic AAA diagnosed? Clinical presentation of symptomatic AAA?

A

Asymptomatic

  • Identified on imaging for other pathology e.g. kidney disease
  • Screening programmes

Symptomatic

  • Pain (may mimic renal colic)
  • Trashing - forms clots in lumen which can break off and impact other vessels
  • Rupture
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10
Q

What can symptomatic AAA pain mimic? What is “trashing”?

A
  • Mimic renal colic

* Formation of clots in lumen which can break off and impact other vessels

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11
Q

Symptoms of AAA rupture? (4)

A
  • Sudden onset epigastric/central pain
  • May radiate through to back
  • May mimic renal colic
  • Collapse
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12
Q

Clinical presentation of AAA rupture? (5)

A
  • May look well
  • Hypo/hypertensive
  • Pulsatile, expansile mass in abdomen that may be tender
  • Transmitted pulse
  • Peripheral pulses
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13
Q

What are the types of AAA rupture? What percentage of those with AAA rupture will not make it to hospital? Will die in surgery?

A
  • Retroperitoneal (majority) - contained rupture
  • Free intra-peritoneal rupture - rapidly fatal
  • 75% do not make it to hospital
  • 50% operative mortality
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14
Q

When to intervene with AAA? (3)

A
  • If AAA symptomatic
  • In asymptomatic - if >5.5cm AP diameter (<5.5 very unlikely to rupture)
  • If asymptomatic - if >0.5 cm/6 months or >1cm/year
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15
Q

Relationship between size of aneurysm and rupture?

A

Bigger the aneurysm, the bigger the risk of rupture

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16
Q

What imaging techniques are used for AAA?

A
  • Duplex ultrasound

* IV contrast CT of arteries (angiogram)

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17
Q

What is a Duplex ultrasound used for in AAA? What can it tell you? (2) What can it not be used for? (2)

A
  • Used for asymptomatic aneurysms and surveillance
  • Can tell you AP diameter of aneurysm and involvement of iliac arteries
  • Does not tell you if aneurysm ruptures or is mycotic
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18
Q

What does IV contrast arterial CT tell you with regards to AAA? (3)

A
  • Shape, size of aneurysm
  • Iliac involvement
  • ONLY way to identify ruptured AAA
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19
Q

What are forms of AAA management? (3)

A
  • Surveillance
  • Open repair
  • Endovascular aneurysm repair (EVAR)
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20
Q

Explain open repair process? (3)
Why do you not want the graft touching the bowel?
What is Dacron graft made of?

A
  • Laparotomy
  • Clamp aorta + iliacs
  • Dacron graft (tube or bifurcated graft depending on location) - LISTEN TO AUDIO
  • Made of polyester
  • Stitches do not dissolve so can eat into bowl, causing haematemesis and death
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21
Q

Explain EVAR process? (3)
Advantages?
Drawbacks?

A
  • Exclusion of AAA from inside the vessel
  • Tubing inserted via peripheral artery
  • X-ray guided

Advantage - much less invasive than open repair
Disadvantage - patients with EVAR will need further procedures throughout lifetime whereas if open repair, will not need further amendments

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22
Q

Aetiology of AAA? (6) Pathology? (2)

Clinical features?

A

AUDIO

  • Smoking, hypertension, diabetes, raised cholesterol, CVD
  • Medial degeneration, Law of Laplace
  • Clinical features - symptomatic (exclude rupture EVAR), asymptomatic (rupture risk)
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23
Q

Outcome of AAA management? (2)

Mortality of rupture?

A
  • 2-5% mortality elective reapir (EVAR/Open)
  • 30-50% morality rupture repair (EVAR/open)
  • Overall rupture mortality 75-90%
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24
Q

What is acute limb ischaemia? Causes?

A
  • Sudden loss of blood supply to limb

* Occlusion of native artery or bypass graft

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25
Q

What will determine urgency and treatment of limb ischaemia?

A

Determining whether it is acute or acute on chronic

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26
Q

Causes of sudden artery occlusion in acute limb ischaemia? (5)

A
  • Embolism (commonly from heart)
  • Atheroembolism
  • Arterial dissection
  • Trauma
  • Extrinsic compression e.g. tumours
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27
Q

Symptoms of acute limb ischaemia? (6)

Clinical features of acute limb ischaemia? (3)

A
  • Pain
  • Pallor
  • Pulseless
  • Perishingly cold
  • Paraesthesia - tingling
  • Paralysis
  • No prior history of claudication
  • Known cause for embolism
  • Full complement of contra-lateral pulses (not on affected leg)
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28
Q

What is claudication? When is it worse?

A
  • Leg pain when walking (etc) due to narrowing or blockage of leg artery
  • Worse when walking uphill
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29
Q

Describe the pain of acute limb ischaemia? (4)

A

AUDIO

  • Severe
  • Sudden onset
  • Resistant to analgesia
  • Calf/muscle tenderness with tight (‘woody’) compartment indicates muscle necrosis (often irreversible ischaemia)
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30
Q

Describe pallor of acute lumb ischaemia? (3)

A
  • Limb initially white with empty veins
  • Later, capillaries fill with stagnated de-oxygenated blood giving a mottled appearance (blanching mottling - salvageable if prompt revascularisation)
  • Arteries distal to occlusion fill with propagated thrombus with rupture of capillaries (non blanching mottling – irreversible ischaemia)
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31
Q

With regards to pallor, when is limb salvageable? Non-salvageable?
What is mottling?

A
  • Salvageable - blanching mottling
  • Non-salvageable - non-blanching mottling
  • Tissues adopt purple-bluish tinge
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32
Q

What does paraesthesia/paralysis of limb indicate? Is the limb salvageable?

A
  • Indicative of muscle and nerve ischaemia

* Salvageable if promp revascularisation

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33
Q

Clinical features of acute limb ishacemia from 0-4 hrs? (4)

A
  • White foot
  • Painful
  • Sensorimotor deficit (parasthesia, paralysis)
  • Salvageable
34
Q

Clinical features of acute limb ishacemia from 4-12 hrs? (3)

A
  • Mottled
  • Blanches on pressure
  • Partially reversible
35
Q

Clinical features of acute limb ishacemia >12 hrs? (5)

Why must you NOT perfuse tissue after 12 hours?

A
  • Fixed mottling
  • Non-blanching
  • Compartments tender/red
  • Paralysis
  • Non-salvageable

Tissue is dead so will spread toxins to other areas of the body (kill kidneys, kill heart etc)

36
Q

How is acute limb ischaemia managed? (5)

Why is anticoagulation part of acute limb ischaemia management?

A
  • ABC – resuscitate and investigate
  • FBC, U/Es, CK, Coag +/- Troponin
  • ECG – MI, dysrhythmia
  • CXR – underlying malignancy
  • Anticoagulate

Why?

  • Stops propagation of thrombus (enlargement)
  • May improve perfusion
37
Q

Is arterial imaging required for acute limb ischaemia? When is arterial imaging required? Examples of arterial imaging? (2)

A

Not if

  • No prior history of claudication
  • Cause for embolism known
  • Full complement of contra-lateral pulses
  • Required if doubts to history
  • e.g. urgent CT angiogram, catheter angiogram
38
Q

How is acute limb ischaemia managed is limb is salvageable? (3)
Non-salvageable? (2)

A

Salvageable

  • Embolectomy
  • Fasciotomy
  • Thrombolysis

Non-salvageable

  • Palliation
  • Amputation
39
Q

What should be done if there are concerns about inflow or run off in embolectomy? What are problems with inflow/run off? What is often present in occluded artery even if primary cause is embolic? Why?

A

AUDIO (next slide also)

  • Intra operative angiogram
  • ie Fogarty embolectomy catheter not passing up/down artery
  • Atherosclerosis
  • Due to ageing population
40
Q

Explain the process of embolectomy

A

AUDIO

41
Q

What do diabetic foot problems encompass? (3) What does this triad lead to? What may this result in?

A
  • Diabetic neuropathy
  • Peripheral vascular disease
  • Infection
  • Leads to tissue ulceration, necrosis and gangrene
  • May result in limb amputation
42
Q

What accounts for more hospital admissions than any other long term complication of diabetes? Strongest factor for limb loss? What percentage of diabetics will undergo contra-lateral amputation within 5 yrs of the first?

A
  • Foot problems
  • Diabetes
  • 50%
43
Q

What are sources of diabetic foot sepsis? (3) Where does no. 3 occur?

A
  • Puncture wound
  • Infection from nail plate or inter-digital space
  • Neuro-ischaemic ulcer
  • Neuro-ischamic ulcers occur on areas of increased pressure i.e. under metatarsal heads
44
Q

Why is diabetic foot sepsis a problem? (5)

A
  • In foot, intrinsic muscles of the digits are confined within compartments
  • Infection travels into compartments
  • If pus cannot escape, pressure builds up in compartment
  • Leads to impairment of capillary blood flow, further ischaemia and tissue damage
  • Can ultimately lead to sepsis and limb loss
45
Q

What are compartments of the foot bound by? (3)

A
  • Plantar fascia
  • Metatarsal bones
  • Interosseous fascia
46
Q

Name the labelled foot compartments (Pic)

A 
A - lateral compartment
B - interoesseous compartments 
C - Medial compartment 
D - Calcaneal compartment 
E - Central compartment
47
Q

Urgency of diabetic foot sepsis?

A

Is a vascular surgical emergency

48
Q

Systemic features of diabetic foot sepsis? (5)

A
  • Pyrexia
  • Tachycardic
  • Tachypnoeic
  • Confused
  • Kussmauls breathing – very acidotic (blow off CO2 to raise pH)
49
Q

Local features of diabetic foot sepsis? (8)

A
  • Swollen affected digit (‘sausage’ like)
  • Swollen forefoot (‘boggy’ feeling to swelling)
  • Tenderness
  • Ulcer with pus
  • Erythema may track up the limb
  • Patches of necrosis
  • Crepitus in the soft tissues of the foot (gas from gas forming organisms)
  • Pedal pulses may or may not be present
50
Q

What causes crepitus in soft tissues of the foot in diabetic foot sepsis?

A

Gas from gas-forming organisms

51
Q

What organisms may be involved in diabetic foot sepsis? (3)

So what antibiotics must be used?

A
  • Gram +ve cocci (Staph aureus, steptococcus)
  • Gram -ve bacilli (E.coli, Klebsiella, Enterobacter, Proteus and Pseudomonas)
  • Anaerobes (bacteroides)

Very broad spectrum

52
Q

Management of diabetic foot sepsis? (3) What is done if patient is very ill?

A
  • Broad spectrum antibiotics
  • Surgical removal of infected tissue
  • Wound left open to encourage drainage (prevent pockets of infection)
  • Guillotine procedure - foot cut off above the ankle
53
Q

How can diabetic foot problems be prevented? (3)

A
  • Patient education
  • Foot assessment (diabetic foot clinic, podiatrist)
  • Pressure offloading footwear
54
Q

Is diabetic foot sepsis a problem of ischaemia? Explain (4)

A

More of a problem of pressure rather than ischaemia

  • Compartment pressure
  • Vascular compromise
  • Necrotic tissue
  • Limb loss
55
Q

Explain branching of the aorta from level of the bellybutton (6)

A
  • At level of bellybutton, aorta splits into 2 common iliacs
  • Common iliacs split into internal and external iliacs
  • External iliac becomes femoral artery which splits into 2 to form deep and superficial femoral
  • Superficial femoral becomes popliteal
  • Popliteal branches into anterior tibial artery and tibioperoneal trunk
  • Tibioperoneal trunk becomes peroneal artery and posterior tibial
56
Q

What do problems with internal iliac affect? External iliac? Superficial femoral?

A
  • Pelvis
  • Thigh
  • Lower leg/foot
57
Q

What is intermittent claudication? (2)

A
  • Occurs when insufficient blood reaches exercising muscle - MUSCLE ISCHAEMIA
  • After variable periods of exercise patient develops ischaemic pain in the affected limb, which is relieved by rest
58
Q

When are symptoms of intermittent claudication worsened?

A
  • Further
  • Faster
  • Steeper
  • Heavier
59
Q

Explain the appearance of the angiogram (pic)

A
  • Left - superficial femoral artery (open all the way down)

* Right - superficial femoral artery, blockage = formation of collaterals

60
Q

Relationship between age and intermittent claudication?

A
  • Prevalence increases with age
61
Q

What are risk factors for intermittent claudication? Surprising risk reducing factor?

A
  • Male gender
  • Age
  • Diabetes
  • Smoking
  • Hypertension
  • Hypercholesterolaemia
  • Fibrinogen
  • Reduces risk - alcohol consumption
62
Q

What are the underlying pathologies of peripheral vascular disease? (3)

A
  • Coronary artery disease (8%)
  • Cerebro-vascular disease (7%)
  • Atherosclerosis (100%)
63
Q

Non-invasive investigations of lower limb ischaemia? (2) Invasive? (3)

A

Non-invasive

  • Measurement of ABPI
  • Duplex ultrasound scanning

Invasive

  • Magnetic resonance angiography
  • CT angiography
  • Catheter angiography
64
Q

What is ABPI? Equation?

A
  • Ankle Brachial Pressure Index - non-invasive test for lower limb ischaemia
  • ABPI = ankle pressure/brachial pressure
65
Q

What do different values of ABPI mean? (3)
What does it mean if ABPI is lowered?
What can give a false positive result in PAD?

A
  • Normal (0.9 - 1.2)
  • Claudication (0.4 - 0.85)
  • Severe (0 - 0.5)
  • Problem with arteries

Calcified vessels (e.g. in diabetes and kidney failure) can give false positive results

66
Q

As ABPI does not allow the location of arterial problem to be identified, what is the next step? What does this allow? (4)

A
  • Duplex ultrasound scanning

Allows you to:-

  • See artery
  • See turbulent flow
  • Assess speed of flow
  • Assess ratio of normal flow to turbulent flow
67
Q

What is MRA? Advantage?

A
  • Magnetic resonance angiography - invasive test for PVD

* No radiation

68
Q

What is CT angiography? Advantage? Disadvantages? (2)

A
  • Invasive test for PVD
  • Advantage - quick
  • Disadvanatages - contrast CT can affect kidneys, uses ionising radiation
69
Q

What is catheter angiography? Explain procedure (3)

A
  • Invasive investigation for PVD
  • Needle inserted into artery followed by catheter
  • Contrast injected
  • X-ray taken
70
Q

Treatment of lower limb ischaemia to slow progression?

A
  • SMOKING
  • lipid lowering
  • antiplatelets
  • hypertension Rx
  • diabetes Rx
  • life style issues
71
Q

Treatment of lower limb ischaemia that improves claudication symptoms?

A
  • Exercise training
  • Drugs
  • Angioplasty / Stenting
  • Surgery
72
Q

What does exercise training for PVD involve? Drug treatment? What are the benefits of exercise treatment? (2)

A
  • 1 hour per day - 30 mins 3 times per week for a minimum of 6 months
  • Cilostozol
  • 20-200% improvement in walking distance
  • Vessels dilate so blood can bypass claudication
73
Q

Describe the process of angioplasty + stent insertion (3)

What are risks with this procedure? (2)

A
  • Tiny holes in artery to deliver fairly large balloon
  • Cracks open diseased segment
  • Stent deployed

Risks

  • Risk of balloon popping, rupturing artery
  • Cracking open diseased segment can result in emboli breaking off
74
Q

What are surgical options for PVD?

A
  • Endarterectomy

* Bypass surgery

75
Q

What is an endarterectomy? What tissues can be used in bypass surgery?

A

Surgical removal of plaque from blood vessel

  • Anatomic
  • Prosthetic (dacron, ePTFE)
  • Vein
76
Q

What are clinical features of critical limb ischaemia? What can ulcers/gangrene be caused by? (2)

A
  • Rest pain due to toe/foot ischaemia e.g. when lying/sleeping
  • Uclers/gangrene due to severe ischaemia and damage
  • Caused by trauma and footwear
77
Q

Symptoms of critical limb ischaemia? (2) What are reliving factors? (2)
Clinical features of critical limb ischaemia? (4)

A
  • Rest pain
  • Worse at night
  • Helped by sitting and putting the leg in a dependent position
  • Helped by getting up and walking about
  • Cool to touch
  • Absence of peripheral pulses
  • Colour change
  • Hair loss
78
Q

What are risk factors for amputation in PVD?

A
  • Smoking - 1 in 10 patients will lose a leg every 5 years if they continue to smoke (10% increase in limb loss)
  • Diabetes - 45% of all major amputees diabetic
79
Q

Treatment of critical limb ischaemia? (3)

Rank asymptomatic PAD, intermittent claudication and critical limb ischaemia in order of amputation risk?

A
  • Analgesia
  • Angioplasty/Stenting
  • Surgical reconstruction/ amputation

Risk

  • Asymptomatic PAD (lowest risk)
  • Intermittent claudication (1%)
  • Critical limb ischaemia (25% - highest risk)
80
Q

What does amputation level affect? (2) Relationship? Mortality of amputation?

A
  • Healing
  • Function
  • The lower down you amputate in lower limb, the greater the chance it will heal
  • Mortality = 15-20%
81
Q

By what percentage does risk increase with above knee operation as opposed to below knee?

A

15%

82
Q

What is the pathology in intermittent claudication and critical limb ischaemia?

A

Pathology

Cardiovascular (28 decks)

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